Emergency Contraception and Sexually Transmitted Infection: Counseling and Opportunities!

It's important for healthcare providers to keep abreast with social norms concerning sexual activity. Several recent articles call attention to the use of contraception in general and emergency contraception specifically.

First, a survey of 2438 heterosexual men who had used an online dating service in the previous year found that men are more likely than not to use contraceptives. Regardless, 20% to 40% of men who reported sexual encounters had not used contraception. The researchers found several interesting points:

• Older men were much more likely to use contraceptives for the purpose of birth control than younger men were. A full 82% of men aged 50 years or older reported using contraception during their last sexual encounter, compared to 69% of men who were 50 or younger.

• Older men were less likely to perceive a need to use condoms than younger men, and were more likely to rely on a vasectomy for contraception.

• The most common contraceptive methods employed were condoms for 35% of participants, vasectomy for 22%, and contraceptive pills (used by the partner) in 21% of encounters.

• Not all men believed that they should share decision-making about contraception with their female partner. In fact, only 57% of men indicated they should share decision-making with their partners during a one-night stand. The likelihood that they would share decision-making increased to 75% for casual relationships and 92% for long-term relationships.

• Approximately one third of participants perceived that emergency contraceptive could be harmful to a woman's health, and 37% of participants indicated they didn't know enough about emergency contraception to answer questions.

The bottom line message here is that younger people and people who are involved in casual sexual behavior remain at highest risk for inadvertent pregnancy and sexually transmitted infection. And, significant misconceptions still circulate about emergency contraception.

Researchers at the Hunter College, City University of New York, School of Nursing interviewed 21 young women (between the ages of 18 and 24) who had recently used over-the-counter emergency contraceptives to determine their perceptions about risk for sexually transmitted infection (STI). Nearly 30% of participants had experienced an STI (chlamydia, gonorrhea, or any other except HIV) in the years before using emergency contraception. Because of this, the researchers fully expected that these participants would have a heightened awareness of sexually transmitted infection.

Conversely, they found that although these women now had a need for emergency contraceptives to prevent unintended pregnancy, the women did not perceive that they were at risk for STI. Most of these women had steady partners or had had sex with partners known to them, and perceived lower risk for infection because they knew the men with whom they were sleeping. They were extremely trusting. These researchers note that when women seek emergency contraception, healthcare providers have an opportunity to counsel about contraception and protection against sexually transmitted infections.

Recently the American College of Obstetricians and Gynecologists' Committees on Health Care for Underserved Women released an opinion statement about access to emergency contraception and counseling. They remind healthcare providers that when women ask for emergency contraception after an episode of unprotected sexual activity, counseling is imperative. Among the recommendations are the following:

• Discuss all contraceptive methods with the patient and encourage her to adopt a regular method.

• Women need emergency contraception as soon as possible after unprotected intercourse, and it is most effective if taken within 24 hours. However, the very latest a woman should take emergency contraception is within 120 hours of the sexual event.

• Make patients aware that a copper intrauterine device (IUD) is the most effective form of emergency contraception available. If possible, encourage the woman to have the IUD inserted immediately, possibly on the same day that she visits for the emergency contraception. A copper IUD can prevent pregnancy if inserted within five days of unprotected intercourse

• The prescription medication ulipristal acetate is more effective than levonorgestrel for up to five days after unprotected intercourse. If you prescribe this medication, call the pharmacy and ensure that they have it available.

• Collaborate with your pharmacist if the patient chooses to use an over-the-counter levonorgestrel so that you provide the same healthcare messages. Talk to a knowledgeable and cooperative member of the pharmacy staff, and ensure that the pharmacist is willing to work with the patient.

• Advise overweight and obese women that levonorgestrel appears to be less effective at preventing pregnancy, but if they choose to use OTC emergency contraception, do not discourage them from doing so.

• Provide patient education materials for the patient to take home with her, and make notes in your electronic health record to remind yourself or help other clinicians follow up when the patient returns.

• Educate patients that emergency contraception will not end an established pregnancy. Healthcare providers need to dispel the myth that emergency contraception will cause an abortion.

• Consider providing an advance prescription for ulipristal acetate that the patient can use later if necessary.

• Have a plan to deal with barriers like language, the stigma of sexual assault, and transportation. Translation services can help discuss problems with patients who speak languages other than your own. Know your state and local rules about sexual assault and make sure that women who have been assaulted have access to emergency contraception. Help women find transportation if they need it. And, encourage your local jails and prisons to screen women who are arrested for recent unprotected sexual activity; nearly 1/3 of these women could benefit from emergency contraception.

ACOG has a number of free resources available to healthcare providers. Find them at https://www.acog.org/More-Info/EmergencyContraception.

Sources:

Committee Opinion No 707: Access to Emergency Contraception. Obstet Gynecol. 2017 Jul;130(1):e48-e52.

Hickey MT, Shedlin MG. Emergency contraceptive pill users' risk perceptionsfor sexually transmitted infections and future unintended pregnancy. J Am Assoc Nurse Pract. 2017 Jun 22. doi: 10.1002/2327-6924.12485. [Epub ahead of print]

Stewart M, Ritter T, Bateson D, McGeechan K, Weisberg E. Contraception? What about the men? Experience, knowledge and attitudes: a survey of 2438 heterosexual men using an online dating service. Sex Health. 2017 Jun 16. doi: 10.1071/SH16235. [Epub ahead of print]