A 16-year-old girl presents to your surgery with a history of unprotected sexual intercourse (UPSI) 70 hours ago. Her last menstrual period was 8 days ago.
Her only past medical history of note is that of epilepsy which is well controlled by carbamazepine. She is worried about becoming pregnant, does not want her mother to find out and is in a hurry to get home before suspicions are raised.
Which of the following options are available to her?
A. Take the combined oral contraceptive pill (COCP) continuously for the next month
B. A copper intrauterine device (IUD) should be inserted with prior screening for sexually transmitted infections (STIs) C. Levonorgestrel 1.5 mg should be given as she is within 72 hours of UPSI
D. Reassure and tell her to come back when she has made her mind up as ulipristal can be taken up to 7 days after UPSI
E. Reassure her that she is in the safe part of her cycle and she should try and use condoms in the future
ANSWER IS C :This is a difficult conversation under time pressures. Ideally you would prefer to counsel the patient about all the options of emergency contraception and the ramifications of unprotected sexual intercourse.
An important part of your counselling will involve future contraception advice. This patient has three options for emergency contraception. A copper IUD (B) inserted up to 5 days after the UPSI, the progesterone antagonist Ulipristal (D) up to 5 days after and the more common levonorgesterol 1.5mg within 72 hours (C). She meets the timeline for all options. Importantly she is taking an enzyme inducer carbamazepine so you could not guarantee the success of levonorgesterol. The Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH) recommends increasing the dose of levonorgesterol to 3mg but this is off licence.
A copper coil would be the most appropriate contraception under these circumstances, also allowing you to perform a full STI screen simultaneously. Option (A) would not be effective as an emergency contraception and she is on an enzyme-inducing drug. Option (E) is not appropriate as depending on her cycle length she may well ovulate in the next 5–6 days. Sperm can survive for a week so she may well fall pregnant if no action is taken.