A 21-year-old woman presents because she has had unprotected intercourse and is worried about pregnancy. She has been on holiday and met a man with whom she had unprotected intercourse 36 h ago, and also 4 days before that.
Her last menstrual period started 13 days ago and she bleeds for 4 days every 27 days. She has had no other episodes of intercourse since her last period. She is generally healthy but has a history of epilepsy for which she takes carbamazepine. She has no other significant medical history.
Abdominal examination is unremarkable and internal examination is not indicated.
· What options are available to this woman and how should she be managed?
Two forms of emergency contraception are generally available:
· emergency intrauterine contraceptive device (IUCD)
· hormonal emergency contraception (levonorgestrel).
Hormonal emergency contraception involves 1.5 mg levonorgestrel, taken as soon as pos- sible after intercourse (preferably within 12 h). It is effective up to 72 h and can be given safely up to 5 days (unlicensed), but the earlier it is taken, the more effective it is. In this case the woman has had intercourse more than 72 h ago and therefore this method should be assumed to be ineffective. She is also taking an enzyme-inducing drug and should therefore be advised, if she were suitable to use this method, to take a higher dose of levonorgestrel (3 mg).
This woman should be advised to have an emergency IUCD inserted, and although she has never been pregnant this is unlikely to be a problem as IUCDs can generally be inserted under local anaesthetic, even in nulliparous women.
It can be inserted up to 120 h (5 days) after unprotected intercourse. If intercourse has occurred more than 5 days previously, the intrauterine device can still be inserted up to 5 days after the earliest likely calculated ovulation. In this case the earliest likely ovula- tion is today (taking account of her 27-day cycle).
The IUCD is also more effective than the hormonal emergency contraception whenever used. Insertion needs to be covered by antibacterial prophylaxis to prevent pelvic inflam- matory disease.
A pregnancy test should always be taken before any emergency contraception, whatever the menstrual history. Women should also be advised to consider sexually transmitted infection testing after unprotected intercourse with a new partner, and should be encour- aged to use a reliable regular method of contraception.
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