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Sexual Assault and Emergency Contraception

MSfC and MCG SAVES

March 23, 2021, 12pm-1pm

Dr. Jennifer Tucker

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Agenda

12-12:10 - Intro/recap of Dr. Tucker’s lecture

12:10-12:15 - Transition to Breakout Groups

12:15 - 12:40 - Breakout Groups

12:40 - 1:00 - Regroup, Debrief, Q&A

M1s - this activity can fulfill a passport item!

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Emergency Contraception

Impact
Clinical uses
Types and doses
Mechanisms of action
Efficacy
Side effects
Ethical considerations
Legislation
Clinical information for patients

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Impact

Half of all pregnancies in the United States are unintended

2.8 million in 2011

Emergency contraception has the potential to decrease the incidence of unintended pregnancy, thus decreasing the need for elective abortion (from 8% to 1%)

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Clinical uses

After unprotected sex
When birth control may have failed

Broken or slipped condom
If a diaphragm or cervical cap comes off or is taken out too early
Missed birth control pills or delay in receiving intramuscular birth control (Depo-provera shot)

After sexual assault or rape

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Types and doses

Hormonal—may be taken up to 5 days after unprotected intercourse

Yuzpe regimen—combined estrogen and progesterone pills (0.1 mg ethinylestradiol and 0.5mg levonorgestrel, taken in 2 doses 12 hours apart)
Plan B—1.5mg levonorgestrel (in one single dose [Plan B One step] or split in 2 doses taken 12 hours apart)

Higher efficacy than Yuzpe method
Next choice ® is the generic form—one single dose

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Mechanisms of action

Inhibition or delay of ovulation
Direct prevention of sperm migration (more with Plan B)
Prevention of fertilization

Interference with corpus luteum function
Thickening of the cervical mucous resulting in trapping of sperm
Alterations in the tubal transport of sperm or egg

Prevention of implantation (?)

Alteration of endometrial receptivity to a fertilized egg
Altered tubal transport of a fertilized egg

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Efficacy (for Plan B)

Time dependent

Efficacy diminishes as time passes from episode of unprotected sex
95% effective for the first 24 hours
85% effective if taken 24-48 hours after unprotected sex
58% effective between 48 and 72 hours
Nearly no efficacy after 72 hours have passed

Though still recommended up to 120 hours after unprotected intercourse

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Side effects

Nausea and vomiting

Alleviated by the administration of an anti-emetic (benadryl, phenergan)
50% of women who take the combined pills experience nausea and 20% vomit

Incidence of these side effects much less with the progestin-only pill

Abdominal pain
Breast tenderness
Fatigue
Headache

Most symptoms generally resolve within 24 hours and rarely last longer than 48-72 hours

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Ella (the newest hormonal EC)

30 mg of Ulipristal acetate, a selective progesterone receptor modulator

Approved by the FDA 8/13/10 for use up to 5 days after unprotected intercourse or a contraceptive failure
Requires a prescription from a physician
Mechanisms of action—prevention of ovulation and alterations to the endometrium affecting implantation
Side effect profile similar to Plan B
More efficacious than Plan B after 72 hours

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What Emergency Contraception does not do:

Result in expulsion of an implanted embryo from the uterus (so no effect on pregnancy once implantation has occurred)
Have any negative impact on an implanted embryo

Hormonal therapy has not been shown to cause any abnormalities in pregnancies that carry to term

Increase the risk of stroke, heart disease, blood clots in women at risk
No deaths or serious complications have been reported in the 25 years that the pills have been used

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IUD’s

Copper-bearing Intrauterine Device

Appear to have detrimental effects on sperm (possibly eggs), both from the copper and from the nature of the foreign body in the uterus
Recent studies suggest that the primary mechanism of action is not prevention of implantation as previously thought

Can theoretically be inserted up to the time of implantation

Given the difficulty in determining the exact time of ovulation, IUD’s are generally only inserted up to 5 days after unprotected sex

Reduce the risk of pregnancy after unprotected sex by more than 99%
Relatively contraindicated in women with active STD’s

Can result in pelvic infection in these circumstances

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Ethical considerations

Does EC interfere with implantation of a fertilized egg?

Studies in both rats and cebus monkeys reveal that emergency contraception works better when taken before the time of ovulation and within 72 hours after unprotected intercourse (better still if within 24-48 hours), suggesting that it has a greater impact on ovulation and pre-fertilization events than on actual implantation

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Ethical considerations (cont)

The progestin-only pill is unlikely to prevent implantation of a fertilized egg, because progestins in the normal cycle effect changes in the endometrium that allow for implantation and continuation of pregnancy

Exogenous progestins are actually able to maintain pregnancy in experimental animals whose ovaries are removed after implantation

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Legislation

8/24/2006—Plan B made available over the counter to individuals 18 years and older (male or female)

Some states have policies allowing women of any age to obtain EC directly from a pharmacy w/out a prescription
Some states allow pharmacists/pharmacies to refuse to fill prescriptions based on moral objections
A few states require pharmacies to fill EC prescriptions

EC is available to patients of any age with a prescription from a health care provider (male or female patients)
As of April, 2009—EC available over the counter for men or women aged 17 and over

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Legislation (cont)

Some states have enacted legislation requiring hospitals or health care facilities to provide info about and/or initiate EC for sexual assault victims

To date, Georgia has no such law
A little murky when Catholic hospitals are involved (1^st amendment rights to follow religious beliefs)

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Most recent legislation!!

On 4/5/2013, a federal court judge ruled that the FDA must allow emergency contraception to be sold over the counter with no age restrictions

Still a good bit of back and forth on this, but law states that Plan B One Step should be available over the counter and no proof of age required to obtain it

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“Compassionate and understanding care should be given to a person who is the victim of sexual assault. Health care providers should cooperate with law enforcement officials, offer the person psychological and spiritual support and accurate medical information. A female who has been raped should be able to protect herself against a potential conception from the sexual assault. If, after appropriate testing, there is no evidence that fertilization has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization”

From the Ethical and Religious Directives for Catholic Health Care Services

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Information for patients

http://ec.princeton.edu/

not-2-late.com, “The Emergency Contraception website”

http://www.plannedparenthood.org/ec/

Planned Parenthood web page on emergency contraception

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Emergency Contraception: Overview

Impact
Clinical uses
Types and doses
Mechanisms of action
Efficacy
Side effects
Ethical considerations
Legislation
Clinical information for patients

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