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 United States abstract continues to experience birth rates among teenagers that are significantly higher than other high-income nations. Use of emergency contraception (EC) within 120 hours after unprotected or underprotected intercourse can reduce the risk of pregnancy. Emergency contraceptive methods include oral Children’s National Health System, Washington, District of Columbia medications 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 levonorgestrel), 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 intrauterine device. 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; condom 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; oral contraceptive pill, contraceptive patch, contraceptive ring, and injectable she approves the final manuscript as submitted. contraception; vomiting 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 sexual intercourse to reduce the risk of pregnancy. Methods [email protected] currently available in the United States are (1) ulipristal acetate (UPA), an oral progesterone 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 pregnancies 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 ovulation. 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 pregnancy test 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 (Actavis 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 Condoms 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