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POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Emergency Contraception Krishna K. Upadhya, MD, MPH, FAAP, COMMITTEE ON ADOLESCENCE

Despite significant declines over the past 2 decades, the abstract continues to experience birth rates among teenagers that are significantly higher than other high-income nations. Use of (EC) within 120 hours after unprotected or underprotected intercourse can reduce the risk of . Emergency contraceptive methods include oral Children’s National Health System, Washington, District of Columbia labeled and dedicated for use as EC by the US Food and Drug Policy statements from the American Academy of Pediatrics benefit Administration (ulipristal and ), the “off-label” use of combined from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American oral contraceptives, and insertion of a copper . Indications Academy of Pediatrics may not reflect the views of the liaisons or the for the use of EC include intercourse without use of contraception; organizations or government agencies that they represent. breakage or slippage; missed or late doses of contraceptives, including the Dr Upadhya was responsible for all aspects of revising and writing the policy statement with input from reviewers and the Board of Directors; , , contraceptive ring, and injectable she approves the final manuscript as submitted. contraception; after use of oral contraceptives; and sexual assault. The guidance in this statement does not indicate an exclusive course Our aim in this updated policy statement is to (1) educate pediatricians and of treatment or serve as a standard of medical care. Variations, taking other physicians on available emergency contraceptive methods; (2) provide into account individual circumstances, may be appropriate. current data on the safety, efficacy, and use of EC in teenagers; and (3) All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, encourage routine counseling and advance EC prescription as 1 public health revised, or retired at or before that time. strategy to reduce teenaged pregnancy. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial BACKGROUND INFORMATION involvement in the development of the content of this publication. DOI: https://doi.org/10.1542/peds.2019-3149 Emergency contraception (EC) refers to methods of contraception that are Address correspondence to Krishna K. Upadhya, MD, MPH, FAAP. E-mail: used after to reduce the risk of pregnancy. Methods [email protected] currently available in the United States are (1) (UPA), an oral receptor agonist-antagonist; (2) levonorgestrel (LNG), PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). an oral progestin; (3) the copper intrauterine device (Cu-IUD); and (4) off- Copyright © 2019 by the American Academy of Pediatrics label use of combined oral contraceptives (Yuzpe method). EC can reduce FINANCIAL DISCLOSURE: The author has indicated she has no financial the risk of pregnancy if used up to 120 hours after unprotected relationships relevant to this article to disclose. intercourse, and hormonal emergency contraceptive pills (ECPs) are more FUNDING: No external funding. 1 likely to be effective the sooner they are used. Use of EC after unprotected POTENTIAL CONFLICT OF INTEREST: The author has indicated she has or underprotected intercourse remains an important strategy to reduce no potential conflicts of interest to disclose. unintended among adolescents and women. By the age of 19 years, approximately two-thirds of youth will have To cite: Upadhya KK, AAP COMMITTEE ON ADOLESCENCE. initiated sexual intercourse.2 Most teenagers report first intercourse with Emergency Contraception. Pediatrics. 2019;144(6): e20193149 a steady partner and consensual sex.3 Approximately 11% of US high

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019:e20193149 FROM THE AMERICAN ACADEMY OF PEDIATRICS school students report experiencing EC is the only contraceptive method thereby preventing the binding of a forced sexual experience ranging designed to prevent pregnancy after progesterone, and inhibits . from kissing to forced intercourse.4 intercourse. Indications for the use of Ulipristal, sold under the brand name Sexual assault is 1 factor associated EC include intercourse without use of ella (Watson, Morristown, NJ), is with risk for unintended pregnancy contraception; condom breakage or a single pill containing 30 mg of UPA among adolescents.5 Youth with slippage; missed or late doses of and is indicated for use up to developmental and other disabilities contraceptives, including the oral 120 hours after unprotected may be at even higher risk of contraceptive pill, contraceptive intercourse. It is important for experiencing sexual abuse or assault patch, contraceptive ring, and patients to be counseled that onset of than their peers are.6,7 Improved use injectable contraception; vomiting menses after UPA use may be later of contraception, not declines in after use of oral contraceptive pills, than expected and a is sexual activity, has been the most and sexual assault. ECPs include indicated if the patient does not have significant contributor to the decline products labeled and approved by the a period within 3 weeks. UPA is in pregnancy risk among US US Food and Drug Administration currently available by prescription teenagers over the past decade.8 (FDA) for use as EC (levonorgestrel only, regardless of age, and many Pediatricians have an important role and UPA) and the off-label use of pharmacies do not have it in stock. to play in enabling adolescent access combination oral contraceptives (the Progestin-Only Pills to all available contraceptive methods Yuzpe method) that have been to address the Healthy People 2020 described in the literature since Levonorgestrel EC was approved by objective of continuing to reduce 1974.13 Insertion of a Cu-IUD within the FDA in 1999 under the brand adolescent pregnancy in the United 5 days of unprotected intercourse is name Plan B and is currently States.9 an additional method of EC available marketed under several names, in the United States. Insertion of a Cu- including Plan B One Step (Teva The most commonly used methods of IUD is the most effective method of Women’s Health, Woodcliff Lake, NJ), contraception reported by teenagers EC and has the extra benefitof Take Action (Teva Women’s Health), who have had intercourse in the providing ongoing contraception Next Choice One Dose ( United States are the condom, when left in place.1 Pharma, Inc, Parsippany, NJ), and My followed by withdrawal, the oral Way (Gavis Pharmaceuticals, Studies have shown that adolescents contraceptive pill, and ECPs.2 Somerset, NJ). Although are more likely to use ECPs when are important for levonorgestrel EC originally consisted they have been supplied or protection against sexually 14 of 2 pills, current regimens are prescribed in advance of need. As of transmitted infections (STIs) as well packaged as a single pill with 1.5 mg August 2013, levonorgestrel EC is as pregnancy, and the oral of levonorgestrel. Package labeling approved for over-the-counter sale contraceptive pill can be an effective indicates that levonorgestrel EC throughout the United States to method for pregnancy prevention; 15 should be taken within 72 hours of people of all ages ; however, barriers however, both methods require strict unprotected intercourse; however, to access include cost and availability adherence by the user to be 16 data support that use up to 120 hours in pharmacies. Surveys suggest that maximally effective. Withdrawal is after intercourse may prevent most practicing pediatricians and not recommended because of its pregnancy.23,24 Adolescents should be pediatric residents do not routinely relatively low effectiveness for instructed to take 1.5 mg of counsel patients about EC and do not pregnancy prevention and because it 17–21 levonorgestrel as soon as possible prescribe it. This policy provides no protection against STIs. and up to 120 hours after statement provides updated guidance Although the American Academy of unprotected intercourse. Adolescents on all methods of EC available to US Pediatrics (AAP) and other medical should be aware that the medicine is adolescents (Table 1) and ongoing organizations recommend the use of less likely to be effective when taken policy and access issues. intrauterine devices (IUDs) and at 120 hours when compared with implants as the most effective immediate use. No physical methods for adolescents,10,11 rates of EC METHODS examination or pregnancy testing is use of these methods remain low. The EC Pills required before use. Adolescents are most recent analysis from the Centers advised to test for pregnancy (at for Disease Control and Prevention UPA Progesterone Agonist-Antagonist home or in a clinic) if they do not (CDC) indicates that only 3% of 15- to In August 2010, the FDA approved have a period within 3 weeks of EC 19-year-olds who have ever had sex a progesterone agonist-antagonist, use. It is important for patients to have used an IUD, and 3% report ever UPA, for use as an EC.22 UPA binds to know that levonorgestrel use may having used an implant.12 the human progesterone receptor, cause the next period to come sooner

Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Selected Regimens for EC Available in the United States Brand First Dose Second Dose, 12 h Later Ethinyl Levonorgestrel per per Dose, mg Dose, mg Progestin-only pills Next Choice or Plan B 2 pills None 0 1.5 Plan B One Step 1 pill None 0 1.5 Ovrette 20 pills 20 pills 0 0.75 Other ECP: ella 30 mg of UPA ——— IUD: Paragard Insert within 120 h of unprotected Insert within 120 h of unprotected NA NA intercourse intercourse Combined and progestin pills Ovral 2 white pills 2 white pills 100 0.5 Levora 4 white pills 4 white pills 120 0.6 Nordette 4 light-orange pills 4 light-orange pills 120 0.6 Seasonale 4 pink pills 4 pink pills 120 0.6 Triphasil 4 yellow pills 4 yellow pills 120 0.5 Alesse 5 pink pills 5 pink pills 120 0.5 Additional combinations are available at https://ec.princeton.edu/questions/dose.html#dose. NA, not applicable. than expected.1 Because use of ECPs Practice Recommendations for by the timing of use within the may result in a delay in ovulation, it is Contraceptive Use” and professional . A recently published imperative to counsel patients to organizations such as the American meta-analysis of ECP trial data abstain from intercourse or use College of Obstetricians and compared the effectiveness of EC condoms for pregnancy prevention Gynecologists acknowledge the use of methods. Pooled data from trials until the next menses. combination oral contraceptives as suggest that UPA resulted in fewer safe and effective for EC.25,26 pregnancies than levonorgestrel did Combined Hormonal Regimens (Yuzpe (relative risk, 0.59; 95% confidence IUD Method) interval, 0.35–0.99; 2 randomized The use of combination oral Studies have established that the controlled trials, n = 3448; I2 = 0%; contraceptives for EC is commonly insertion of a Cu-IUD within 5 days of high-quality evidence).1 referred to as the Yuzpe method.13 unprotected or underprotected Levonorgestrel also resulted in fewer Used since 1974, its acceptability and intercourse is the most effective pregnancies than the Yuzpe method – efficacy were limited by adverse method of EC.27 29 It must be did (relative risk, 0.57; 95% effects of and vomiting. The inserted by a trained provider. In confidence interval, 0.39–0.84; 6 Yuzpe method involves taking 2 doses comparison with ECPs, the randomized controlled trials, n = of pills 12 hours apart, each effectiveness of the Cu-IUD for EC 4750; I2 = 23%; high-quality containing a minimum of 100 µgof results from the copper component evidence).1 It should be noted, ethinyl estradiol and a minimum of and is not believed to vary by time of however, that current CDC guidance 500 µg of levonorgestrel. Other pill insertion within 120 hours of does not indicate a preference for formulations used for EC are included unprotected or underprotected sex. UPA over levonorgestrel regimens. in Table 1. Similar information is The mechanisms of action of Two secondary analyses of ECP trial fi available from the Of ce of hormonal IUDs differ from those of data identified that repeat Population Research at Princeton the Cu-IUD, and hormonal IUDs have unprotected intercourse in the same University, which maintains not been approved for use as EC. One cycle was associated with EC a comprehensive source of published study found that women failure.31,32 The delay of ovulation information on EC (http://ec. presenting for EC who desired an IUD from ECPs highlights the need for princeton.edu/). The availability of for contraception could be offered abstinence or contraception after many combination oral levonorgestrel ECPs and also have ECP use. contraceptives with or a hormonal IUD placed at the same levonorgestrel makes this alternative visit for ongoing contraception.30 particularly helpful when there is no EFFECT OF BMI ON EFFECTIVENESS OF or limited access to an EC product. ALL METHODS Although combination oral COMPARATIVE EFFECTIVENESS OF ECPS Efficacy of the Cu-IUD is not affected contraceptives have not been labeled The effectiveness of oral EC depends by body weight. CDC specifically for EC, the CDC “Selected on inhibiting ovulation and is affected recommendations indicate that young

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019 3 women in need of EC who do not the use of UPA. Finally, repeat use of vomiting can be decreased wish to use a Cu-IUD or who do not ECPs should prompt discussion of significantly by using an have access to IUD insertion should more effective, ongoing 1 hour before an estrogen-containing be offered ECPs regardless of their contraception, but there is no specific regimen. are ineffective if weight. limit on repeated use, including taken after nausea is already 41 Although no clinical trials have within the same cycle. As noted present. If vomiting occurs within specifically evaluated the impact of below, however, the use of hormonal 3 hours of a dose, the dose should be BMI on the effectiveness of oral EC, contraceptives within 5 days of UPA repeated. As with daily use of oral meta-analyses have suggested that may reduce the effectiveness of UPA. contraceptives, other adverse effects might include , breast both levonorgestrel and UPA may be Ulipristal less effective in adolescents and tenderness, headache, abdominal – women who are overweight.31 33 In The most common adverse effects pain, and dizziness. It should be noted response to these data and labeling reported by users of UPA include that CDC Medical Eligibility Criteria headache (18%), nausea (12%), and indicate that benefits of estrogen- changes to EC products in Europe, the 36 FDA conducted its own review of the (12%). It is containing pills for EC generally evidence and issued a statement in recommended to redose UPA if outweigh the risks of use even in 2016 indicating that the data vomiting occurs within 3 hours of the adolescents or women with health initial dose. For clinicians who are conditions, such as thromboembolic regarding BMI and the effectiveness 35 of levonorgestrel EC are conflicting providing this in a setting disease (ie, category 2). where the patient is discharged and made no labeling changes. The Cu-IUD FDA stated that there are no safety before 3 hours after the dose and concerns with the use of without an ongoing relationship with The Cu-IUD can be inserted within fi levonorgestrel EC in women with BMI the patient (ie, emergency 5 days of the rst act of unprotected greater than 25 or with body weight departments or urgent care), it may sexual intercourse as EC. Otherwise, greater than 165 pounds and that the be important to discuss provisions for eligibility criteria and initiation most important factor affecting the repeat dosing with patients if procedures for the Cu-IUD are the medication’s effectiveness is how indicated. same for emergency or nonemergency Cu-IUD insertion. Pain quickly it is taken after unprotected Levonorgestrel-Only Methods or underprotected intercourse.34 with insertion is possible with use of The most common the Cu-IUD for EC, and some patients reported after use of levonorgestrel may be fearful of pain and/or the ADVERSE EFFECTS AND EC is heavier menstrual bleeding; required pelvic examination. Events CONTRAINDICATIONS spotting may also be reported.37 The associated with ongoing use of the The only contraindication for use of rate of nausea and vomiting with Cu-IUD include expulsion (∼6% in EC is known pregnancy. According to levonorgestrel EC is approximately first year) and heavy menstrual the CDC Medical Eligibility Criteria for half that with the Yuzpe method, and bleeding and/or painful periods Contraceptive Use, pregnancy is an the routine use of antiemetics is not (∼12%). Contraindications for Cu- absolute contraindication for indicated. If vomiting does occur IUD use include anatomic features insertion of a Cu-IUD (category 4).35 within 3 hours of use, the dose should that prevent insertion, Wilson ECPs are not indicated for use in be taken again. Repeated use of disease, and signs of active cervical patients with documented or levonorgestrel EC is associated with and/or pelvic infection.35 Of note, suspected pregnancy; however, the same adverse effects as 1-time negative STI test results are not according to CDC Medical Eligibility use. A Cochrane Review of the subject required before the insertion of an Criteria, no harms to the woman, found no serious adverse effects in IUD. However, if an adolescent has pregnancy, or fetus of inadvertent trials of repeated use.38 not been screened for gonorrhea and ECP use during pregnancy are known according to screening to exist.35 Use of ECPs will not disrupt Yuzpe and Estrogen-Containing guidelines,42 screening can be a pregnancy that is implanted in the Methods performed at the time of IUD , and ECPs are not The most common adverse effects insertion, and IUD insertion should . Years of use of that occur during the first 24 to not be delayed. The American College hormonal contraceptives indicate that 48 hours of using estrogen-containing of Obstetricians and Gynecologists there is no risk of teratogenicity from EC methods are nausea (∼50%) and Long-Acting Reversible Contraception use of levonorgestrel EC or the Yuzpe vomiting (∼20%), which seem to be Program provides links to resources method. There have also been no unaffected by food intake.39–41 The for clinicians who are interested in reports of fetal malformations after severity and incidence of nausea and obtaining training on IUD insertion

Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS (www.acog.org/About-ACOG/ACOG- individuals at risk of pregnancy, it is average cost of UPA in studied Departments/Long-Acting- important for young men to be pharmacies was approximately $50. Reversible-Contraception). counseled on this method as well as Another study of pharmacy on condom use and the regular use of availability of UPA was conducted in other contraceptive methods so that Massachusetts and reported that 7% OTHER CLINICAL CONSIDERATIONS they can communicate with their at- of pharmacies surveyed had UPA in 44 Initiating Contraception After Use of risk partners about optimal stock. contraceptive use. ECPs Although EC methods are indicated Although there is no specific for use only in patients at risk of contraindication for repeated use of ADOLESCENTS AND EC: AWARENESS pregnancy, previous AAP policy EC, it should be emphasized to AND ACCESS statements advised that educating patients that ECPs are intended for Data from the CDC indicate that the adolescent male patients is emergency use and routine use of use of EC by female teenagers who important.45 Evidence suggests that ECPs to prevent pregnancy is not as had sexual intercourse at least once most male teenagers are not – effective as the regular use of other has increased over the past decade knowledgeable about EC.45 47 One forms of contraception. Ongoing from 8% in 2002 to 22% in 2011 to study conducted among an older hormonal contraceptives may be 2013.2 This increase is likely related adolescent and young adult initiated or resumed immediately to regulatory changes that increased population (ages 18–25 years) after use of levonorgestrel ECPs or nonprescription access to recruited from a Job Corps site and the Yuzpe method; however, condoms levonorgestrel EC during this time. a free clinic in Los Angeles surveyed or abstinence should be used in Despite the FDA approval of male and female participants and addition for 7 days for back-up levonorgestrel for over-the-counter found that 18% of male participants protection.25 Initiation of ongoing access without an age restriction, reported having a partner who had hormonal contraceptives after the use additional access barriers remain. In previously used EC.48 Significantly of UPA should be delayed for 5 days its most recent survey, the American fewer male than female participants to minimize the risk of interference Society for Emergency Contraception in that study reported having with UPA activity.25 Prescriptions or found that only 64% of pharmacies received information about EC from a supply of hormonal contraceptives have ECPs in stock on their shelves, a health care provider. Another study can be given at the time of UPA and among those that do, nearly half of a younger convenience sample of provision; however, patients should use a lock of some kind requiring sexually experienced adolescent male be instructed not to initiate them employee assistance to obtain it from participants (ages 13–24 years) in until 5 days after the dose of UPA. In the shelf.16 Additionally, despite Denver reported that only 42% had addition, as with levonorgestrel or multiple brand-name and generic heard of EC.49 One study explored the Yuzpe method, patients should be products on the market, the cost of how willing young men are to accept counseled to abstain from intercourse levonorgestrel ECPs remains at $40 to an advanced supply of EC in a clinic or use condoms for 7 days after the $50, on average. This cost may be setting and found that a majority who initiation of ongoing contraception or prohibitive, so pediatricians are were offered EC accepted it.46 until the start of their next period, encouraged to be aware of other It is important that information about fi 25 whichever occurs rst. resources for patients to obtain EC be included in all contraceptive affordable ECPs, which may include and STI counseling for adolescents Assessing for STI Risk college health services, school-based wherever these visits occur: the The discussion of EC methods with clinics, or Title X clinics. Insurance primary care office, the emergency patients must include the fact that coverage may help with the cost department, specialty clinics, or none of these methods protect from barrier; however, coverage may vary inpatient units. Discussions should STIs. Because of the cooccurring risk by plan. In addition to the cost include indications for use and how of STIs, offering STI testing at the visit barrier, some stores also continue to patients can access EC in a timely enforce an unjustified age restriction for EC or encouraging patients to 16 fashion. Yet, provider communication schedule follow-up visits for STI on purchase. about EC remains low and differs by testing or treatment are advisable. In Access to UPA is also often limited. patient characteristics. Findings from addition, follow-up visits are an One study in Hawaii reported data a nationally representative sample of important time to discuss options for from a secret-shopper study of sexually active 15- to 24-year-old ongoing contraception, abstinence, pharmacies throughout the state that women in the 2011–2015 National and consensual intercourse. Although found that less than 3% had UPA in Survey of Family Growth found that EC is exclusively for use by stock at the time of the request.43 The provider communication about EC

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 144, number 6, December 2019 5 during a visit for a pelvic examination medical discourse indicates that knowledgeable about the rights of the or Papanicolaou test was infrequent personal values of physicians and adolescent with regard to consent for (19%) compared with continue to affect access contraception in their state and communication about to EC, particularly for ensure that adolescents are aware of – (67%) and differed by patient adolescents.59 63 Some physicians these rights. Pediatricians can also be characteristics, including race and/or decline to provide EC to teenagers, an important source of information ethnicity and insurance status.50 For regardless of the circumstance,20 and for parents to help them example, a higher proportion of non- others may provide EC only if sexual communicate with their adolescents Hispanic black (25%) and Hispanic assault has occurred.20,64 These and to educate them about the (27%) women reported receiving decisions by physicians and importance of contraception and provider counseling about EC than pharmacists have important adverse other prevention strategies to reduce did non-Hispanic white (14%) consequences for adolescents in their risks associated with sexual activity if women. Reasons for differences in the ability to access EC. their adolescents make the decision reporting of counseling by race and/ to have sex. ’ or ethnicity have not been identified A physician s decision to provide EC by research to date. Adolescents with at a time of need but not in advance disabilities (both physical and of need may be related to the SUMMARY AND RECOMMENDATIONS physician’s beliefs about whether it is cognitive) and their families should We recommend the following. be counseled on EC as part of routine acceptable for teenagers to have 20 1. Pediatricians should be aware that anticipatory guidance,51 especially sex. Often, physicians hold fl sexual behavior is prevalent because data suggest that children con icting values when approaching among teenagers and that many with disabilities have 2 times the risk issues with sexually active teenagers may be of being sexual assaulted compared teenagers. Physicians may object to the victims of sexual assault. with children without disabilities.52 unprotected intercourse or Despite the availability of Offering advance prescription of ECPs intercourse outside of marriage, but hormonal and long-acting is encouraged. they may also feel the need to prevent unwanted pregnancy among contraceptives, the pregnancy Laws allowing minors to consent to teenagers. It is important that prevention methods most birth control services, including EC, pediatricians are aware of the ways in commonly used by US teenagers without parents and rights to which the underlying beliefs they are condoms and withdrawal. EC is fi con dentiality vary by state. The bring to their clinical practice affect an important back-up method to Guttmacher Institute regularly the care that they provide. which all teenagers should have updates information on the general access. The AAP has issued a policy categories of reproductive health 2. Indications for use of EC include statement on refusal to provide services to which minors can consent unprotected or underprotected 53 information or treatment on the basis by state. Minors in special intercourse, such as failure to use of conscience, stating that circumstances, such as those in the any form of contraception; sexual pediatricians have a duty to inform foster care or juvenile justice systems, assault; and imperfect their patients about relevant, legally may face unique barriers to access contraceptive use (eg, condom fi 54 available treatment options to which and con dentiality. State laws breakage or slippage and missed they object and have a moral regarding reporting age of consent for or late doses of oral contraceptive obligation to refer patients to other sexual activity and mandated pills, contraceptive patch, physicians who will provide and reporting of sexual activity involving contraceptive ring, or injectable 55 educate about those services.65 minors also vary by state. contraception). Pediatricians may also encounter 3. Pediatricians should provide ECPs PERSONAL BELIEFS FOR PHYSICIANS situations in which adolescents and (levonorgestrel or UPA) or Cu-IUD AND PHARMACISTS their parents differ in their insertion to adolescents and young Despite the fact that hormonal EC will acceptance of sexual intercourse and adults who are in immediate need not disrupt an established pregnancy contraception. Recognizing the of EC. In addition, the AAP and studies showing that access to EC importance of parents and families to recommends that pediatricians does not make it more likely that adolescent health and helping provide prescriptions and/or adolescents will engage in more sex adolescents make decisions with a supply of ECPs (with refills and or less likely that they will use which they are comfortable can be condoms) so adolescents have condoms or other challenging. In these cases, it is them on hand in case of future contraceptives,56–58 public and important for pediatricians to be need (ie, advanced provision).

Downloaded from www.aappublications.org/news by guest on September 26, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS When a visit is not possible, ECPs Cu-IUD is not affected by weight. coverage of EC without cost can safely be prescribed over the Patients who do not wish to use sharing to further reduce cost phone without requiring a Cu-IUD or do not have access to barriers. a pregnancy test. IUD insertion should be offered EC 4. ECPs are most effective in pills regardless of their weight. LEAD AUTHORS decreasing risk of pregnancy when 8. Repeat episodes of unprotected used as soon as possible, but may sex during the same cycle after the Krishna K. Upadhya, MD, MPH, FAAP be used up to 120 hours after use of ECPs increase the risk of unprotected or underprotected pregnancy because they work by COMMITTEE ON ADOLESCENCE, 2016–2017 intercourse. Adolescents should be delaying ovulation. Adolescents Cora C. Breuner, MD, MPH, FAAP, instructed to use EC as soon as who use ECPs should be counseled Chairperson possible after unprotected to abstain or use another method Elizabeth M. Alderman, MD, FAAP, FSAHM intercourse and to then schedule to prevent pregnancy until their Laura K. Grubb, MD, FAAP Laurie L. Hornberger, MD, MPH, FAAP a follow-up appointment with next period. Ongoing hormonal Makia E. Powers, MD, MPH, FAAP their primary provider to address contraceptives may be initiated Krishna K. Upadhya, MD, FAAP the need for STI testing and immediately after the use of Stephenie B. Wallace, MD, FAAP ongoing contraception. levonorgestrel ECPs or the Yuzpe 5. Advanced provision of ECPs method. Ongoing hormonal LIAISONS increases the likelihood that contraceptives should not be Liwei L. Hua, MD, PhD – American Academy teenagers will use EC when initiated sooner than 5 days after of Child and Adolescent Psychiatry needed, reduces the time to use, the use of UPA to minimize the Margo Lane, MD – Canadian Pediatric Society and does not decrease condom or risk of interference with UPA Meredith Loveless, MD – American College of other contraceptive use. activity. Nonhormonal methods Obstetricians and Gynecologists Seema Menon, MD – North American Society Levonorgestrel ECPs are available (eg, condoms) may be initiated of Pediatric and Adolescent Gynecology to male and female patients immediately after ECP use. Lauren B. Zapata, PhD, MSPH – Centers for regardless of age without 9. The AAP recommends that all Disease Control and Prevention a prescription but may be adolescents receive counseling expensive when purchased over about EC as part of routine STAFF the counter and are often covered anticipatory guidance in the by insurance with a prescription. context of a discussion on sexual Karen Smith James Baumberger, MPP UPA is available by prescription health and only. Pediatricians should be regardless of current intentions aware that the stock of available for sexual behavior. In addition, it ABBREVIATIONS ECPs, especially UPA, may vary by is important that information pharmacy and that local patterns about EC be included in all AAP: American Academy of of availability, cost, insurance contraceptive and STI counseling Pediatrics coverage, and sources of low-cost for adolescents wherever these CDC: Centers for Disease Control EC in their practice area may affect visits occur, including emergency and Prevention the ability of their patients to departments, clinics, and hospitals. Cu-IUD: copper intrauterine device obtain recommended services. Information provided should EC: emergency contraception 6. When a dedicated ECP product or include indications for use and ECP: emergency contraceptive pill Cu-IUD are not options, the use of options for access, including over- FDA: US Food and Drug combined oral contraceptive pills the-counter availability and Administration for EC (Yuzpe method) may be advance prescription or supply if IUD: intrauterine device recommended. Adverse effects available in the clinic. It is STI: sexually transmitted infection may include nausea, vomiting, and important that pediatricians also UPA: ulipristal acetate abdominal pain, and provide this counseling to coadministration of an antiemetic adolescents with physical and may be considered with this cognitive disabilities and their method. parents. At the policy level, REFERENCES 7. Meta-analyses have suggested that pediatricians should advocate for 1. Shen J, Che Y, Showell E, Chen K, Cheng both levonorgestrel and UPA may low-cost or free, nonprescription L. Interventions for emergency be less effective in individuals access to ECPs for teenagers contraception. Cochrane Database Syst who are overweight. Efficacy of the regardless of age and insurance Rev. 2017;8(8):CD001324

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