Annex 7 · Protocols for emergency contraception

Emergency contraceptive pills

· There are two emergency contraceptive pill (ECP) regimens that can be used: the levonorgestrel-only regimen (this is the recommended regimen) or the combined estrogen-progesterone regimen (Yuzpe).

· In both regimens, a first dose should be taken as soon as convenient, but not later than 72 hours after the rape, and a second dose 12 hours later. There are products that are specially packaged for emergency contraception, but at present they are registered only in a limited number of countries. If pre-packaged ECPs are not available in your setting, emergency contraception can be provided using regular oral contraceptive pills which are available for family planning purposes (see the table below for guidance).

· Counsel the survivor about how to take the pills, what side-effects may occur, and the effect the pills may have on her next period. ECPs do not prevent pregnancy from sexual acts after treatment. If needed, provide her with condoms for use in the immediate future.

· Make it clear to the survivor that there is a small risk that the pills will not work. Most patients will have a normal menstruation within 21 days after the treatment. Menstruation may be up to a week early or a few days late. If she has not had a period within 21 days after the treatment, she should return to have a pregnancy test or to discuss the options in case of pregnancy.

· Side effects: especially if the Yuzpe regime is used, nausea can occur. If vomiting occurs within 2 hours of taking a dose, repeat the dose.

· Precautions: ECPs will not be effective in the case of a confirmed pregnancy. ECPs may be given when the pregnancy status is unclear and pregnancy testing is not available, since there is no evidence to suggest that the pills can harm the woman or an existing pregnancy. There are no other medical contraindications to use of ECPs.

^a EE = ethinylestradiol; LNG = levonorgestrel; NG =norgestrel.

(Adapted from: Consortium for Emergency Contraception, Emergency contraceptive pills, medical and service delivery guidelines. Seattle, WA, 2000).

Use of an intrauterine device (IUD) as an emergency contraceptive

· If the survivor presents within five days after the rape, insertion of a copper-bearing IUD is an effective method of emergency contraception. It will prevent more than 99% of expected subsequent pregnancies.

· Women should be offered counselling on this service so as to reach an informed decision.

· A skilled provider should counsel the patient and insert the IUD.

· The IUD may be removed at the time of the woman's next menstrual period or left in place for future contraception.