Case Study Reports: Unprotected Intercourse

UNPROTECTED INTERCOURSE

History

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.

Examination

Abdominal examination is unremarkable and internal examination is not indicated.

Questions

·              What options are available to this woman and how should she be managed?

Answer:

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).

Emergency intrauterine contraceptive device

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.