[Table, Emergency contraceptive pills (ECPs)]. - Medical Eligibility Criteria for Contraceptive Use

EMERGENCY CONTRACEPTIVE PILLS (ECPs)
PREGNANCY	NA	NA	NA	NA = not applicable Clarification: Although this method is not indicated for a woman with a known or suspected pregnancy, there is no known harm to the woman, the course of her pregnancy, or the fetus if ECPs are accidentally used.
BREASTFEEDING	1	1	2	Clarification: Breastfeeding is not recommended for 1 week after taking UPA since it is excreted in breast-milk. Breast-milk should be expressed and discarded during that time (1).
PAST ECTOPIC PREGNANCY	1	1	1
OBESITY ^†	1	1	1	Clarification: ECPs may be less effective among women with BMI ≥ 30 kg/m² than among women with BMI < 25 kg/m². Despite this, there are no safety concerns. Evidence: There is limited evidence from 1 study that suggests obese women with BMI ≥ 30 kg/m² experience an increased risk of pregnancy after use of LNG compared with women with BMI < 25 kg/m² (2). Two studies suggest obese women may also experience an increased risk of pregnancy after use of UPA compared with non-obese women, though this increase was not significant in 1 study (2, 3).
HISTORY OF SEVERE CARDIOVASCULAR DISEASE* (ischaemic heart disease, cerebrovascular attack, or other thromboembolic conditions)	2	2	2
MIGRAINE*	2	2	2
SEVERE LIVER DISEASE* (INCLUDING JAUNDICE)	2	2	2
CYP3A4 INDUCERS ^† (e.g. rifampicin, phenytoin, phenobarbital, carbamazepine, efavirenz, fosphenytoin, nevirapine, oxcarbazepine, primidone, rifabutin, St John's wort/hypericum perforatum)	1	1	1	Clarification: Strong CYP3A4 inducers may reduce the effectiveness of ECPs. Evidence: According to labelling information, rifampicin markedly decreases UPA levels by 90% or more which may decrease its efficacy (1, 4). Theoretical concerns therefore extend to use of other CYP3A4 inducers as well as to COC and LNG ECPs, which have similar metabolic pathways to UPA. A small pharmacokinetic study found that concomitant efavirenz use decreased LNG levels in women taking LNG ECP (0.75 mg) by 56% compared with LNG ECP alone (5).
REPEATED ECP USE	1	1	1	Clarification: Repeated ECP use is an indication that the woman requires further counselling on other contraceptive options. Frequently repeated ECP use may be harmful for women with conditions classified as Category 2, 3 or 4 for combined hormonal contraception (CHC) or POC use.
RAPE*	1	1	1

EMERGENCY CONTRACEPTIVE PILLS (ECPs)

ECPs do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, the correct and consistent use of condoms is recommended. When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.

CONDITION

CATEGORY

CLARIFICATIONS/EVIDENCE

COC

LNG

UPA ^†

^† recommendations reviewed for the MEC 5th edition, further details after this table
* additional comments after this table

COC = combined oral contraceptive
LNG = levonorgestrel contraceptive
UPA = ulipristal acetate

PREGNANCY

NA = not applicable

Clarification: Although this method is not indicated for a woman with a known or suspected pregnancy, there is no known harm to the woman, the course of her pregnancy, or the fetus if ECPs are accidentally used.

BREASTFEEDING

Clarification: Breastfeeding is not recommended for 1 week after taking UPA since it is excreted in breast-milk. Breast-milk should be expressed and discarded during that time (1).

PAST ECTOPIC PREGNANCY

OBESITY ^†

Clarification: ECPs may be less effective among women with BMI ≥ 30 kg/m² than among women with BMI < 25 kg/m². Despite this, there are no safety concerns.

Evidence: There is limited evidence from 1 study that suggests obese women with BMI ≥ 30 kg/m² experience an increased risk of pregnancy after use of LNG compared with women with BMI < 25 kg/m² (2). Two studies suggest obese women may also experience an increased risk of pregnancy after use of UPA compared with non-obese women, though this increase was not significant in 1 study (2, 3).

HISTORY OF SEVERE CARDIOVASCULAR DISEASE*
(ischaemic heart disease, cerebrovascular attack, or other thromboembolic conditions)

MIGRAINE*

SEVERE LIVER DISEASE*
(INCLUDING JAUNDICE)

CYP3A4 INDUCERS ^†
(e.g. rifampicin, phenytoin, phenobarbital, carbamazepine, efavirenz, fosphenytoin, nevirapine, oxcarbazepine, primidone, rifabutin, St John's wort/hypericum perforatum)

Clarification: Strong CYP3A4 inducers may reduce the effectiveness of ECPs.

Evidence: According to labelling information, rifampicin markedly decreases UPA levels by 90% or more which may decrease its efficacy (1, 4). Theoretical concerns therefore extend to use of other CYP3A4 inducers as well as to COC and LNG ECPs, which have similar metabolic pathways to UPA. A small pharmacokinetic study found that concomitant efavirenz use decreased LNG levels in women taking LNG ECP (0.75 mg) by 56% compared with LNG ECP alone (5).

REPEATED ECP USE

Clarification: Repeated ECP use is an indication that the woman requires further counselling on other contraceptive options. Frequently repeated ECP use may be harmful for women with conditions classified as Category 2, 3 or 4 for combined hormonal contraception (CHC) or POC use.

RAPE*

From: II, Using the recommendations

Cover of Medical Eligibility Criteria for Contraceptive Use

Medical Eligibility Criteria for Contraceptive Use. 5th edition.

Geneva: World Health Organization; 2015.

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