UPDATE ON CONTRACEPTION

“Emergency contraception,” “the morning-after pill,” and “Plan B” are all phrases commonly used in most gynecologists’ offices. Regrettably, these phrases are not heard as frequently among patients. With half of all pregnancies unintended and 40% of these pregnancies ending in abortion, there is clearly an unmet need for both contraception and emergency contraception (EC). Although more women have turned to EC in recent years, this contraceptive approach remains highly underutilized in the US population. Despite some increase in usage, we have not yet realized a lower rate of unintended pregnancy or abortion.

Yuzpe and colleagues first published findings on the use of combined oral contraceptives (OCs) for postcoital contraception in 1974. Since then, researchers have been trying to manipulate various hormonal configurations in an attempt to best prevent pregnancy after unprotected intercourse. For years, we have quoted success rates as high as 85% when EC is initiated within 72 hours of unprotected intercourse¹—but early studies may have overestimated the ability of EC to prevent unintended pregnancy. More recent investigations have shown that the magical “morning-after pill” and the physicians recommending it are long overdue for a wake-up call.

This installment of the Update on Contraception will review recent evidence on the efficacy of EC and make recommendations for practice, focusing on:

• the reasons EC has failed to reduce the rate of unintended pregnancy
• the efficacy of oral levonorgestrel (LNG) versus ulipristal acetate
• the impact of overweight and obesity on the efficacy of oral agents
• the overall superiority of the copper intrauterine device (IUD).

Half of all pregnancies are unintended, and 40% of unintended pregnancies end in abortion. These figures reflect an unmet need for both contraception and emergency contraception, which remains highly underutilized in the United States.

Access to EC is increasing, but women still lack basic information about it

Kavanaugh M, Schwarz EB. Counseling about and use of emergency contraception in the United States. Perspect Sex Reprod Health. 2008;40(2):81–86.

Kavanaugh M, Williams S, Schwarz EB. Emergency contraception use and counseling after changes in United States prescription status. Fertil Steril. 2011;95(8):2578–2581.

In 1974, Yuzpe and colleagues first published findings on the use of combined estrogen-progestin OCs for postcoital contraception.² At the same time, Kesseru and colleagues were evaluating progestin-only regimens for the same purpose.³

For many subsequent years, combinations of common OC pills containing ethinyl estradiol and LNG were used for EC, until 1998, when a progestin-only method containing two 0.75-mg LNG pills was approved by the Food and Drug Administration (FDA) and marketed in the United States under the brand name Plan B. That approval was based on a double-blind, randomized trial by the World Health Organization that demonstrated an almost threefold higher incidence of pregnancy with use of the Yuzpe regimen, compared with this LNG regimen.¹

Access to the LNG-only method in the United States increased when the product was given behind-the-counter status in 2006, making it possible for women 18 years and older to obtain the medication without a prescription. In 2009, access was approved—also without a prescription—for 17-year-old women. The same year, the FDA approved Plan B One-Step, allowing women to take both 0.75-mg tablets together as a single tablet, theoretically improving treatment adherence.

Seeking a way to further increase use of EC, many investigators explored the potential benefits of advance provision. The idea was not new, as it had been proposed even for the Yuzpe method, and utilization increased significantly after 2006. Reviews of data from the National Survey of Family Growth (NSFG) showed an increase in EC use among women who had ever had sexual intercourse with a man from 4.2% of women surveyed in 2002 to 9.7% of women surveyed in 2006 to 2008, as reported by Kavanaugh and colleagues. Regrettably, this increase did not reduce the number of unintended pregnancies during the same time periods. Clearly, men and women fail to use EC every time they are at risk of unintended pregnancy.⁴

One of the biggest barriers to EC use is probably the lack of information patients receive from providers. Only 3% of respondents to the 2006–2008 NSFG indicated that they had received any counseling about EC in the past year, a number relatively unchanged from the 2002 survey. This finding suggests that the increase in EC use is likely due to the publicity surrounding the EC status change in 2006.