Repeated Emergency Contraception in One Cycle

Repeated emergency contraception in one cycle is safe in most patients but is a sign that a regular method is needed. Each dose protects only against the episode treated and delays ovulation, so a later act in the same cycle needs a new dose or a copper IUD. Frequent use may harm patients in category 3 or 4 for hormonal methods.

Pharmacology. Levonorgestrel and ulipristal acetate delay ovulation. No cumulative toxicity is known from repeated doses. Menstrual disturbance is more likely with frequent use.

Effectiveness. Each oral dose has the same effect as a first dose: 1 to 2 in 100 women become pregnant after oral emergency contraception for each episode. Repeated use over time is less effective than a regular method.

Return to fertility. Immediate.

Eligibility. Repeated use follows the categories for a single dose. Patients whose conditions are category 3 or 4 for hormonal methods, such as current breast cancer, should avoid frequent oral doses.

History. Which oral drug was taken earlier in the cycle and how long ago, hours since the new episode, cycle day, method failures and reasons for repeat need, enzyme inducers and weight.

Counselling points for the clinician. Repeat demand is an indication for counselling. Explore reasons: unplanned intercourse, partner pressure, sexual violence, lack of access to a method. Obtain consent and protect confidentiality.

Special groups.

• Adolescents: no age limit applies.

• Sexual violence: ask directly and refer for care.

• Breastfeeding: levonorgestrel is preferred oral option.

Choosing for a second episode.

Regimen lines.

• Levonorgestrel: 1.5 mg by mouth as one dose within 120 hours of the new episode.

• Ulipristal acetate: 30 mg by mouth as one dose within 120 hours of the new episode.

• Copper IUD: copper T 380A, inserted once within 5 days. Immediate protection, lasts up to 12 years, no backup.

Pregnancy exclusion. Pregnancy is reasonably excluded when there has been no unprotected intercourse since the last normal menses and menses are not overdue. With repeated episodes, earlier acts may not be covered, so a test 3 weeks after the last episode is needed.

Vomiting. Within 2 hours of an oral dose, repeat it with an antiemetic. After more than 2 hours, give nothing further.

Moving to a regular method. Start at once after the dose. Combined or progestin-only pills the day after levonorgestrel, or after 5 days following ulipristal acetate, with 7 days of backup for combined pills and 2 days for progestin-only pills. Injectable the same day with 7 days of backup. Copper IUD the same day.

Follow up. Review within 4 weeks to confirm the regular method and test for pregnancy.

Expected effects. Irregular bleeding, spotting and changes in the timing of menses are more common with frequent use. These are not dangerous.

Management.

• Irregular bleeding: reassure if the test is negative and move to a regular method.

• Nausea: ondansetron 4 mg by mouth as one dose, repeated once after 8 hours if needed. Maximum 12 mg in 24 hours, for no more than 2 days. Limit to 8 mg in 24 hours in severe liver disease. No kidney adjustment is needed. Avoid in congenital long QT syndrome. In pregnancy use only when the benefit is clear. Short courses are acceptable in breastfeeding.

• Headache: a mild analgesic if blood pressure is normal. Refer if blood pressure is high.

Failure. A pregnancy after repeated doses is not known to be harmed by them. Assess for ectopic pregnancy when a positive test comes with pain or bleeding.

Common errors. Giving levonorgestrel within 5 days after ulipristal acetate, omitting the copper IUD offer, and continuing repeated doses without moving to a regular method.

Referral and escalation. Refer for severe lower abdominal pain, fainting or a positive pregnancy test with pain or bleeding. Refer patients who disclose coercion or sexual violence for full care.