ECP Chatline 28

April 2005

Question 1:

I am confused because different sources say that patients on POPs can use another means of contraception for 2 OR 7 OR 14 days before they are "safe" again. At the ECP teleconference, it was suggested that 2 days extra contraception is sufficient for POPs.

Answer 1:

You will, unfortunately, find that depending on the source of your information and when it was published, re pill-taking, you will get varying information. Basically, 48 hours is considered quite sufficient, still. This is based on the fact that the POP contraceptive effect is considered to be on mucous thickening, which is restored very quickly - 48 hours being sufficient. The conservative advice was based on a number of factors, but I have been told that one of the main considerations in advising this (apparently between 1993 to 2003 in the UK FPA pamphlets) was to keep things consistent in case women who had previously been on the POP went onto the COC and got confused as to when they would be safe from. (!!).

John Guillebaud in his 4th edition of "Contraception: your questions answered" states that "from 2004 onwards the leaflets, following the advice of WHO in its important document "Selected Practice Recommendations" have returned to the earlier wording for the management of a late or missed tablet, namely...abstain from sex or use additional contraception for the next 2 days".

Firstly, I think we (those of us working in FPA type environments) are well aware that the POP manufacturers are ULTRA cautious in the advice they put in their patient information leaflets.

Question 2:

If Noriday information says to rule out pregnancy after 2 missed pills then should the ECP be given at all (considering that pregnancy is a contraindication for ECP)?

Answer 2:

Remember that you can't rule out pregnancy for 2 weeks after the possible time of conception, to start with. At the time that you would be considering giving ECP, pregnancy hasn't occurred (remember we discussed that the ECP is a Contraceptive - works BEFORE conception - not a contragestive, or postconceptional agent.). So not an issue here. (if you have access to Guillebaud's "Contraception: Your Questions Answered", see pp 455-56 in edition four - the 1st part of the section on Emergency/Postcoital Contraception). Most definitely do give the ECP if UPSI after 2 missed Noriday, provided you're satisfied she's not ALREADY pregnant from other UPSIs.

Question 3:

If she doesn't have periods on the POP, should I be telling her to rule out pregnancy any time she misses 2 pills?

Answer 3:

*IF* she has been at risk, yes, but not till the 2 weeks after her UPSI is up. She doesn't have to do a pregnancy test when she fronts up for an ECP at the time of her 2 missed pills - it would be too early.

Question 4:

Is ECP ok for use up to 5 days after UPSI? Is a script for Postinor 2 tablets bd appropriate at this late stage?

Answer 4:

The efficacy of ECP declines gradually after the UPSI. At 24 hours it is 95%, at 48 hours it is 85%, at 72 hours it is 58%. Activity does not stop suddenly, but continues to decline. Doctors are able to prescribe outside the licensed indications of 72 hours, whereas pharmacists are not. So a doctor can prescribe for days 4 and 5 in the hope that it might still be effective – better to try than not bother.

The double dose, however, is not appropriate, and there is absolutely no reason to do this just because of it being day 5.  Perhaps the GP wanted to give her an extra dose for future supply? I don't know (if the client wasn't on enzyme inducers, that is). The evidence does not support any advantage to administering a double dose.

By the end of the year, Schering should have brought out the new double dose stat product and pharmacists will be able to follow the doctors new prescribing patterns legally.