Olivia presents to the children’s emergency department at 3:40 one Monday afternoon, still in her school uniform and with her friend Annabel. Annabel does all the talking to start with and tells the receptionist her friend has “a gynae problem”. She is somewhat assertive with the triage nurse, arguing that Olivia needs to be seen by a doctor in a private room, not in a cubicle with curtains. They disclose that they are both 15 years old. When you arrive in the room, Olivia tells you she’s come to A&E to get “the morning after pill”.
Emergency contraception (EC) requests are a common reason for presenting to GPs, sexual health services and the emergency department. As a children’s doctor, it can be a shock to the system to recognise that adolescents are just as likely as adults to need emergency contraception. There is often a learning gap in the paediatric medicine curriculum. In the UK, around 7% of all women of childbearing age have used emergency contraception in the past 12 months. 10-20% of sexually active teenagers acknowledge they do not always use condoms when having sex. A request for emergency contraception in a teenager signals that contraceptive and sexual health needs are not being met.
What do you need to cover in the history?
- Why does she think she needs emergency contraception?
- When did unprotected sex (UPSI) occur? (i.e. how long ago)
- Where is she in her cycle? (i.e. when was her last menstrual period (LMP)?)
- Is her cycle regular and predictable?
- How many other episodes of UPSI have there been this cycle?
- Who did she have sex with?
- Was it consensual? Consider Sexual Assault Referral Centre (SARC) or forensic medicine input. STI risk? Childhood Sexual Exploitation Risk.
- Was he a regular partner? (STI risk especially)
- Remember she is 15 – the Fraser Guidelines apply here – does she have the capacity to consent to sex? And to the treatment she is seeking? The NSPCC have a brilliant summary of Gillick Competence and Fraser Guidelines.
- What contraception, if any, does she normally use?
- Does she have a preference for the form of emergency contraception?
- What is her weight? And BMI?
- Is she on any regular medication which might affect the efficacy of oral emergency contraception?
- What plans has she got for ongoing contraception?
Olivia tells you she had sex on Saturday night at around 2 am. She was staying over at her boyfriend’s house. Her boyfriend, Jack, and she have been in a relationship for about a year. He told her this morning that he thought the condom might have split. Olivia says she is normally careful about using condoms and feels embarrassed. You ask a bit more about Jack. Annabel tells you Jack is her twin brother. They are all in the same year at school and have known each other for years. Olivia says her LMP was ten days ago; her periods are regular – every 28 days. This is the only time since her LMP that she has had sex. Jack is her only sexual partner, and she is pretty sure he is hers too. Her BMI is 19, she has no past medical history, and she is on no medication.
Now it’s time for a revision session on menstrual physiology*
*and on the life span of eggs and sperm without a good understanding of which, providing emergency contraception is confusing
In a 28-day cycle, the first day of the period is always called day 1. Ovulation then occurs around day 14 of a 28/7 cycle. If the ovum is not fertilised within 12-24 hours, menstruation will occur 14 days later. The first part of the cycle is called the follicular phase, and the second is the luteal phase. The luteal phase is fixed in length in all women. If the cycle length varies, the follicular phase may be longer or shorter than 14 days. Still, following ovulation, if the ovum does not meet a sperm and implant, menstruation will always follow 14 days later.
Sperm released into the female genital tract can live for up to 120 hours. If unprotected sexual intercourse (UPSI) has occurred any time from 6 days before the earliest possible calculated ovulation to 24 hours after ovulation, there is a risk of pregnancy. If a sperm fertilizes an ovum, implantation will occur 5-6 days after ovulation.
A brilliant diagram in the BJFM article is linked in the references section, which effectively shows dates, phases, risks and times of action.
These dates and timelines are crucial in establishing pregnancy risk and in supplying emergency contraception. If ovulation has already occurred, a method which acts by postponing ovulation will be ineffective. A method that prevents implantation cannot be used after the earliest possible implantation. It is unlikely to be effective but, more importantly, because it could be considered to be providing a termination of pregnancy which is only legal in specific situations.
What are the options for emergency contraception for Olivia?
There are three options licensed for emergency contraception in the UK. The Copper IUCD, oral levonorgestrel (Levonelle) and Ulipristal (Ella-One)
The Copper IUCD is considered the gold standard first choice for EC because it:
- Is the only method which is effective post-ovulation.
- Is unaffected by body weight.
- Is unaffected by enzyme-inducing drugs.
- Provides ongoing contraception if required.
- Has a failure rate of only 0.09% when used for emergency contraception.
- Can cover multiple episodes of UPSI provided early in the cycle.
Any copper IUCD can be used for emergency contraception though the “gold standard” for ongoing use is a device with a minimum of 375mm of copper, for example, the T-safe 380a. It is probably worth emphasizing here that this is not a Mirena IUS which cannot be used for emergency contraception. A copper IUCD for emergency contraception can be fitted up to 5 days after the earliest possible ovulation (up to day 19 in a 28-day cycle). Fitting a copper IUCD for emergency contraception can cover several episodes of unprotected sex earlier in the cycle, provided it is before day 19 of a 28-day regular cycle. If a patient has had a single episode of unprotected sex after day 19, a copper IUCD can still be fitted.
There is unlikely to be a service within your emergency department for fitting copper IUCDs. If a copper IUCD is the chosen option, you will have to arrange for Olivia to attend a contraception and sexual health clinic or her GP if they have a coil fitting enhanced service. She’s on day 10 of her cycle, so this is possible as she doesn’t “need” it until day 19, but are you sure she will go there? Not having children is NOT a contraindication to having a copper IUCD fitted. Still, it can be extremely uncomfortable, and she may need a cervical block or gas and air to tolerate the procedure.
Oral EC in the form of Levonorgestrel and Ulipristal both work by delaying ovulation. This is an important piece of information to remember because if your patient has already ovulated, oral emergency contraception will not work. It is also worth being aware of for those patients who believe life begins at fertilisation and who may be ethically or religiously opposed to preventing implantation via the use of a copper IUCD but who would find the postponement of ovulation (as per other hormonal contraceptive measures also) acceptable. The flowchart in the FFPRHC guidelines is really useful to consult every time you have a case of this sort.
Ulipristal (Ella-One) is the second line after a copper IUCD when emergency contraception is needed. It does have several interactions, most importantly with enzyme inducers and progestogens. It is contraindicated in asthma if the patient is taking oral steroids. It is important to note that if a patient has taken a progestogen within the preceding five days, ulipristal will not work. It is not suitable for “missed pills” requiring emergency contraception, and it is impossible to “quickstart” POP/COCP/depo progestogen/Nexplanon if you give ulipristal.
Levonorgestrel is the only emergency contraception available over-the-counter from pharmacies and on prescription in the UK. It should only be used if the risk of pregnancy is low and copper IUCD and Ella-One are both not suitable/not available. It is given as a 1.5g stat dose (though this should be doubled to 3g if she weighs over 70kg or has a BMI over 26 and cannot have Ella-One). If levonorgestrel is given, the clinician can (and if reviewing the FFPRHC gold standard and NICE CKS advice, should) “quickstart” alternative contraception immediately with condoms until the next period. The patient should do a pregnancy test three weeks after use if she has not had a normal period. If your patient is on an enzyme inducer and declines IUCD, levonorgestrel is unlicensed but is the only other option as she cannot use ulipristal.
What else do I need to think about?
Any teenager with unprotected sex is at risk of STIs and pregnancy. There is no role for doing swabs urgently as they will not pick up STIs contracted due to this episode of unprotected sex. Your patient should be signposted to a Contraception and Sexual Health (CASH) Clinic or her GP surgery for swabs in 3 weeks. You may want to write some free text on your discharge letter to ensure the surgery are aware of this, and if the department isn’t too busy, you might even want to ring her GP surgery and book her in for an appointment with the practice nurse for swabs.
Every teenager presenting needing emergency contraception has unmet ongoing contraceptive needs. Whilst the provision of such contraception may well be outside the scope of your role in the Emergency Department, basic counselling about ongoing contraception with signposting to CASH/GP and some relevant patient information leaflets such as those from www.fpa.org.uk should be within the scope of all clinicians.
If you have any concerns about a young person’s sexual activity and think there is any risk of sexual exploitation, abuse or inability to consent to treatment or to the sexual activity they have disclosed, you need to raise this with the safeguarding lead in your department before you let her leave.
You supply Olivia with ulipristal and some written counselling information about reliable contraception. You phone her GP surgery and get her booked in for a telephone appointment with a GP to discuss contraception a few days later and an appointment with the practice nurse for triple swabs for an STI screen in three weeks. Olivia rings her mum whilst in A&E and tells her what has happened. Her mum comes to pick her up and is engaged with the suggestion for ongoing follow-up and contraception.