Contraceptive counselling often features in OSCEs and therefore it’s important to be familiar with the various types of contraception available. This article focuses on counselling patients regarding Emergency Contraception including the common questions patients ask, the answers you’ll be expected to articulate and how best to structure the consultation overall. This guide should not be used to inform clinical decision making, it is for educational purposes only.

Check out the Emergency Contraception OSCE mark scheme here.


Opening the consultation

  • Introduce yourself
  • Check the patient’s details (name/date of birth)
  • Check the patient’s understanding of emergency contraception
  • Explore the reasons why the patient wants emergency contraception

 


Patient’s ideas, concerns and expectations

It is important to explore the patient’s ideasconcerns and expectations early in the consultation, as you may need to correct any misconceptions about emergency contraception and address any of the patient’s concerns.

When exploring concerns, it is important to do so in a sensitive and honest manner.

 


When to use Emergency Contraception?

Some patients may find the process of acquiring emergency contraception quite distressing. Therefore, it is important to explore their need for emergency contraception.

Emergency contraception should be used if someone has had unprotected sexual intercourse (UPSI), or if they think their contraception may have failed. Note that emergency contraception is not necessary within the first 21 days after giving birth.

 


Safeguarding

As part of this consultation, it is important to screen for potential sexual/domestic abuse, as women may not volunteer this information. You should first clarify, in a sensitive manner, if the unprotected sexual intercourse that has resulted in this consultation was consensual. You should also ask if the patient currently feels safe and supported in their current relationship (if relevant), asking specifically about domestic violence. You should also reiterate that the consultation is confidential.

 


Access to Emergency Contraception

Emergency contraception is free from the following places: ¹

  • Any GP clinic that provides contraceptive services
  • Any sexual health or most genitourinary medicine clinics
  • Any young person’s service
  • NHS walk-in centres
  • Many pharmacies
  • Some A&E departments

 

Emergency contraceptive pills can be purchased from:

  • Most pharmacies (however the patient will need to be over the age of 16)

 


Sexually transmitted infections

It is important to consider the risk of the patient having a sexually transmitted infection. This involves taking a sexual history to determine risk.

 


Types of Emergency Contraception

There are three main types of emergency contraception in the UK:

  • The Copper Intrauterine Device (also known as the “Copper Coil” or “Emergency IUD”)
  • EllaOne (Emergency Contraceptive Pill with Ulipristal Acetate)
  • The Emergency Contraceptive Pill with Levonorgestrel (Progesterone)

Each of these contraceptive methods will be explained in this article.

 


Copper Intrauterine Device (IUD)

Explain to the patient that a Copper IUD is a small plastic and copper device that can be fitted up to 5 days, (120 hours) after unprotected sex. ¹

  •  “The Copper IUD is a small plastic and copper T-shaped device which can be fitted into your womb up to 5 days after unprotected sex.”

How does the Copper IUD work?

  • It is thought the copper IUD has an inhibitory effect on both fertilisation and implantation.
  • Fertilisation inhibition occurs through direct toxicity effects of the copper on both ovum and sperm.
  • The copper IUD can also thicken cervical mucus, making it difficult for sperm to access the uterus.

 

How effective is the Copper IUD?

Often patients want to know how effective each method of emergency contraception is, as this can help guide their decision on which method to choose. As a result, it’s useful to know some basic statistics on efficacy. However, if you’re unsure, signpost the patient to a reliable source and don’t guess!

  • “Less than 1% of women who use the copper IUD as emergency contraception will get pregnant.” ²

 

Pros and Cons of the Copper IUD

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of choosing a particular type of emergency contraception.

  •  “If it is okay with you, I’d like to tell you about the benefits and disadvantages of the Copper IUD, then hopefully you will have enough information to make a decision.”

 

Advantages of the Copper IUD

Effective contraception

  • “The Copper IUD is the most effective method of emergency contraception.”

 

Regular contraception

  • “When you have the IUD fitted, you can keep it as your regular contraception for up to 10 years.”

 

No effect on other medication

  • “The Copper IUD will not have any effect on your other medications, this makes it a good option if you are taking certain medications such as antiepileptic drugs.”

 

No hormonal content

  • “Unlike some other forms of contraception, there are no hormones in the Copper IUD.”

 

Disadvantages of the Copper IUD

Bleeding

  • “Some people may experience irregular bleeding for a few days after the fitting of the IUD.”

 

Heavier, more painful periods

  • “Your periods may be heavier, longer and more painful, especially in the first few months.”

 

Procedure required

  • A small procedure is required to insert the IUD, although this should only last around 5 minutes, some women find it quite uncomfortable.”

 

Some risks of the Copper IUD

Expulsion of the IUD

  • “Sometimes the IUD can come out without you realising. If this does happen, we can give you advice on what to do next, and we will teach you how to check that the coil is still in place.”
  • “The most likely times for this to happen are soon after insertion and/or during a period, so we typically advise to check your IUD is in place after each period, once a month.”
  • “If you were concerned the IUD might be been expelled, you would need to use an alternative method of contraception and seek review from your local GP or sexual health service.”

 

Damage to the womb

  • “When you get the IUD fitted there is a very small risk that the device might make a hole in your womb or cervix.”
  • “This is rare, occurring in around 2 in a 1000 copper IUD insertions.”
  • “If this was to happen, you may have to undergo surgery to remove the device and repair the hole.”

 

Infection

  • “There’s a small chance of you getting an infection during the first few weeks after an IUD is put in. You may be advised to have a check for sexually transmitted infections before an IUD is fitted or at the time it’s fitted.”
  • “If you were to develop an infection, you would likely notice some abdominal pain, vaginal bleeding, fever and abnormal discharge. This can often be treated with a course of antibiotics, however, in some cases, the IUD may need to be removed.”

 

Ectopic pregnancy

  • “The copper IUD is a highly effective contraceptive method, however if you do fall pregnant whilst using the copper IUD, there is a high risk that the pregnancy may have implanted outside of the womb, in the fallopian tubes, which is known as an ectopic pregnancy.”
  • “Ectopic pregnancy is potentially life-threatening and therefore if you have a positive pregnancy test whilst using the copper IUD you need to see a doctor urgently, who will assess you and arrange a scan to check the location of the pregnancy.”
  • “Your overall chance of having an ectopic pregnancy is still less than someone not using contraception.”

 

How is the Copper IUD fitted?

It is useful to explain the process in a beforeduring and after structure. This will also help you remember the key points for each step.

Before

  • “Before the copper IUD is fitted, we need to be confident you are not already pregnant. A urine pregnancy test will be performed, to check you are not pregnant.”
  • “The coil can be fitted at any time in your menstrual cycle.”
  • “Ideally, you should take some paracetamol and ibuprofen around 1 hour before the procedure, as this will help make things more comfortable.”
  • “A doctor or nurse will perform a bimanual vaginal examination, which involves placing two fingers into your vagina and one hand on your tummy to assess the position of the womb, which is important to know before inserting the device.”

 

During

  • “The nurse or doctor will insert a speculum into the vagina, to allow the neck of the womb to be visualised.”
  • “You may then choose to have some local anaesthetic injected into the neck of the womb, which can make the insertion process less uncomfortable.”
  • “A surgical instrument is then attached to control the position of the neck of the womb. There can sometimes be some discomfort when this is attached.”
  • “A small plastic tube is then passed through the neck of the womb, to check the size of the womb cavity, before being removed.”
  • “The Copper IUD is then inserted using another thin plastic tube. Once the coil is inside of the womb, the T-shaped arms open out to secure the device. As the Copper IUD is inserted through the neck of the womb, you may experience period-like cramping.”
  • “The insertion device is then removed.”
  • “Finally, the two threads of the coil will be trimmed, so that they sit high up in the vagina.”
  • “Overall the procedure should take around 5 minutes in total.”

 

After

  • “After the procedure, you may have painful cramps and light vaginal bleeding for the next few hours, so we advise resting and using painkillers as needed.”

 

Follow up

  • Patients should be told to return for a pregnancy test if they have not had a normal period within seven days of their expected next period or if they have irregular bleeding.

Early removal

  • “The IUD can be removed during your next period via a simple procedure. Should you want to have the device removed, you need to make an appointment with your GP or local sexual health clinic.”
  • “You should return for a pregnancy test if you have not had a normal period within 7 days of your expected next period, or if you have irregular bleeding.”
  • “It is important to know that if you are planning to have the IUD removed, you will need to abstain from sex or use an alternative method of contraception for the week prior to removal. This is because sperm can survive for several days in the vagina and womb and therefore there is a theoretical risk of pregnancy after removal of the device.”

 

Use of the Copper IUD as ongoing contraception

  • “The copper IUD is an effective form of ongoing contraception for up to 10 years, should you want to continue to use it.”
  • “As long as you are able to feel the threads yourself in a months time, you do not need to come back for a review. If however, you are unable to feel them, you will need to book an appointment.”
  • “You should return for a pregnancy test if you have not had a normal period within 7 days of your expected next period, or if you have irregular bleeding.”
  • “The coil lasts for 10 years when used for contraception, so you would need to have the device replaced or use an alternative method of contraception once the expiry date is reached.”

 

How do I check the Copper IUD threads?

“A copper IUD has one or two threads attached to the end that hang a little way down from your womb into the top of your vagina. The nurse or doctor will tell you how many threads there should be.”

The patient should be shown how to check the Copper IUD threads using a test device, to allow them to get an idea of what the threads should feel like.

“We would advise checking you can feel your threads a few times in the first month and that at regular intervals each month (e.g. after your period). If you were concerned the coil might be been expelled (e.g. you can’t feel the threads), you would need to use an alternative method of contraception and seek review from your local GP or sexual health service.”

 


The Emergency Contraceptive Pill with Ulipristal Acetate (EllaOne)

The only emergency contraceptive pill with Ulipristal Acetate (UPA) sold in the UK is EllaOne. Explain to the patient that EllaOne is a tablet which should be taken within 120 hours of unprotected sex.

  •  “EllaOne has an ingredient called Ulipristal Acetate. It is just one pill that should be taken within 5 days after having unprotected sex.”

 

How effective is EllaOne?

  • “EllaOne has been proven to be more effective than the other commonly used emergency contraceptive pill (Levonorgestrel). However, around 1-2% of women who take EllaOne will still fall pregnant.” ³

 

Pros and Cons of EllaOne

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of choosing EllaOne.

  •  “If it is okay with you, I’d like to tell you about the benefits and disadvantages of EllaOne, then hopefully you will have enough information to make a decision.”

 

Advantages of EllaOne

Can be taken within 5 days of unprotected sex

  • “EllaOne can be taken up to 5 days after unprotected sex, however, we advise that you try to take the pill as soon as possible.”

 

No procedure needed

  • “There is no procedure needed when taking the EllaOne pill for emergency contraception.”

 

Very few side effects

  • “There are very few side effects from EllaOne and most people don’t experience any side effects at all.”

 

Disadvantages of EllaOne

Nausea and vomiting

  • “Some people may feel sick and rarely, some people may vomit after taking EllaOne. If you vomit within 3 hours after taking the pill, then please come back and speak to us as you may need another dose.”

 

Changes to next period

  • Your next period may be earlier or later than expected after taking EllaOne. If you don’t have a period within 1 week of the expected time, then we would recommend that you take a pregnancy test.”

 


The Emergency Contraceptive Pill with Levonorgestrel

The emergency contraceptive pill with levonorgestrel contains progesterone and should be taken within 72 hours of unprotected sex.

  •  “The emergency contraceptive pill with levonorgestrel is a pill that contains a type of progesterone which is similar to the natural hormone that is produced by the ovaries. It can be taken within 3 days of unprotected sex.”

 

How effective is the Emergency Contraceptive Pill with Levonorgestrel?

  • “Around 1% to 2.6% of people become pregnant after taking the emergency contraceptive pill with levonorgestrel.”

 

Pros and Cons of the Emergency Contraceptive Pill with Levonorgestrel

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of using the emergency contraceptive pill with levonorgestrel.

  •  “If it is okay with you, I’d now like to tell you about the benefits and disadvantages of the emergency contraceptive pill with levonorgestrel, then hopefully you will have enough information to make a decision.”

 

Advantages of the Emergency Contraceptive pill with Levonorgestrel

No procedure needed

  • “There is no procedure needed when taking the pill with levonorgestrel for emergency contraception”

 

Very few side effects

  • “There are very few side effects from taking the contraceptive pill with levonorgestrel and most people don’t experience any side effects at all.”

 

Disadvantages of the Emergency Contraceptive pill with Levonorgestrel

Nausea and vomiting

  • “Some people may feel sick and rarely, some people may vomit after taking the pill. If you vomit within 3 hours after taking the pill, then please come back and speak to us as you may need another dose.”

 

Changes to next period

  • Your next period may be earlier or later than expected after taking the pill with levonorgestrel. If you don’t have a period within 1 week of the expected time, then we would recommend that you take a pregnancy test.”

 

Shorter window to take the pill than other emergency contraception

  • “The emergency pill with levonorgestrel can only be taken within 3 days after unprotected sex, whilst the other emergency contraceptive methods can be used within 5 days.”

 

High BMI issues

  • “If you have a BMI of over 26, you may need to seek advice about increasing the dose of levonorgestrel.”

 


Closing the Consultation

  • Ask the patient if they have any further questions or concerns that haven’t been addressed.
  • Throughout the consultation you should check the patient’s understanding at regular intervals, using phrases such as “Can you just repeat back to me what we’ve just discussed regarding…”.
  • It may also be useful to quickly summarise what you have spoken about and direct the patient to any websites or leaflets with further information.
  • Make it clear that it is entirely the patient’s choice on what contraception she would like, and offer her time to think about her decision.
  • Encourage the patient to use condoms if is she is currently not using any contraception and is sexually active.
  • Thank the patient for her time.

 


Frequently Asked Questions

How will I know if the emergency contraception has worked?

The only way to be sure if emergency contraception has worked is by either taking a pregnancy test or having a normal period. It is recommended that a pregnancy test should be taken if:

  • The patient feels like they are pregnant
  • The patient has not had a period within three weeks of having the emergency contraception
  • If a hormonal method of contraception was started soon after using emergency contraception

 

Can I take an emergency contraceptive method more than once?

The same type of emergency contraceptive pill can be taken more than once in the same menstrual cycle, however, a different pill may not be taken. If the patient still has the emergency copper IUD fitted, then they should be protected from pregnancy for up to 10 years.

 

What should I do about taking other contraception?

If the regular pill or patch was forgotten or used incorrectly, then the regular pill should be taken or new patch applied within 12 hours of taking the emergency contraception with levonorgestrel or 5 days after taking EllaOne (additional contraception such as condoms should be used during this 5-day time period).

Additional contraception should be used for 7 days after if using the combined pill or patch, or for 2 days with the progesterone only pill.

 


Summary of Emergency Contraceptive Methods

 Emergency Copper IUDEllaOneEmergency Contraceptive Pill with Levonorgestrel
Mode of Action
  • Plastic and copper coil
  • An inhibitory effect on both fertilisation and implantation
  • Delays ovulation for 5 days or more
  • Inhibits ovulation and causes luteal dysfunction ³
Advantages
  • Non-hormonal
  • Can be used as regular contraception for up to 10 years
  • Can be inserted up to 5 days following unprotected sex
  • No long-term side effects
  • No procedure needed
  • Can be taken up to 5 days after unprotected sex
  • No long-term side effects
  • No procedure needed

 

Disadvantages
  • An uncomfortable procedure needed to fit the IUD
  • Period type pain and bleeding are common a few days following fitting

 

  • Less effective than the emergency contraceptive IUD
  • May affect the next period
  • Can only be taken up to 3 days after unprotected sex
  • May affect the next period
  • Less effective than other emergency contraceptive methods
Risks
  • Small risk of infection, perforation and expulsion
  • Vomiting and headaches
  • Vomiting and headaches
Cautions
  • Use with caution in those with severe asthma
  • Use with caution in those with a BMI of more than 26 or a weight of more than 70 kg
Contraindications
  • Less than 28 days following giving birth
  • Less than 5 days following a miscarriage or abortion
  • Active sexually transmitted infection
  • Less than 21 days following giving birth
  • Less than 5 days following a miscarriage or abortion
  • Less than 21 days following giving birth
  • Less than 5 days following a miscarriage or abortion

 


References

1. FPA.org.uk. (2018). Your guide to emergency contraception [online] Available at: https://www.fpa.org.uk/sites/default/files/emergency-contraception-your-guide.pdf [Accessed 20 Jan. 2019].

2. NHS UK. (2018). Your contraception guide [online] Available at: https://www.nhs.uk/conditions/contraception/emergency-contraception/?tabname=methods-of-contraception#at-a-glance-facts-about-emergency-contraception [Accessed 20 Jan. 2019].

3. FSRH (2017). FSRH CEU Clinical Guidance: Emergency Contraception [online] Available at: https://www.fsrh.org/standards-and-guidance/documents/ceu-clinical-guidance-emergency-contraception-march-2017/ [Accessed 20 Jan. 2019].


 

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