Cost is another potential barrier. The cost of oral EC varies from about $10 to $70, plus the cost of a doctor visit for a teen who needs a prescription. Obtaining the copper IUD without insurance coverage would cost hundreds of dollars, to cover the price of insertion as well as the device.5
Increasing access: What you can do
In view of the barriers that adolescents face in obtaining EC, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, among other organizations, recommend that physicians give advance prescriptions to teens under the age of 17. 2,25
But how likely are they to actually buy the medication and use it on an emergency basis?
A 2007 Cochrane review found that giving women advance prescriptions for EC did not reduce pregnancy or abortion rates.26 Other studies have found that EC use is highest among women with the lowest risk of pregnancy—those who are already using contraception and are less likely to have unprotected intercourse. Those at the highest risk for unintended pregnancy were found to be less likely to use EC after every episode of unprotected intercourse.23,26 One RCT demonstrated that rates of pregnancy and sexually transmitted infection were not significantly increased by advance provision of EC, leading the researchers to conclude that it was therefore unreasonable to restrict access.27
While it is prudent to make women aware that EC is available should they need it, the focus should be on the fact that consistent use of a reliable form of contraception—an IUD or hormonal contraception, in particular—gives them the best chance of preventing an unwanted pregnancy.
What to do when that call comes in
When a woman calls to report a contraceptive failure or tells you she has had unprotected intercourse, start by finding out how recently it occurred. Subsequent questions and actions that can be used by triage nurses or physicians on call are detailed in the easy-to-use EC telephone triage protocol (FIGURE)28 on page 395. Whether you prescribe oral EC or schedule an appointment to insert a copper IUD within the next few days, there are a number of key points to keep in mind.
Initiate EC as soon as possible, but make it available to any woman who requests it for up to 5 days after unprotected intercourse.
Advise patients that oral EC is safe for most women—even those with contraindications to oral contraceptives. No physical examination is necessary, and there’s usually no need for a pregnancy test.2 The one exception: A woman who has not had a period in the past 30 days should be given a pregnancy test before taking UPA.2
Offer EC at any time in the cycle. Although EC works primarily in the preovulatory phase, it should be offered regardless of the phase of the patient’s menstrual cycle. That’s because of the possibility of late ovulation, as well as the difficulty in accurately determining the phase of a woman’s cycle based on a history alone.
Make EC available to any woman who has been sexually abused. At many emergency departments, EC is not routinely offered to women who come in after being raped, although it clearly should be.29
FIGURE
Telephone triage protocol for emergency contraception
EC, emergency contraception; IUD, intrauterine device; LNG, levonorgestrel; Rx, prescription; UPA, ulipristal acetate.
Adapted from: Reproductive Health Access Project. http://www.reproductiveaccess.org/contraception/tel_triage_ec.htm.28
Patient counseling about EC
Advise patients for whom you prescribe oral EC that the medication delays ovulation, which means they could be at risk for pregnancy later in the cycle. Stress the need to use an alternative means of contraception (a barrier method is recommended for women taking UPA) until their next menses and to come in for a pregnancy test if their period is more than a week late.
Point out, too, that EC can be used more than once within the same cycle, if necessary. That said, even a single request for EC should result in a discussion of effective, longer-term contraception, including the possibility of an IUD.
CORRESPONDENCE Sarina Schrager, MD, MS, University of Wisconsin School of Public Health, Department of Family Medicine, 1100 Delaplaine Court, Madison, WI 53715; sbschrag@wisc.edu