Access to all forms of contraception remains critical to ensure youths can navigate the developmentally expected transition to sexual activity while achieving their reproductive and life goals.
The term emergency contraception (EC) refers to methods of contraception that are used after intercourse to reduce the chance of pregnancy. EC use is indicated in circumstances including intercourse without contraception use; condom breakage or slippage; missed or late doses of contraceptives, including the oral contraceptive pill, contraceptive patch, contraceptive ring and injectable contraception; vomiting after taking oral contraceptive pills; and sexual assault.
Methods of EC available in the U.S. include two dedicated oral emergency contraceptives (ulipristal acetate and levonorgestrel), copper intrauterine device (IUD) and off-label use of oral contraceptives (Yuzpe method).
The updated AAP policy statement Emergency Contraception from the Committee on Adolescence highlights what pediatricians need to know to ensure their patients have access to EC when needed and to advocate for policies supporting access. The policy is available at https://doi.org/10.1542/peds.2019-3149 and will be published in the December issue of Pediatrics.
EC effectiveness
While not available in most pediatric offices, insertion of a copper IUD within five days of unprotected intercourse is the most effective EC method and has the added benefit of providing ongoing contraception.
For adolescents who need EC but do not desire or have access to a copper IUD, ulipristal acetate or levonorgestrel should be recommended. These oral emergency contraceptive pills (ECPs) may be used up to 120 hours after intercourse. However, they are effective only if taken prior to ovulation, so use as soon as possible is critical.
Repeated acts of unprotected intercourse within the same menstrual cycle are the most likely reason for pregnancy after EC use.
Data also indicate that both ulipristal acetate and levonorgestrel may be less effective in individuals with overweight. However, concern about decreased effectiveness based on a patient’s weight should not prevent ECP use. The policy states that young people who do not wish to use a copper IUD or do not have access to IUD insertion should be offered EC pills regardless of their weight.
Ongoing hormonal contraceptives may be initiated immediately after use of levonorgestrel ECPs; however, they should not be initiated sooner than five days following use of ulipristal to minimize the risk of interference with ulipristal’s activity. Nonhormonal methods (e.g., condoms) may be initiated immediately following ECP use.
Adolescents need to be aware that other methods of contraception, including IUDs, implants, injectables, pills, patches and rings, are more effective at preventing pregnancy than EC if used correctly. Importantly, it also should be emphasized that intercourse without condoms is a risk for sexually transmitted infections.
Improving access
Ulipristal acetate is available by prescription only. Studies have shown that many pharmacies do not stock it, creating an additional barrier.
In 2013, the Food and Drug Administration approved the sale of levonorgestrel EC without a prescription regardless of age. Secret shopper studies indicate that some pharmacies continue to enforce age restrictions, and the cost of the over-the-counter product can be prohibitive.
To help mitigate access barriers and promote timely use, the policy recommends providing patients with EC before they need it through direct provision or prescription, for example at routine and contraceptive visits. Pediatricians also have an important role in advocating for policies that promote affordable access to EC without age restrictions.
Pediatricians who provide care to adolescents in any setting, including primary care, emergency departments and hospitals, can play a crucial role in promoting positive sexual and reproductive health outcomes. EC is one tool available to prevent pregnancy, and information about EC should be included as a part of counseling about pregnancy and sexually transmitted infection prevention in all settings.
Dr. Upadhya is the lead author of the policy statement and a member of the AAP Committee on Adolescence.
