A Clinician's Guide to Emergency Contraception

Lin-Fan Wang, MD, MPH

Disclosures

September 19, 2014

Ways to Help Patients Access Emergency Contraception

Given the hurdles and confusion that surround purchasing these products OTC, healthcare providers can facilitate access to emergency contraception by writing advance prescriptions when necessary or counseling patients about navigating purchase them at local pharmacies.

Provide Advance Prescriptions

The advance prescription of emergency contraception is supported by multiple medical organizations. Studies have shown that prescribing emergency contraception in advance increases the likelihood that women take the medication and take it sooner, without harm or increased risky sexual or contraceptive behavior.[11,12]

Any primary care, gynecologic, or emergency department visit can be an opportunity to provide prescriptions for emergency contraception, with refills. Having emergency contraception as a back-up method may be helpful for women who rely on condoms as their primary contraceptive method. For women initiating a more effective method on the same day as the visit, also known as the Quick Start method, ECPs can also be taken; however, a barrier method or abstaining from sexual intercourse is recommended for seven days after taking an LNG method or for 14 days or until the next menses after taking an UPA method.[13]

Providers can assist their patients in navigating the logistical barriers to accessing ECPs by making a plan in advance. For example, you can counsel your patients to fill an advance prescription so that they have emergency contraception on hand before it is needed. This is particularly helpful if the patient's insurance plan covers ECPs. You could also call the pharmacy to confirm that ECPs are in stock.

Compared with LNG emergency contraception, ella is more effective and does not decrease in efficacy between 72 and 120 hours after unprotected intercourse.[2] Owing to this advantage, ella should be considered first for advance prescriptions. LNG products may be preferred if cost or pharmacy availability is an issue. Emerging data suggest that LNG emergency contraception products may be less effective among women with body mass index ≥ 30 kg/m2 [3] or those who weigh more than 176 lb.[4] A recent review by the European Medicines Agency, however, concluded that the available data are too limited and not robust enough to conclude that the effectiveness of LNG emergency contraception is affected by weight. The clinical implications of these early data are therefore uncertain.[6]

The OTC availability of LNG pills has the potential to improve patient access and privacy, but there are several financial and logistical barriers. On average, pharmacies in the United States charge $48 for Plan B One-Step and $41 for the generic versions.[14] Insurance plans are now required by the Affordable Care Act (ACA) to cover ECPs without additional out-of-pocket costs, but insurance plans generally require a prescription to cover the cost, regardless of OTC status.[15] Prescriptions may also be required for Medicaid coverage or reimbursement from health savings accounts or similar sources. Having a prescription may also make it easier for people who are embarrassed about buying ECPs without a prescription or who want to avoid additional questions from pharmacy staff about their use of LNG emergency contraception when these products are behind the counter.

In addition, a nationwide survey of pharmacies, including ones in grocery stores and big-box stores, conducted from September 2013 to March 2014 found that fewer than one half of the stores stocked Plan B One-Step, and only 13% of the stores made the product available on the shelf without locking it up, requiring consumers to seek help from an employee.[14] A survey of 400 retail pharmacies conducted in June and July 2013 found that 95% of the stores did not stock ella, although many reported that they could order the product for next-day delivery.[16]

Educate Adolescent Patients

Research demonstrates the safety of LNG pills for emergency contraception use by adolescents, and multiple medical organizations support OTC access for this group without age restrictions; these groups include the American Academy of Pediatrics, the American Congress of Obstetrics and Gynecology (ACOG), and the Society for Adolescent Health and Medicine.[17]

However, pharmacy staff may convey misinformation about the availability of LNG pills for adolescents. This was substantiated by a study of pharmacies in 5 major cities, conducted September to December 2010,[18] when Plan B was approved for OTC access for women aged 17 years or older. Mystery callers telephoned pharmacies, posing as 17-year-old women seeking emergency contraception. Approximately one half of the pharmacies gave these callers the incorrect age requirement; nearly all pharmacies reported an incorrect, older age restriction. In nearly 1 out of 5 calls, the caller was "told that she could not obtain emergency contraception under any circumstance."

Since this study was done, age restrictions have been lifted for both Plan B and generic one-step LNG products, but adolescents may continue to receive misinformation from pharmacy staff, creating barriers to access. Although targeted interventions are needed on the pharmacy level, providers can play a role in helping their adolescent patients access ECPs by providing advance prescriptions, educating adolescents on their rights, and establishing teen-friendly clinic policies. These policies include informing adolescents and, if applicable, their parents or guardians, about how reproductive healthcare is kept confidential, providing time at each clinic visit to privately discuss reproductive health without a parent or guardian, maximizing accessibility of care by ensuring that clinic hours are convenient and accommodating walk-in appointments, and providing free or minimal-cost contraceptive and reproductive healthcare services.[19,20]

Educate Men

Engaging men in family planning may improve access and use of contraception. Now that men of all ages are able to purchase Plan B One-Step, educating them about emergency contraception as well as dual protection (use of condoms and a more effective method of birth control), empowers them to be active participants in preventing unintended pregnancy. Studies have found that young men are much less knowledgeable than women about emergency contraception and its OTC availability.[21,22] In addition, pharmacy staff may inappropriately restrict sales to men. Studies have found that pharmacists may ask for the female partner to be present during purchase, may ask for identification, or may outright refuse to sell men emergency contraception on the basis of their gender.[23,24,25]

Offer the Copper IUD

The Cu-IUD as emergency contraception has several advantages over ECPs, but it remains underutilized.[5] The Cu-IUD is the most effective form of emergency contraception and works up to five days after unprotected intercourse[26,27]; its efficacy is not affected by body mass index or weight[4,5]; and it has few contraindications.[28] Nulliparous and adolescent women have high satisfaction and continuation rates with this method.[29,30] In addition, the Cu-IUD can be retained as a regular form of birth control for up to 12 years[7,31]; is cost-effective[32]; and can be removed anytime, with complete return of fertility expected.[29] Recent studies show that some women seeking emergency contraception or pregnancy testing would opt for same-day insertion of the Cu-IUD, if given the option.[33,34] Providers can better meet their patients' needs by discussing this option with patients who are candidates for emergency contraception and desire a long-term contraceptive method.

The ACA requires insurance plans to cover Cu-IUD without additional out-of-pocket costs. However, limited numbers of trained providers, inadequate clinic and administrative support, and the high cost of maintaining an advance supply of Cu-IUDs make providing this option challenging. Numerous medical and advocacy organizations are working to overcome these barriers. ACOG's LARC Program, for example, provides information and guidance on integrating long-acting reversible contraception (LARC), including Cu-IUDs, into your practice. Another program, getLARC provides funding to family medicine residency programs to integrate LARC services at a community health center or federally qualified health center.

It is vital that patients have access to all forms of birth control so that they can pick the best method for them. Although considerable gains have been made, barriers to emergency contraception still exist. Healthcare providers play an important role in improving access for their patients. Providing education on OTC emergency contraception, offering advance prescriptions, and including the Cu-IUD as an emergency contraception option may help reduce these barriers and improve family planning use and services.

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