EHC currently involves a single dose of levonorgestrel at 1.5mg. EHC prevents ovulation and does not have any detectable effect on the endometrium or progesterone levels when given after ovulation. EHC is not effective once the process of implantation has begun.
Levonorgestrel was licensed in 1999 as Levonelle-2 (aprescription only medicine, POM) and Levonelle (for pharmacy supply). Both versions comprised two tablets, each containing 750 mcg of levonorgestrel. This was based on randomised controlled trials (RCTs) which showed efficacy of a regime of two 750 mcg levonorgestrel tablets taken 12 hours apart, within 72 hours of unprotected sexual intercourse.
Subsequently, a RCT in 2002 found that there was no difference in efficacy when comparing a divided dose (two 750 mcg tablets) and a single dose of levonorgestrel (1.5mg). The conclusion was that giving a single dose simplified treatment without an increase in side effects. In October 2004, Levonelle was discontinued and replaced by Levonelle One-Step (single 1.5 mg dose). Levonelle-2 was replaced by a Levonelle 1500 (single 1.5 mg dose) in November 2005.
The exception is for women who are taking enzyme-inducing drugs. The Clinical Effectiveness Unit (CEU) of the Faculty of Family Planning and Reproductive Healthcare recommends repeating the 1.5 mg dose at 12 hours. No studies have been found to confirm that this dose increase is required, and women should be made aware that this advice is based on clinical judgement and is outside of the product licence. Women should always be offered the alternative of a copper intrauterine device (IUD), which is unaffected by concomitant drug use.
Pharmacy based EHC provision is promoted in the UK National Strategy for Sexual Health and HIV in order to try to improve access to EHC. A qualitative study published this month explored pharmacists' views on the supply of EHC via patient group direction (PGD) in the UK. The PGD does include the importance of encouraging women to seek advice about long-term contraception, and advice is also given about sexually transmitted infections (STIs).
Pharmacists were broadly very positive about their experiences supplying EHC.
Benefits identified by pharmacists included:
Concerns identified by pharmacists included:
A study published in October 2005 explored the use of EHC from the perspective of users. The study was qualitative and conducted with women presenting for EHC to one of three health care settings in Melbourne, Australia. Thirty-two women ranging in age from 18 to 45 years were interviewed. The paper identifies the four typical "types" of users of EHC.
A study published in the British Medical Journal (BMJ) in July 2005 analysed data on contraceptive practice for women aged 16-49 years in the period 2000-2. The data was taken from the Omnibus Survey, a multipurpose survey in which around 7,600 adults living in private households in the UK are interviewed each year.
After EHC was made available over the counter (OTC), levels of use of different types of contraception by women aged 16-49 remained similar. No significant change occurred in the proportion of women using EHC or having unprotected sex. A change did occur in where women obtained EHC; a smaller proportion of women obtaining EHC from doctors and a greater proportion buying it OTC. In 2001 7.9% of women using EHC and 19.7% bought it over the counter (OTC). In 2002 7.2% used EHC and 32.6 bought it OTC.
Women who bought OTC EHC tended to be older, wealthier and single. No significant change occurred in the proportion of women using more reliable methods of contraception or in the proportion of women using EHC more than once during a year. Of note is that the survey did exclude women under the age of 16 years and did not consider free supply of EHC under PGD.
References:
Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit.
FacultyStatement on Levonelle 1500 and the use of liver enzyme inducing drugs. November 2005.
World Health Organization. Levonorgestrel for emergency contraception. October 2005.
Bissell P, Savage I, Anderson C. A qualitative study of pharmacists' perspectives on the supply of emergency hormonal contraception via patient group direction in the UK. Contraception 2006; 73: 265-270.
Marston C, Meltzer H, Majeed A. Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional surveys. BMJ 2005; 331: 271.
Keogh L A. A qualitative study of women's use of emergency contraception. J Fam Plann Reprod Health Care 2005; 31: 288-293.