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According to experts, the demographic situation in the Russian Federation at the moment is unfavorable. There is a decrease in fertility, but not due to the use of highly effective contraception, but because of the still high number of abortions. Despite the fact that in recent years there has been a decrease in the number of abortions in the country, their level is quite high (according to the Ministry of Health and Social Development of the Russian Federation, in 2004 this figure was 40.6 per 1000 women of fertile age).
One of the methods to reduce the number of unplanned pregnancies is emergency contraception (EC). In some cases (rape, coercion to have sexual contact), emergency contraception is the only method of contraception and is used as an extraordinary measure of protection not only from unwanted pregnancy, but also from the psychological trauma associated with it.
WHO experts believe that many women in the world are not aware of the existence of sufficiently effective methods of EC, and therefore do not seek medical attention in a timely manner. The lack of information about the methods of EC is one of the reasons for the high incidence of unwanted pregnancies and subsequent artificial abortions.
In recent years, interest in this method of contraception has increased significantly, developed an effective scheme of its use.
Emergency, or postcoital contraception is considered to be the means that a woman can use within a few days after unprotected intercourse to prevent pregnancy. In the literature, this method of contraception has many names, in particular “emergency”, “emergency”, “urgent”, “fire” and even “the morning after ...”, but perhaps the most successful name is “emergency”, which indicates that this method should be applied in emergency, extreme cases.
The goal of EC is to prevent unwanted pregnancy after unprotected intercourse at the stages of ovulation, fertilization and implantation.
Emergency contraception should be recommended as an emergency measure of protection from unwanted pregnancy for women who have been raped; if there are doubts about the integrity of the used condom; in situations where sexual contact is shifted
contraceptive intravaginal diaphragm; during ex-pulsation of the Navy; skipping oral contraceptive use or in cases where the planned methods of contraception for some reason cannot be used. Patients who rarely have sex, and young women who may have unwanted pregnancies after sexual contact without the use of contraceptives, also need postcoital contraception.
It is known that the probability of conception is not the same during the menstrual cycle. So, J.Barret et al. (1969) calculated that the risk of pregnancy after unprotected sexual intercourse averages 20% during all days of the menstrual cycle and rises to 30% or more during the peri-ovulatory period. A study in the UK showed that during sexual intercourse during ovulation, approximately 50% of women become pregnant during the first cycle. It is known that the viability of sperm cells in the female genital tract lasts from 3 to 7 days, and an unfertilized egg cell lasts 12-24 hours. In this regard, according to most researchers, it is advisable to prescribe EC during the first 24-72 hours after sexual contact.
The absolute contraindications for hormonal EC method are the same as for hormonal contraceptives: history of thromboembolism, thrombophlebitis, severe liver disease, bleeding of unknown etiology, breast cancer and endometrium. It is also undesirable to use it intensively smoking women over 35 years.
The most effective are two methods of EC: the use of hormonal drugs and the introduction of intrauterine contraceptive.
Hormonal emergency contraception
For emergency contraception, the following hormonal agents can be used: estrogens, estrogen-testagenic drugs, gestagens, antigonadotropins, antiprogestins.
The mechanism of the action of hormonal EC, according to different authors, is in violation of the menstrual function, suppression or distance of the ovulation process, violation of the processes of fertilization, transport of the fertilized egg and its implantation. Despite the fact that opinions about the mechanism of hormonal EC action are contradictory, most authors believe that it has a major effect on the endometrium, disrupting the process of implantation of the embryo.
Estrogens were among the first drugs used for emergency contraception. This method was proposed by A.Haspels in the 60s. However, the author’s first publications on the use of high doses of estrogens refer to the years 1972 and 1976. In the literature there is information about the use of diethylstilbestrol, conjugated estrogen, ethinyl estradiol for 5 days after sexual intercourse.
The method of emergency contraception by estrogens is recognized as highly effective, but in recent years it has been rarely used, since its use has a fairly high frequency of adverse reactions in the form of nausea and vomiting and complications associated with violations of blood coagulation factors are not excluded. In addition, most researchers believe that with the ineffectiveness of the method, the resulting pregnancy should be interrupted, since estrogens can have a teratogenic effect on the fetus.
Combined estrogen-progestin drugs
Combined estrogen-progestin drugs are one of the most common means of emergency contraception. This method is called the Albert Yuzpe method, after the Canadian doctor, who first applied it and began to widely promote it. The method consists in the double appointment of 200 μg of ethinyl estradiol and 1 mg of levonor-Gestrela within 72 hours after sexual intercourse with a break of 12 hours.
One of the advantages of this method is that for the purpose of EC it is possible to use almost any commercially available combined hormonal drug, including a low-dose one, and the number of tablets will vary depending on their composition and dosage.
The effectiveness of the Yuzpe method has been studied by various authors. According to A.Yuzpe et al. (1974), it is 96-98%. The effectiveness of the Yuzpe method depends on the duration of the interval between sexual contact and the use of EC (the smaller the interval, the higher the efficiency), as well as the day of the menstrual cycle during which sexual intercourse occurred. Analysis of the literature data showed that the effectiveness of this method is reduced if unprotected sexual intercourse occurred immediately before ovulation.
Side effects in the form of nausea, vomiting, dizziness are observed, according to different authors, with different frequency. So, R.No and M.Kwan (1993) noted nausea in 40.5%
women, vomiting - in 22.4%, dizziness - in 23.1%, breast tenderness - in 22.8%.
Thus, the Yuzpe method is an effective means of hormonal EC, but 1/3 of women have side effects.
The use of levonorgestrel for emergency contraception was first reported by R. No and M. Kwan (1993).
Levonorgestrel is a synthetic compound structurally related to norethisterone, strongly and selectively binding to progesterone receptors and exhibiting biological activity without any prior transformations. This is the most active progestogen, which is a derivative of 19-norsteroidov. It has a longer half-life, as it does not have the effect of primary passage through the liver, which ensures 100% biological activity.
Levonorgestrel does not have an estrogenic effect and has a slight androgenic effect, as well as a pronounced affinity for progesterone receptors. This explains its most pronounced progestogenic effect, in particular on the endometrium. Progestins inhibit the mitotic activity of endometrial cells, causing its early secretory transformation, which prevents the implantation of a fertilized egg. In addition, progestogens reduce the contractile activity of the fallopian tubes by reducing the contractile activity and the threshold of excitability of muscle cells, which explains one of the mechanisms of EC - a violation of egg transport. Progestins have an inhibitory effect on the secretion of gonadotropic hormones and, as a consequence, prevent ovulation.
In 1998, a randomized controlled study on the use of levonorgestrel was completed compared to the Yuzpe method for EC, which was approved by WHO. The results of the study showed that the effectiveness of levonorgestrel is higher than that of the Yuzpe method - 98.9 and 96.8%, respectively. Levonorgestrel tolerance was also better than the Yuzpe method: nausea was observed in 23.4 and 50.5% of women, respectively, vomiting - in 5.6 and 18.8%, dizziness - in 11.2 and 16.7%, fatigue - in 16.9 and 28.5%.
Thus, the effectiveness of levonorgestrel is higher, and tolerability is better than the Yuzpe method.
According to the authors of the study, this is due to the peculiarities of the interaction of estrogen and progestin, as well as
lower dose of levonorgestrel using the Yuzpe method. The following conclusion was made: the Yuzpe method can be replaced by the use of levonorgestrel, which is more effective and is characterized by a lower incidence of side effects.
In Russia, two drugs containing levonorgestrel are registered for emergency contraception: Postinor and Esca-sing.
A postinor containing 0.75 mg of levonorgestrel in one tablet is recommended as follows: one tablet no later than 72 hours after sexual intercourse, another tablet should be taken 12 hours later.
Eskapel contains 1.5 mg of levonorgestrel and is applied once no later than 96 hours after unprotected sexual intercourse.
The efficacy and safety of a single dose of 1.5 mg of levonorgestrel - the dose contained in Escapel is confirmed by the results of a WHO study, in which more than 4,000 women from 14 countries participated.
This emergency mode is recommended by the emergency contraceptive consortium as a first choice method.
If you follow the recommended dosing regimen, levonorgestrel does not significantly affect blood clotting factors, fat and carbohydrate metabolism.
On the basis of the Scientific Center for Obstetrics, Gynecology and Peri-Natology, in 2000, the Center for Emergency Contraception (CEC) was established.
910 cases of levonorgestrel use (Postinor, containing 750 mcg of levonorgestrel in one tablet) as an emergency contraceptive preparation were analyzed.
The effectiveness of levonorgestrel was 98.6%. Adverse reactions in the form of nausea were observed in 17.9% of women, vomiting - in 5.3%, mastalgia - in 15.9%, headache - in 13.3%.
Among women who applied to the Emergency Contraception Center, in 38 patients (aged 16 to 25 years), unprotected sex was the result of sexual violence. Postinor was recommended for all women according to the standard scheme. Analysis of the results showed that no pregnancy occurred in any patient. Adverse reactions in the form of headache were observed in 7.9% of patients, nausea - in 13.2% (Prilepskaya V.N., Bebneva T.N., 2002).
Danazol is a semisynthetic steroid derived from 17a-ethynyltestosterone, which has the ability to suppress the production of gonadotropins (LH and FSH) hy-
of course, resulting in inhibition of ovulation and endometrial atrophy.
For the first time, the use of danazol for emergency contraception was reported by S. Rowland et al. (1983). The frequency of pregnancy was 6%, but side effects (nausea, vomiting) were observed much less frequently than when using the Yuzpe method. For the purpose of emergency contraception, danazol is recommended to be taken twice in 600 mg with an interval of 12 hours for 72 hours after unprotected intercourse.
According to G.Zuliani et al. (1982), the frequency of pregnancy with the use of danazol as an emergency contraception was: at a dose of 800 mg - 1.7%, at a dose of 1200 mg - 0.8%. Currently, danazol for the purpose of emergency contraception is rarely used because of the small number of studies on this issue.
This synthetic antiprogestin, specifically blocking progesterone receptors, is a steroid derivative of norethisterone. The drug is known as a tool for the production of medical abortion in the early stages. Mifepristone can also be used for the purpose of EC, especially in cases where other hormonal methods of contraception are contraindicated in a woman. Depending on the phase of the cycle, mifepristone blocks or delays ovulation or interferes with endometrial transformation.
Until recently, for EC, mifepristone was used in a dose of 600 mg once for 72 hours or 200 mg from the 23rd to the 27th day of the menstrual cycle.
Under the leadership of WHO (1999), a multicenter randomized study was conducted comparing the efficacy and side effects of a single dose of 600, 50, and 10 mg of mifepristone for emergency contraception. The results of this study showed that the dose of mifepristone can be reduced to 10 mg without decreasing the effectiveness. The frequency of pregnancy at doses of the drug 10, 50, 600 mg was respectively 1.2; 1.1 and 1.3%. After taking mifepristone, the following side effects were observed: nausea, vomiting, headache, tension in the mammary glands, abdominal pain. The most frequent delay was menstruation: in 36% of cases with a dose of mifepristone 600 mg, in 23% with a dose of 50 mg and in 18% with a dose of 10 mg. The results of the same study showed that the effectiveness of mifepristone does not decrease with an increase in the interval between sexual
Fig. 2.32. Mifepristone.
intercourse and taking the drug up to 120 hours, which is an advantage over the Yuzpe method and levonorgestrel.
In Russia, Mifepristone-72 (10 mg) and Mifepristone 10 mg (“MIR-PHARM”) drugs for emergency contraception have been registered.
A clinical study was conducted at the Scientific Center for Obstetrics, Gynecology and Perinatology, Russian Academy of Medical Sciences to study the efficacy and safety of the drug Mifepristone (10 mg) of the MIR-PHARM company (Fig. 2.32). Surveyed 30 women aged 18 to 33 years (mean age 23.8 + 1.7 years) who applied for the selection of emergency contraception and had no contraindications for the use of hormonal methods of contraception. Mifepristone was prescribed according to the scheme: 10 mg once no later than 72 hours after unprotected intercourse. The results of the study showed that the efficacy of Mi-Fepristone was 100%: no pregnancy occurred in any of the 30 patients. Adverse reactions were observed in 16% of patients in the form of longer (up to 46 days on average) or postponing cycles (34-36 days). After 3 months after the use of mifepristone, the cycle was regular in all the examined patients.
Intrauterine emergency contraception
Introduction IUD can be made within 5-7 days after unprotected sex. There is evidence that the effectiveness of this method is higher than when using the Yuzpe method. With the appointment of intrauterine
contraception as an EC should take into account the individual characteristics of the woman, contraindications to the introduction of the IUD, and the patient’s desire to continue using this method for a long time. Considering the risk of inflammatory diseases of the uterus and appendages during the first 10-14 days after the introduction of the IUD, it is not advisable to use it as an EC for young patients who have not given birth in the presence of a large number of sexual partners, for occasional sexual relationships.
An important advantage of intrauterine contraception is that the IUD can be used by women who turned to the doctor after 72 hours after unprotected sexual intercourse, when the hormonal method is too late to use.
Absolute contraindications to the use of IUDs for the purpose of EC are the same as for other types of intrauterine contraception (pregnancy, STIs or pelvic inflammatory diseases in the present or in the last 3 months before the IUD insertion, previous septic abortion or sepsis after childbirth, sexual bleeding pathways of unknown etiology, cervical cancer).
Efficiency, the absence of hormonally dependent side effects, the possibility of using it later than 72 hours after unprotected sexual intercourse and further prolonged use allow using this method in cases where the hormonal EC method is too late to use.
Patient Counseling Basics
before and after emergency contraception
Before using EC it is necessary to provide individual advice on the correct application of the method, its advantages and disadvantages.
In the Emergency Contraception Center on the basis of the NTS AGiP RAMS, an algorithm for counseling and managing patients before and after the appointment of EC is proposed:
1. Specification of the date of the last menstruation and the exclusion of a possible pregnancy. Если у пациентки не было менструации в ожидаемый срок по другим причинам (применение инъекционного контрацептива, послеродовой период, кормление грудью, нерегулярный менструальный цикл) или пациентка не помнит дату последней менструации, до тех пор пока не будет проведен тест на беременность, ЭК рекомендовать нельзя.
2. Уточнение интервала времени, прошедшего с момента незащищенного полового акта. Если с момента незащищенного полового акта прошло более 72 ч, гормональные методы ЭК рекомендовать не следует, так как их эффективность в данном
случае значительно снижается. Следует проконсультировать пациентку о возможности применения ВМС с целью ЭК (до 5 дней после незащищенного полового акта). После применения ЭК до наступления следующей менструации следует регулярно пользоваться каким-либо дополнительным методом контрацепции.
3. Информирование пациентки о возможных побочных эффектах после применения ЭК. Если у пациентки отмечается рвота в течение 2 ч после приема гормональной таблетки, то дозу необходимо повторить. Если менструация наступает на неделю позже предполагаемого срока, то необходимо рекомендовать пациентке проведение тестов на беременность.
4. Медицинское наблюдение за пациентками после применения ЭК предусматривает исключение возможной беременности, консультирование относительно выбора метода плановой контрацепции и обучения навыкам правильного применения современных контрацептивов.
Результаты исследований свидетельствуют о том, что любой метод экстренной контрацепции значительно безопаснее, чем аборт, но плановая контрацепция предпочтительнее, чем экстренная.
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Еще в древние времена женщины после полового контакта исполь-зовали те или иные препараты и приспособления, пытаясь предотвратить наступление беременности. Физические упражнения для выведения спермы из половых путей, зелья, семена или травы, принимаемые орально или вводимые во влагалище, а также посткоитальное спринцевание — вот неполный перечень средств, которые известны еще с 1500 г. до н.э.
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