PIWH A Clinician's Guide to Providing Emergency Contraceptive Pills

Publication date: 2000

in partnership with the Family Planning Council of Southeastern PA California Family Health Council and in collaboration with AVSC International Reproductive Health Technologies Project Medical Students for Choice National Family Planning and Reproductive Health Association American Medical Women’s Association PATH (Program for Appropriate Technology in Health) a clinician’s guide to providing emergency contraceptive pills mary ann castle, PhD francine coeytaux, MPH a clinician’s guide to providing emergency contraceptive pills 2 3 CONTENTS I. About This Guide 5 II. What is Emergency Contraception? 6 III. Before You Start Providing ECPs 8 IV. Policies 10 V. Organizational and Management Issues 11 VI. Staff Training Needs 14 VII. Special Situations 16 VIII. Establishing Billing and Insurance Procedures 21 IX. Sample Telephone Screening Protocol 22 X. Instructions For Use 24 References 26 Additional Resources 28 Acknowledgements 31 “I consider this very timely quide essential for all clinicians, including pediatricians. It will serve to popularize ECPs among providers, a necessary phase of increasing public interest and putting knowledge within reach of more women.” Helen Rodriquez-Trias md, faap, pediatrician-consultant in health programs “I applaud the Pacific Institute for Women’s Health for this excellent handbook that guides health care providers, administrators, and other site staff on important service delivery issues that should be addressed if emergency contraception is to become more available and accessible.” Vanessa Cullins md, mph, mba, facog, vice-president and medical director, avsc international “This Guide is excellent and should be of great help to clinicians who are prepared to offer this important service to their patients.” Allan Rosenfield md, dean, mailman school of public health, columbia university “I look forward to sharing this guide with colleagues in school-based health clinics, Adolescent Medicine programs, and teen out-reach programs. Linda Prine md, medical director, sidney hillman family practice and faculty, beth israel medical center “This guide provides the practical, specific help clinicians and managers need to implement emergency contraception services successfully. Overcoming simple pragmatic obstacles is a crucial part of making this option actually useful and accessible for the many women and men who might appropriately take advantage of a “second chance” to avoid pregnancy.” Felicia H. Stewart md, co-director, center for reproductive health research & policy, and faculty, ucsf “Nurse practitioners have played a key role in advancing access to emergency contraception. This guide will help them and all clinicians enter into conversations with clients about this essential and important contraceptive option.” Linda Dominguez rnc, np, assistant medical director, pp of new mexico, and chair elect, national association of nurse practitioners in women’s health I. ABOUT THIS GUIDE This guide is intended to help clinicians incorporate the provision of Emergency Contraceptive Pills (ECPs) in their practices, whether working in clinic settings or in private practice. Addressing in advance a few critical management issues will greatly assist in easily integrating ECPs into routine practice. It is our hope that this guide will support practitioners who have elected to make this important option available to clients. Recommendations made in this guide are based on research conducted by the Pacific Institute for Women’s Health in collaboration with the Family Planning Council of Southeastern Pennsylvania and the California Family Health Council. Clinicians and staff of a variety of clinic and hospital settings in Philadelphia shared with us their experiences with the provision of ECPs to diverse populations.1 We developed the guide using their experiences and earlier research conducted with women who had used ECPs at Planned Parenthood of New York City.2, 3 The guide was field tested among twenty clinicians practicing in Los Angeles and several dozen clinicians and directors of reproductive health programs from throughout the country reviewed the draft. 5 II. WHAT IS EMERGENCY CONTRACEPTION? Emergency contraception is a form of contraception that can be used immediately after sexual intercourse but before preg- nancy is established. It is intended for emergency situations such as unprotected intercourse, contraceptive failure or rape. Emergency contraceptive pills (ECPs) prevent pregnancy by delaying ovulation, inhibiting fertilization and/or preventing implantation.4, 5, 6, 7 They are most effective when taken within 72 hours (3 days) after unprotected intercourse. ECPs should not be confused with abortifacients. In fact, ECPs will not be effective if a pregnancy is already established. Two ECP products, Preven™ and Plan B™, are now being marketed in the U.S. Preven™ consists of four pills of com- bined estrogen and progestin. Women take the first two pills as soon as possible after unprotected intercourse, followed by the second two pills 12 hours later. Plan B™ consists of two progestin-only pills (levonorgestrel) also taken in a 12-hour interval. In addition to being more effective, the progestin-only pills have greatly reduced side effects (less nausea and vomiting). As an alternative to the specially packaged ECPs, certain high- dose or low-dose contraceptive pills can be repackaged in small bottles or other suitable containers and dispensed with instructions for emergency use. This is called the Yuzpe regimen. The repackaged pills also require taking two doses at a 12 hour interval. (See Table 1 on pg. 22.) The combined estrogen/progestin pills, when taken correctly, reduce the risk of pregnancy by 75% for a single act of unprotected intercourse. Progestin-only pills reduce risk by 89%. New evidence shows that the sooner ECPs are taken, the more effective they are, with a sharp decrease in effectiveness after 72 hours.8 Emergency contraception can also be provided by insertion of an IUD up to 5 days after unprotected intercourse. It is more effective than pills, and may be a good option for women who would like to use the IUD as an ongoing method of birth control and are not at serious risk for infection.9 The History of ECPs In the early 1970s, gynecologists and researchers began exploring the possibility of using birth control pills to avoid pregnancy after sex (post-coital contraception). Feminist clinics, a few Planned Parenthood affiliates and college campus health centers began to offer the "morning-after pills" to women who had had unprotect- ed sex. The common approach was to cut up packets of birth control pills and give the required number of pills to women with instructions on their use. But due to misconceptions about its safety and concerns about possible overuse, the method languished and few other providers or women knew about it. Not until the 1990s did the “morning-after pill” move from limited awareness and availability of cut-up packets of birth control pills to FDA-approved emergency contraception.10 In February 1997, the FDA declared six brands of oral contraceptives to be safe and effective for emergency contraception and today we have two emergency contraception products on the market: Preven™ and the progestin-only product, Plan B™. 6 7 QUESTIONS TO CONSIDER YES NO • Will you refer clients requesting ECPs after hours? • Can you schedule “emergency” clients within the 72 hour time limit for effectiveness? • Do you have sufficient staff to provide counseling, education and follow-up for clients? • Can your practice serve more clients? Will providing ECPs expand your practice? • Are there other health services that would refer ECP clients to your practice? • Do you share a practice or office space with clinicians who are opposed to offering contraceptive services or who are opposed to emergency contraception? Does your staff share these opinions? • Are the ECPs you are prescribing available in the local pharmacies? III. BEFORE YOU START PROVIDING ECPs Here are some questions you might want to address before providing ECPs. Issues you need to address: After-hours access - Because ECPs are more effective the sooner treatment is started, you may need to have referral procedures in place to serve your clients on weekends and after hours when your office is closed. Referrals could include other physicians or clinics with different hours, emergency rooms, and, in some states, certain pharmacies. It is best to have checked with other providers and to establish protocols informing clients who to see and where to go for after-hours assistance. Emergency rooms are one possible source. But be sure to verify that they do provide ECPs because not all emergency rooms across the nation offer ECPs, even to women who have been raped. Dispensing/Prescribing - Physicians, Physician Assistants, Nurse Practitioners and Nurse Midwives may all be able to prescribe and dispense ECPs. Some clinics allow nurses to dispense ECPs under the supervision of a Physician. Clarification of state regula- tions regarding prescriptive authority of nurses should be sought. Pharmacist cooperation - Identify local pharmacists who will fill ECP prescriptions. Some clinicians have met with pharmacists to inform them that ECPs are FDA approved, effective in preventing unwanted pregnancies, and have few side effects. In some parts of the U.S., misinformation, confusion or ideological opposition has resulted in some pharmacists refusing to fill ECP prescrip- tions. Most pharmacies will dispense ECPs if they think there is a local demand. Have a plan if local pharmacists refuse to fill the prescriptions. Some clinicians have chosen to directly dispense ECPs to their clients. Pricing - Ask your local pharmacists about pricing (from which you can make a chart for the office staff and your clients). The cost of ECPs in the pharmacies range from $18-$50.11 Prices can often be lowered by quoting the competition. 8 9 IV. POLICIES There are policies and procedures you will need to establish before initiating your ECP service. V. ORGANIZATIONAL AND MANAGEMENT ISSUES The following is a list of organizational and management issues you will need to address in order to deliver quality ECP services. Ensuring your clients access to ECPs when they need it: ä Establish procedures for fitting walk-in or call-in clients into the daily schedule. To be effective, ECPs must be taken as soon as possible after unprotected sex or rape. ä Establish a phone-in ECP protocol and train the receptionist to avoid delaying care for women who need to obtain pills immediately. ä Consider providing ECP prescriptions or pills in advance to your regular clients as a backup if their birth control method fails or they have unprotected sex. ä Establish a referral system for clients calling in for ECPs during off-hours, weekends, and holidays. ä Consider prescribing ECPs by telephone (See Section IX). Because a physical exam and pregnancy test are not necessary prior to treatment, ECPs can be provided to clients upon request by telephone. ä Consider establishing standing orders to allow staff to provide ECPs in your absence. Time Management: ä Staff should be prepared to see walk-in clients (new and old) in order to serve women requiring immediate care (pills must be taken as soon as possible after unprotected sex or rape and within 72 hours.) ä As with the introduction of any new product, staff will initially need to spend more time to counsel and inform clients. 10 11 THINKING ABOUT POLICIES YES NO Will you offer ECPs: • To women of all ages including adolescents? • As part of your patients’ general reproductive health care education? • To women who are not your regular patients? • To men? Will you provide ECPs: • By dispensing prescriptions? • By dispensing pills? • By prescription over the phone? • In advance, “just in case”? To rule out pregnancy will you: • Be satisfied with a brief, self-administered medical history (as opposed to a physical exam and/or pregnancy test? Note: These are not recommended.)11 • Require that a medical history form be reviewed by a nurse practitioner or clinician before ECPs are provided? Supplies: ä If you choose to repackage birth control pills, you will need to ensure sufficient supplies of pills as well as clear, comprehen- sive, written information about how to use the pills. Note: Be aware that state regulations about repackaging differ. ä Do you have supplies of: nn repackaged pills? nn Preven™? nn Plan B™? ä Do you have enough supplies to offer clients a sample in advance of need? ä Do you have supplies and/or samples of anti-nausea medica- tion to manage side effects? Counseling needs: ä Provide your clients with comprehensive instructions and infor- mational materials about ECPs. Have on hand materials appro- priate for your clientele – in different languages, appropriate reading levels, and for special populations such as teens, men, women with special needs, and rape victims. ä Counsel clients about potential side effects. The most common side effects of ECPs are nausea and vomiting. These effects do not typically last more than 24 hours and may be reduced by providing anti-nausea medication before taking ECPs. (Note: In the progestin-only pills these side effects are significantly lowered.) ä Remind your clients that ECPs do not provide protection against sexually transmitted diseases. ä Review with clients the early symptoms and signs of STDs and emphasize the need to use condoms to protect against STDs and HIV. ä Underscore the need for effective contraception (other than ECPs). ä Encourage clients to return for follow-up care in order to obtain an ongoing contraceptive method and/or to be tested for possible infection. ä Counsel clients that if they do not have a menses within 3 weeks of taking ECPs, they need to follow up for possible preg- nancy. ä Inform clients where to go should the ECPs fail and they become pregnant. If you do not perform abortions, have a list of referrals to local clinics or physicians who provide pregnancy counseling, perform abortions (surgical or medical) and pro- vide prenatal care. ä If you decide to prescribe ECPs in advance (as a backup method should they be needed in the future) carefully describe their correct usage and only prescribe them to clients interest- ed in having them. The use of ECPs by regular contraceptive users can be confusing. For example, oral contraceptive users who miss taking some pills do not need ECPs but rather need to be instructed on how to get back on schedule. ä Provide referrals for crisis intervention for rape victims and women who have been abused. 12 13 VI. STAFF TRAINING NEEDS Q: Who should be trained? A: Experience has shown that it is important for all staff to receive training. This includes the receptionist or telephone operator who has first contact with ECP clients. Q: What should be included in training? A: In addition to being trained to provide counseling and instruc- tions in a supportive and confidential manner, all staff need to be knowledgeable about: ä The need for and benefits of ECPs ä ECPs’ mode of action ä How to use ECPs ä The urgency to provide the method as soon as possible within 72 hours after unprotected intercourse ä Medical contraindication (pregnancy) Note: women who cannot take estrogen should use progestin-only regimen. ä Side effects and how to respond to calls about side effects (most often nausea and vomiting) ä Prevention of STDs and HIV ä Emergency contraceptive pill options (Preven™, Plan B™ and repackaged oral contraceptive pills) ä Correct usage when already using other contraceptive methods ä The client’s heightened anxiety about avoiding pregnancy and obtaining ECPs ä Issues related to abuse and violence ä Follow-up and referrals ä To ensure clients’ rights to privacy, train all staff, including telephone operators and receptionists to maintain strict confidentiality for ECP clients. Q: What are your staff’s attitudes about ECPs? A: In addition to educating staff about ECPs, it is important to offer providers and staff an opportunity to discuss their con- cerns and attitudes regarding the mode of action and safety of ECPs. One effective strategy for staff development is to invite a clinician who already prescribes ECPs to come discuss his/her experience with your staff prior to initiating an ECP service. Q: What are some common concerns and misconceptions staff might have about ECPs? A: Some staff may believe that ECPs are abortifacients. ECPs should not be confused with mifepristone (i.e. the “French abor- tion pill” or RU 486). Staff with religious beliefs that make them unable to support abortion may be resistant to an ECP service because of beliefs that emergency contraception is abortion. A description of the mode of action will go far to correct misinfor- mation. ECPs are most effective within three days after inter- course and are not effective if implantation has occurred. Reinforce that staff have responsibilities to clients who hold dif- ferent beliefs, who need and request ECPs, and who deserve the highest quality of care and strict confidentiality. Providers frequently fear that clients (particularly teens) will repeatedly take ECPs or use them as a regular contraceptive. Research has shown that few women repeatedly request ECPs.12, 13 This information considerably diminishes the concerns of providers and staff. Alleviate this concern by providing informa- tion about the effectiveness of other contraceptives as com- pared to ECPs. 14 15 VII. SPECIAL SITUATIONS What if a client requests ECPs 73 (or more) hours after sexual intercourse without contraception or with contraceptive failure or rape? ECPs are not as effective after 72 hours but could still be used. Assess the pregnancy risks with the client to assist her in making an informed decision about whether or not to use ECPs and stress the fact that the pills may not be effective in preventing pregnancy. What if an adolescent who is requesting ECPs does not want her parents to know? Staff are often distressed by adolescent sexuality. An adolescent’s request for ECPs may be the first major autonomous decision in her life. Adolescents’ rights to contraception and confidentiality are protected in most states (see note below) and must be respected. In addition to providing ECPs, staff should also view this as an opportunity to counsel her about contraception, STDs, HIV and general reproductive health. Urge her to come back for follow-up and continued care (both contraceptive and testing for STDs). Discussing ECPs with adolescents requires a flexible and creative approach and should cover a wide range of issues of importance to them. Staff must take into account the developmental stage of the individual teen when counseling. Teens are not always in a position to control their sexual lives and staff need to be trained to recognize possible cases of sexual abuse. Time should be taken to discuss not only her risks of getting pregnant should she continue to have unprotected intercourse but also her risks of contracting a sexually transmitted disease. Staff also need to have dealt with their own attitudes regarding teen sexuality and ECPs. For example, staff may believe that teens who use ECPs will be less likely to use regular contraceptives but research findings do not bear this out.1, 13 What if a woman who is disabled requests ECPs? ECPs are a suitable contraceptive option for some women with special needs. Staff must be reminded that women with disabilities have equal rights to a full range of reproductive health care services, including ECP services. This is particularly important for women who may not have information about available options. Avoid making assumptions about the ability, or lack of ability, of women with special needs to have control over their reproductive lives and to act on their decisions regarding contraception. What if a woman requesting ECPs indicates that she had sex without contraception because she was raped? Anyone requesting ECPs – and particularly women who have been raped – should be served immediately. Concerns about providing ECPs to women who are raped stems from the fact that most 16 17 Important Note: Adolescents’ right to confidentiality with regard to reproductive health care is protected by law in some states. Some states have laws requiring parental involvement in a minor’s abortion decision. ECPs are not abortifacients and those laws do not apply to ECPs. (Note: go to www.crlp.org for legal information regarding ECPs) providers cannot offer the other services that should be available from emergency room staff who has been trained in collecting rape evidence or in writing reports for legal cases. However, because rape is often perpetrated by relatives, friends and acquaintances, victims are frequently reluctant to go to an emergency room for fear that they will have to officially report the incident. They may also be embarrassed or ashamed and fear they will be blamed for the rape. Staff need to recognize that some clients requesting ECPs may have been victimized, requiring a particularly sensitive, yet non- intrusive, approach. They need to be trained to recognize such situations and know how to proceed when caring for clients who have been abused. Be prepared to inform rape victims of services that are available in an emergency room and provide them with referrals to victims’ services, crisis centers and safe havens. (Note: Not all emergency rooms provide ECPs to rape victims.) If the victim is reluctant to report the rape, her needs for ECPs, contraception and screening/treatment of STDs still must be addressed. Most states mandate the reporting of abuse against minors. (Note: Rape victims should also be encouraged to have follow-up counseling and to develop safety plans.) What about the risk of STDs or HIV/AIDS, especially for women who have been raped? Any act of unprotected intercourse can put a woman at risk of contracting a sexually transmitted disease (STD). Given the high prevalence of STDs in the United States, all women using ECPs should be counseled about their risks of contracting STDs, including HIV. The fear of contracting an STD (and HIV in particular) may be acute among clients whose requests for ECPs are the result of sexual assault and must be addressed. Point of Information: Although the risk of acquiring HIV from a sexual assault has been reported to be generally low,14 staff must be prepared to refer clients and help them gain rapid access to testing and treatment to minimize the risk of harmful social, psychological, and physical consequences of the exposure, including HIV transmission. Risks are more likely if the woman has an STD or trauma to mucosal tissue.15, 16 Be prepared to discuss the potential health and mental health issues with the client. Information on counseling, testing and treatment for STDs should also be provided. What if men request ECPs? Special attention and education should be paid to men requesting ECPs. Consider using the opportunity to encourage them to use regular contraception and prevent the spread of STDs by using condoms. Have available information and materials specifically designed for men and hand out condoms when appropriate. 18 19 What if a woman who used ECPs informs you that the pills were not effective and she is pregnant? A woman who becomes pregnant after having used ECPs needs to be counseled about her options. Reassure her about the safety of ECPs if she chooses to continue the pregnancy. There is no evidence that ECPs negatively affect fetal development.17, 18 If you cannot provide the services she will need (whether prenatal or abortion services) provide information, including names and telephone numbers, of clinicians/clinics where she can obtain appropriate pregnancy counseling and services including abortion. VIII. ESTABLISHING BILLING AND INSURANCE PROCEDURES Questions to consider in establishing billing and reimbursement procedures: ä What will you charge for an ECP visit? ä If you decide not to use the marketed products, such as Preven™ or Plan B™, what will you charge for repackaging and distributing birth control pills? ä How will you bill? ä Which insurance plans cover ECPs? (This varies by plan and by state). ä What forms do your staff need to complete? ä How will you integrate procedures for record keeping and reporting into your existing data system? ä How will you document client visits? nn Follow-up visits? nn Referrals? nn Emergencies? nn Phone Rx? ä How will you ensure clients’ confidentiality? Important: Outgoing bills should not include any reference to ECPs, particularly in the case of adolescents. 20 21 Ways to do outreach and publicize your ECP services: • Make ECP materials available in your clinic • Register your service on the National EC Hotline (call 1-888-NOT2LATE to register) • Inform other professionals and health care providers in the community about your services • Establish back up and emergency services for ECPs with other organizations and professionals • Include local high schools and college campuses in your outreach plan • Advertise your ECP service • Discuss this option with clients in advance of need 22 23 IX . S A M P LE T E LE P H O N E S C R E E N IN G P R O T O C O L Sc re en in g Q ue st io ns : 1. H av e yo u ha d un pr ot ec te d se x du rin g th e la st t hr ee d ay s? nn Ye s nn N o D at e( s) : Ti m e( s) : a. m ./ p. m . 2. W he n w as t he fi rs t da y of y ou r la st m en st ru al p er io d? D at e: Is t hi s le ss t ha n 4 w ee ks a go ? nn Ye s nn N o 3. W as t hi s pe rio d no rm al in b ot h its le ng th a nd t im in g? nn Ye s nn N o If t he r es po ns e is Y es to a ll th re e qu es tio ns , y ou m ay p re sc ri be E C Ps o ve r th e te le ph on e. If t he r es po ns e to a ny o f t he q ue st io ns is N o, o r yo u su sp ec t th at t he s ex ua l h is to ry m ay b e in ac cu ra te , t he pa tie nt m ay s til l b e el ig ib le fo r EC Ps b ut w ill r eq ui re a p re gn an cy t es t fir st . T he p at ie nt m ay p er fo rm t hi s te st a t ho m e us in g a co m m er ci al k it an d re po rt t he r es ul ts t o th e cl in ic b y te le ph on e, o r sh e m ay c om e in t o th e cl in ic fo r a te st . If t he r es ul t of t he t es t is n eg at iv e, y ou m ay p re sc ri be E C Ps . T he p at ie nt s ho ul d be in fo rm ed t ha t sh e m ay b e pr eg na nt b ut it m ay b e to o ea rl y fo r th e te st t o de te ct t he p re gn an cy . I n th at c as e th e EC Ps w ill n ot p re ve nt th e pr eg na nc y no r ar e th ey li ke ly t o ca us e an y ha rm t o it. If t he r es ul t of t he t es t is p os iti ve , a dv is e th e pa tie nt o f h er o pt io ns . R ef er ra l Q ue st io ns : 4. W om en w ho a re a t ris k of p re gn an cy m ay a ls o be a t ris k fo r se xu al ly t ra ns m itt ed d is ea se if t he y ha ve h ad s ex w ith a n ew p ar tn er o r a pa rt ne r w ho h as h ad s ex w ith a no th er p er so n. W ou ld y ou li ke a r ef er ra l f or S TD s cr ee ni ng ? nn Ye s nn N o 5. Em er ge nc y co nt ra ce pt io n is n ot a s ef fe ct iv e as a ny o th er m et ho d of c on tr ac ep tio n fo r lo ng -t er m u se . A re y ou in te re st ed in le ar ni ng a bo ut o ng oi ng c on tr ac ep tio n? nn Ye s nn N o If t he r es po ns e to e ith er o f t he se q ue st io ns is Y es ,p ro vi de t he p at ie nt w ith a n ap pr op ri at e re fe rr al fo r ST D sc re en in g an d/ or o ng oi ng c on tr ac ep tio n. If y ou r si te d oe s no t re fe r to lo ca l p ro vi de rs o f t he se s er vi ce s, o r if th e pa tie nt is n ot in y ou r ar ea , s he c an ca ll 1- 80 0 -2 30 -P LA N t o m ak e an a pp oi nt m en t w ith t he n ea re st P la nn ed P ar en th oo d. If t he r es po ns e to e ith er q ue st io ns is N o, th e pa tie nt s ho ul d be in fo rm ed t ha t sh e ca n ca ll ba ck fo r a re fe rr al if s he c ha ng es h er m in d. R ep rin te d w ith p er m is si on fr om P AT H , S ea tt le , W as hi ng to n. 24 25 X . I N S T R U C T IO N S F O R U S E H ow t o Ta ke E C P ä Sw al lo w t he fi rs t do se n o la te r th an 3 d ay s (7 2 ho ur s) a ft er y ou ’v e ha d se x. ä Sw al lo w t he s ec on d do se 1 2 ho ur s af te r th e fir st d os e. ä Ti m e yo ur fi rs t do se s o yo u w on 't ha ve t o w ak e up in t he m id dl e of t he ni gh t fo r yo ur s ec on d do se . ( Fo r ex am pl e, t ak e th e fir st d os e at 8 a .m ., an d th e se co nd d os e at 8 p .m .) ä D O N O T ta ke a ny e xt ra p ill s. T ak in g m or e w ill N O T w or k be tt er , a nd m ay m ak e yo u si ck t o yo ur s to m ac h. W ha t to E xp ec t M an y w om en fe el s ic k to t he ir s to m ac hs w he n th ey t ak e EC Ps . S om e m ay th ro w u p. I f y ou t hr ow u p m or e th an o nc e w ith in 1 -2 h ou rs a ft er t ak in g a do se , c al l y ou r pr ov id er . So m e w om en m ay fe el d iz zy , t ir ed , o r ha ve t en de r br ea st s. T he se s id e ef fe ct s ar e no t se ri ou s. T he y us ua lly s to p in a d ay o r tw o. Yo ur n ex t pe ri od m ay c om e on t im e, o r it m ay b e a fe w d ay s ea rl y or la te . EC Ps a re n ot 1 0 0 % e ff ec tiv e. I f y ou r pe ri od d oe s no t st ar t w ith in 3 w ee ks , c al l y ou r pr ov id er fo r an e xa m a nd p re gn an cy t es t. EC Ps a re n ot 1 0 0 % e ff ec tiv e. I f y ou r pe ri od d oe s no t st ar t w ith in 3 w ee ks , c al l y ou r pr ov id er fo r an e xa m an d pr eg na nc y te st . Pr ev en tin g Pr eg na nc y D o no t ha ve u np ro te ct ed s ex af te r us in g EC Ps . B e su re t o us e co nd om s, s pe rm ic id e or a d ia ph ra gm t o pr ot ec t yo ur se lf fr om ge tt in g pr eg na nt u nt il yo ur n ex t pe ri od . EC Ps a re fo r on e- tim e em er ge nc y pr ot ec tio n. Th ey a re n ot a s ef fe ct iv e as o th er t yp es o f b ir th c on tr ol . A ft er y ou r pe ri od , t al k to y ou r pr ov id er a bo ut fi nd in g th e be st b ir th c on tr ol m et ho d fo r yo u. T o pr ot ec t yo ur se lf fr om S TD a nd H IV , u se c on do m s an d a sp er m ic id e ev er y tim e yo u ha ve s ex . R ep rin te d w ith p er m is si on fr om E TR A ss oc ia te s, S an ta C ru z, C A . Ta bl e 1 If y ou t ak e Fi rs t D os e Se co nd D os e (t yp e o f pi ll ) (n u m be r o f pi ll s to s w al lo w (n u m be r o f pi ll s to s w al lo w as s o o n a s po ss ib le ) 12 h o u rs a ft er f ir st d o se ) Pl an B ™ 1 w hi te p ill 1 w hi te p ill Pr ev en ™ 2 bl ue p ill s 2 bl ue p ill s O vr al 2 w hi te p ill s 2 w hi te p ill s Le vl en 4 lig ht -o ra ng e pi lls 4 lig ht -o ra ng e pi lls Le vo ra 4 w hi te p ill s 4 w hi te p ill s Lo /O vr al 4 w hi te p ill s 4 w hi te p ill s N or de tt e 4 lig ht -o ra ng e pi lls 4 lig ht -o ra ng e pi lls Tr i-L ev le n 4 ye llo w p ill s 4 ye llo w p ill s Tr ip ha si l 4 ye llo w p ill s 4 ye llo w p ill s Tr iv or a 4 pi nk p ill s 4 pi nk p ill s A le ss e 5 pi nk p ill s 5 pi nk p ill s Le vl ite 5 pi nk p ill s 5 pi nk p ill s O vr et te 20 y el lo w p ill s 20 y el lo w p ill s 26 27 REFERENCES 1. Castle MA, Friedlander E, Bird ST and Coeytaux F. Introducing Emergency Contraceptive Pill Services at Family Planning Clinics in Philadelphia: The Organizational and Social Context, Pacific Institute for Women’s Health, Los Angeles, California 1999. Available on-line at www.piwh.org. 2. Castle MA, Walsh K, Casannova, C. Planned Parenthood of New York City. Emergency Contraception Pills Service Research, Final Report, June 1, 1999, Metis Associates, New York. 3. Breitbart V, Castle MA, Walsh K, Casannova C. “The Impact of Patient Experience on Practice: The Acceptability of Emergency Contraceptive Pills in Inner-City Clinics.” JAMWA, 53(5) Supplement 2:255-257, 1998. 4. Trussell J, Raymond EG. “Statistical evidence about the mechanism of action of the Yuzpe regimen of emergency contraception.” Obstetrics and Gynecology 93:872-876, 1999. 5. Swahn ML, Westlund P, Johannisson E, Bygderman M. “Effect of post-coital contraceptive methods on the endometrium and the menstrual cycle.” Acta Obstreticia et Gynecologiica Scandinavica 75:738-744, 1996. 6. Ling WY, Robichaud A, Zayid I, Wrixon W, MacLeod SC. “Mode of action of DL-norgestrel and ethinylestriaiol combination in postcoital contraception.” Fertility and Sterility 32:297-302, 1979. 7. Taskin O, Brown RW, Young DC, Poindester AN, Wiehle RD. “High doses of oral contraceptives do not alter endometrial 1 and v 3 integrins in the late implantation window.” Fertility and Sterility 63:850-855, 1994. 8. Task Force of Postovulatory Methods of Fertility Regulation. “Randomized controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception.” Lancet 352(9126):428-433, 1998. 9. Trussell J, Ellertson C. “Efficacy of Emergency Contraception.” Fertility Control Reviews. 4(2):8-11, 1995. 10. Pillsbury B, Coeytaux F, Johnston A. From Secret to Shelf: How Collaboration is Bringing Emergency Contraception to Women. Pacific Institute for Women’s Health, 1999. Available on-line at www.piwh.org. 11. Trussell J, Duran V, Shochet T, Moore, K. “Access to Emergency Contraception.” Obstetrics and Gynecology 93:267-270, 2000. 12. Harvey SM, Beckman LJ, Sherman C, Petitti D. “Women’s Experience and Satisfaction with ECPs.” Family Planning Perspectives. 31(5): 237-240, and 260, September-October 1999. 13. Glasier A, Baird D. “The effects of self-administering emergency contraception.” New England Journal of Medicine 339:1-4, 1998. 14. AIDS Institute. HIV Prophylaxis following Sexual Assault: Guidelines for Adults and Adolescents New York State Department of Health 1998. 15. Jenny C, Hoston TM, Bowers A. et al. “Sexually Transmitted diseases in victims of rape.” New England Journal of Medicine 322:713-716 , 1990. 16. Royce, RA, Sena A, Cates W et al. “Sexual transmission of HIV.” New England Journal of Medicine 336(15):1072-78, 1997. 17. Food and Drug Administration. “Prescription drug products; certain combined oral contraceptives for use as post-coital emergency contraception.” Notice. Federal Register February 25, 1997; 62:8610-8612. 18. Bracken MB. Oral Contraceptives and congenital malformations in offspring: a review and meta-analysis of the prospective studies. Obstetrics and Gynecology 76:552-557, 1990. 28 29 ADDITIONAL RESOURCES American College of Obstetricians and Gynecologists http://www.acog.org, (206) 638-5577 Evidence-based guidelines for clinical issues in obstetrics and gynecology. Includes ACOG Practice Patterns for Emergency Contraception (1996). Association of Reproductive Health Professionals http://www.arhp.org/ec, (202) 466-3825 Information about emergency contraception including: Emergency Contraception: Training the Trainer Slide presentation. Center for Reproductive Law and Policy http://www.crlp.org, (212) 514-5534 Emergency Contraceptive Pills: Common Legal Questions About Prescribing, Dispensing, Repackaging and Advertising. Video - Speak EC: What Every Woman Needs to Know About Emergency Contraception, 11 minutes. $11.50 including shipping. Consortium for Emergency Contraception http://www.path.org/cec/, (206) 285-3500 Information about emergency contraception available from the website including: Emergency Contraceptive Pills: Medical and Service Delivery Guidelines (1996). Emergency Contraceptive Pills: A Resource Packet for Health Care Providers and Program Managers (1998) English, Spanish and Portuguese. Hard copies are available from the Population Council, (212) 339-0500. Emergency Contraceptive Pills, Module 5, A Comprehensive Training Course. Available from Pathfinder International, (617) 924-7200. ETR Associates http://www.etr.org, (831) 438-4060 Client materials including: Emergency Contraception Pamphlet in English or Spanish. (50 for $16, 100 for $30) Emergency Contraception Patient Video 9 minute video in English or Spanish. ($15) Emergency Contraception Poster In English or Spanish (10 for $15) Food and Drug Administration (FDA) http://www.fda.gov/ Use the search feature to find FDA documents on emergency contraception (EC). Journal of the American Medical Women’s Association http://www.jamwa.org/vol53/toc53_5.html Fall 1998 53(5) issue is devoted to emergency contraception. Kaiser Permanente Southern California Kathie.J.Heller@kp.org, (626) 564-3451 Emergency Contraception Training Tool Box Includes 18 minute medical staff training video, slide presentation, sample protocols, brochures in English and Spanish and phone screening guidelines. ($54.95 includes shipping) National Emergency Contraception Hotline 1-888-NOT-2-LATE Hotline run by the Office of Population Research and Reproductive Health Technologies Project providing information on emergency contraception and phone numbers for closest providers. In English and Spanish. Office of Population Research at Princeton University http://not-2-late.com Directory of providers, instructions for use, frequently asked questions, and publications. Pacific Institute for Women’s Health http://www.piwh.org, (310) 842-6828 List of publications on emergency contraception on web site. Also available: A Demonstration Project to Evaluate the Acceptability of Emergency Contraception to Health Care Providers and Consumers (1998) Outlines the four phases of implementing a large-scale EC demonstration project in a major HMO. A Guide for Workshops to Train Women at the Community Level about Emergency Contraception and STD/HIV-AIDS Prevention (2000) English and Spanish. Emergency Contraception, a Woman’s Right: A guide for workshops, dissemination and information to women’s organizations (1999) English, Spanish and Portuguese. Portuguese version includes training poster and brochure. Emergency Contraceptive Pills: Service Protocol and Reference Manual (1996) Provider’s manual developed by PATH, Kaiser Permanente of Southern California and the Pacific Institute for Women’s Health. From Secret to Shelf: How Collaboration is Bringing Emergency Contraception to Women (1999) Report chronicles the history of ECPs. Available on web site. PATH (Program for Appropriate Technology in Health) http://www.path.org, (206) 285-3500 The following documents will be available on the PATH website by September 2000: Emergency Contraception Training Curriculum for Medical Providers Includes a 45 minute slide presentation and trainer’s notes. Emergency Contraception Training Curriculum for Social Services Providers Includes a 35 minute presentation and trainer’s notes. Emergency Contraception Client Brochure in Five Different Languages Informational brochures for clients that can be adapted and duplicated. 31 EC Standing Orders Protocol Screening and counseling protocol for dispensing ECPs with standing orders for administration. What is Emergency Contraception? Fact Sheet Fact sheet with basic information regarding different types of emergency contraception, mechanism of action, side effects, and effectiveness. Emergency Contraception Questions and Answers Most frequently asked questions regarding emergency contraception with concise answers. Referral Cards Wallet-sized cards to refer clients to local services of emergency contraception. Plan B http://www.go2planB.com, (800) 330-1271 Planned Parenthood Federation of America www.plannedparenthood.org, (800) 669-0156 Information on website on how to use emergency contraception, the side effects, where to get EC, and the costs. Also available: Emergency Contraception: Client Materials for Diverse Audiences, 2nd Edition Client brochures and usage instruction for emergency contraception in 13 languages developed by PATH. (Available from the PATH website at www.path.org or $3.00 each plus 15 percent shipping and handling. Item number 5415). Emergency Contraception: Resources for Providers Information packet developed by PATH and co-sponsored by American College of Obstetricians and Gynecologists and the Association of Reproductive Health Professionals among others. Includes a resource book for providers with current information about prescribing practices, counseling issues and service delivery considerations ($5.00 each plus 15 percent shipping and handling. Item number 5410.) Emergency Contraception Handbook (1999) Information on what is EC, how it works and how to use it. ($6.50 each, $5 for 12 or more. In English and Spanish.) Preven http://www.preven.com, (888) preven2 Reproductive Health Technologies Project http://www.rhtp.org, (202) 530-2900 Provides up-to-date information on EC, operates the National Emergency Contraception Hotline (1-888-NOT-2-LATE). Public education and media campaign materials available including: public service announcements, posters, postcards and wallet cards (Spanish and English), as well as materials designed for African-American and Spanish-speaking communities. 30 Acknowledgements We thank Barbara Fisher, PhD, University of Witsrandsrand, Johannesburg, SA for her assistance in writing this guide. The guide has also benefited from the close reading and insights of: Patricia Anderson, MPH (Medical Students for Choice) Sheryl Thorburn Bird, PhD, MPH (University of Oregon, Eugene) Paul Blumenthal, MD (Johns Hopkins Bayview Medical Center) Jane Boggess, PhD (Pharmacy Access Project) Karla Buitrago (Medical Students for Choice) Michael Burnhill, MD (Planned Parenthood Federation of America) Sharon Camp, PhD (Women’s Capital Corporation) Wendy Chavkin, MD, MPH (Journal of American Medical Women’s Association) Remy Coeytaux, MD (University of North Carolina) Vanessa Cullins, MD, MPH, MBA (AVSC International) Linda Dominguez, RNC, NP (Planned Parenthood of New Mexico) Susan Einsendrath (American Medical Women’s Association) Eva Friedlander, PhD (Planning Alternatives for Change) Anna Garcia (California Family Health Council) Marji Gold, MD (Montefiore Medical Center) Robert Hatcher, MD, MPH (Emory University School of Medicine) Jane Hutchings, MPH (PATH) Annie Keating (Physicians for Reproductive Choice and Health) Donna Lieberman, JD (New York Civil Liberties Union) Kirsten Moore, MPA (Reproductive Health Technologies Project) Deborah Oyer, MD (Aurora Medical Services) Billie Jean Pace, MD (International Coalition of Women Physicians) Diana Petitti, MD, MPH (Kaiser Permanente Southern California) Carol Petraitis (Clara Bell DuVall Education Fund) Barbara Pillsbury, PhD (Pacific Institute for Women’s Health) Debbie Postlethwaite, RNP, MPH (Kaiser Permanente Northern California) Linda Prine, MD (Beth Israel Medical Center)) Helen Rodriguez-Trias, MD, FAAP (Consultant in Health Programs) Allan Rosenfield, MD (Columbia University, School of Public Health) Nancy Stanwood, MD (University of North Carolina) Felicia Stewart, MD (Center for Reproductive Health Research) Jini Tanenhaus, RPA-C (Planned Parenthood of NYC) James Trussell, PhD (Princeton Office of Population Research) Terri Walsh, MPH (California Family Health Council) Elisa Wells, MPH (PATH) Susan Welner, MD (Georgetown University) John Westfall, MD, MPH (University of Colorado School of Medicine) Jennifer Winkler, MPH (PATH) Susan Yanow, MSW, LICSW (Abortion Access Project) Our sincere thanks to the providers in Pennsylvania and California who shared their experiences with us and to The John Merck Fund and The David and Lucile Packard Foundation for their generous support. Pacific Institute for Women’s Health Mission The Pacific Institute for Women’s Health, a non-profit organization, is dedicated to improving women’s health and well-being locally and globally. The Institute takes a comprehensive approach to the complex realities of women’s lives and works through applied research, policy work, community involvement, consultation and training. Any part of this report may be copied or adapted to meet local needs without permission from the Pacific Institute, provided that the parts copied are distributed free or at cost (not for profit) and that the source is identified. Any commercial reproduction requires prior permission from the Pacific Institute. The Pacific Institute would appreciate receiving a copy of any materials in which the text is used. 2999 Overland Ave., Suite 111 Los Angeles, CA 90064 tel 310.842.6828 fax 310.280.0600 e-mail piwh@piwh.org web www.piwh.org © 2000 by the Pacific Institute for Women’s Health. All rights reserved.

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