Emergency Contraception - American Academy of Pediatrics

Page created by Tiffany Cannon
 
CONTINUE READING
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
                                                                                         into account individual circumstances, may be appropriate.
other physicians on available emergency contraceptive methods; (2) provide
                                                                                         All policy statements from the American Academy of Pediatrics
current data on the safety, efficacy, and use of EC in teenagers; and (3)                 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
                                                                                         involvement in the development of the content of this publication.
BACKGROUND INFORMATION
                                                                                         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                   kupadhya@childrensnational.org
currently available in the United States are (1) ulipristal acetate (UPA), an
                                                                                         PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
oral progesterone receptor agonist-antagonist; (2) levonorgestrel (LNG),
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.
likely to be effective the sooner they are used.1 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.
                                                                                           Emergency Contraception. Pediatrics. 2019;144(6):
initiated sexual intercourse.2 Most teenagers report first intercourse with
                                                                                           e20193149
a steady partner and consensual sex.3 Approximately 11% of US high

                                   Downloaded from www.aappublications.org/news by guest on July 31, 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
to all available contraceptive methods     Yuzpe method) that have been                     Progestin-Only Pills
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 benefit of                   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                                                                 of 2 pills, current regimens are
                                           prescribed in advance of need.14 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;                                                            should be taken within 72 hours of
                                           people of all ages15; however, barriers
however, both methods require strict                                                        unprotected intercourse; however,
                                           to access include cost and availability
adherence by the user to be                                                                 data support that use up to 120 hours
                                           in pharmacies.16 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                                                         levonorgestrel as soon as possible
                                           prescribe it.17–21 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                                                        required before use. Adolescents are
                                           EC Pills
most recent analysis from the Centers                                                       advised to test for pregnancy (at
for Disease Control and Prevention         UPA Progesterone Agonist-Antagonist              home or in a clinic) if they do not
(CDC) indicates that only 3% of 15- to     In August 2010, the FDA approved                 have a period within 3 weeks of EC
19-year-olds who have ever had sex         a progesterone agonist-antagonist,               use. It is important for patients to
have used an IUD, and 3% report ever       UPA, for use as an EC.22 UPA binds to            know that levonorgestrel use may
having used an implant.12                  the human progesterone receptor,                 cause the next period to come sooner

                              Downloaded from www.aappublications.org/news by guest on July 31, 2021
2                                                                                                FROM THE AMERICAN ACADEMY OF PEDIATRICS
TABLE 1 Selected Regimens for EC Available in the United States
 Brand                                                     First Dose                             Second Dose, 12 h Later           Ethinyl Estradiol   Levonorgestrel
                                                                                                                                           per               per
                                                                                                                                        Dose, mg           Dose, mg
 Progestin-only pills
    Next Choice or Plan B                                   2 pills                                         None                            0                1.5
    Plan B One Step                                          1 pill                                         None                            0                1.5
    Ovrette                                                20 pills                                       20 pills                          0                0.75
 Other ECP: ella                                        30 mg of UPA                                         —                             —                  —
 IUD: Paragard                               Insert within 120 h of unprotected             Insert within 120 h of unprotected             NA                 NA
                                                         intercourse                                    intercourse
 Combined estrogen and progestin
   pills
   Ovral                                                  2 white pills                                  2 white pills                    100                0.5
   Levora                                                 4 white pills                                  4 white pills                    120                0.6
   Nordette                                           4 light-orange pills                           4 light-orange pills                 120                0.6
   Seasonale                                               4 pink pills                                   4 pink pills                    120                0.6
   Triphasil                                             4 yellow pills                                 4 yellow pills                    120                0.5
   Alesse                                                  5 pink pills                                   5 pink pills                    120                0.5
Additional combinations are available at https://ec.princeton.edu/questions/dose.html#dose. NA, not applicable.

than expected.1 Because use of ECPs                            Practice Recommendations for                                 by the timing of use within the
may result in a delay in ovulation, it is                      Contraceptive Use” and professional                          menstrual cycle. A recently published
imperative to counsel patients to                              organizations such as the American                           meta-analysis of ECP trial data
abstain from intercourse or use                                College of Obstetricians and                                 compared the effectiveness of EC
condoms for pregnancy prevention                               Gynecologists acknowledge the use of                         methods. Pooled data from trials
until the next menses.                                         combination oral contraceptives as                           suggest that UPA resulted in fewer
                                                               safe and effective for EC.25,26                              pregnancies than levonorgestrel did
Combined Hormonal Regimens (Yuzpe                                                                                           (relative risk, 0.59; 95% confidence
Method)                                                        IUD                                                          interval, 0.35–0.99; 2 randomized
The use of combination oral                                    Studies have established that the                            controlled trials, n = 3448; I2 = 0%;
contraceptives for EC is commonly                              insertion of a Cu-IUD within 5 days of                       high-quality evidence).1
referred to as the Yuzpe method.13                             unprotected or underprotected                                Levonorgestrel also resulted in fewer
Used since 1974, its acceptability and                         intercourse is the most effective                            pregnancies than the Yuzpe method
efficacy were limited by adverse                                method of EC.27–29 It must be                                did (relative risk, 0.57; 95%
effects of nausea and vomiting. The                            inserted by a trained provider. In                           confidence interval, 0.39–0.84; 6
Yuzpe method involves taking 2 doses                           comparison with ECPs, the                                    randomized controlled trials, n =
of pills 12 hours apart, each                                  effectiveness of the Cu-IUD for EC                           4750; I2 = 23%; high-quality
containing a minimum of 100 µg of                              results from the copper component                            evidence).1 It should be noted,
ethinyl estradiol and a minimum of                             and is not believed to vary by time of                       however, that current CDC guidance
500 µg of levonorgestrel. Other pill                           insertion within 120 hours of                                does not indicate a preference for
formulations used for EC are included                          unprotected or underprotected sex.                           UPA over levonorgestrel regimens.
in Table 1. Similar information is                             The mechanisms of action of                                  Two secondary analyses of ECP trial
available from the Office of                                    hormonal IUDs differ from those of                           data identified that repeat
Population Research at Princeton                               the Cu-IUD, and hormonal IUDs have                           unprotected intercourse in the same
University, which maintains                                    not been approved for use as EC. One                         cycle was associated with EC
a comprehensive source of                                      published study found that women                             failure.31,32 The delay of ovulation
information on EC (http://ec.                                  presenting for EC who desired an IUD                         from ECPs highlights the need for
princeton.edu/). The availability of                           for contraception could be offered                           abstinence or contraception after
many combination oral                                          levonorgestrel ECPs and also have                            ECP use.
contraceptives with norgestrel or                              a hormonal IUD placed at the same
levonorgestrel makes this alternative                          visit for ongoing contraception.30
particularly helpful when there is no                                                                                       EFFECT OF BMI ON EFFECTIVENESS OF
or limited access to an EC product.                                                                                         ALL METHODS
Although combination oral                                      COMPARATIVE EFFECTIVENESS OF ECPS                            Efficacy of the Cu-IUD is not affected
contraceptives have not been labeled                           The effectiveness of oral EC depends                         by body weight. CDC
specifically for EC, the CDC “Selected                          on inhibiting ovulation and is affected                      recommendations indicate that young

                                     Downloaded from www.aappublications.org/news by guest on July 31, 2021
PEDIATRICS Volume 144, number 6, December 2019                                                                                                                           3
women in need of EC who do not               the use of UPA. Finally, repeat use of           vomiting can be decreased
wish to use a Cu-IUD or who do not           ECPs should prompt discussion of                 significantly by using an antiemetic
have access to IUD insertion should          more effective, ongoing                          1 hour before an estrogen-containing
be offered ECPs regardless of their          contraception, but there is no specific           regimen. Antiemetics are ineffective if
weight.                                      limit on repeated use, including                 taken after nausea is already
Although no clinical trials have             within the same cycle. As noted                  present.41 If vomiting occurs within
specifically evaluated the impact of          below, however, the use of hormonal              3 hours of a dose, the dose should be
BMI on the effectiveness of oral EC,         contraceptives within 5 days of UPA              repeated. As with daily use of oral
meta-analyses have suggested that            may reduce the effectiveness of UPA.             contraceptives, other adverse effects
both levonorgestrel and UPA may be                                                            might include fatigue, breast
                                             Ulipristal                                       tenderness, headache, abdominal
less effective in adolescents and
women who are overweight.31–33 In            The most common adverse effects                  pain, and dizziness. It should be noted
response to these data and labeling          reported by users of UPA include                 that CDC Medical Eligibility Criteria
changes to EC products in Europe, the        headache (18%), nausea (12%), and                indicate that benefits of estrogen-
FDA conducted its own review of the          abdominal pain (12%).36 It is                    containing pills for EC generally
evidence and issued a statement in           recommended to redose UPA if                     outweigh the risks of use even in
2016 indicating that the data                vomiting occurs within 3 hours of the            adolescents or women with health
regarding BMI and the effectiveness          initial dose. For clinicians who are             conditions, such as thromboembolic
of levonorgestrel EC are conflicting          providing this medication in a setting           disease (ie, category 2).35
and made no labeling changes. The            where the patient is discharged
                                             before 3 hours after the dose and                Cu-IUD
FDA stated that there are no safety
concerns with the use of                     without an ongoing relationship with             The Cu-IUD can be inserted within
levonorgestrel EC in women with BMI          the patient (ie, emergency                       5 days of the first act of unprotected
greater than 25 or with body weight          departments or urgent care), it may              sexual intercourse as EC. Otherwise,
greater than 165 pounds and that the         be important to discuss provisions for           eligibility criteria and initiation
most important factor affecting the          repeat dosing with patients if                   procedures for the Cu-IUD are the
medication’s effectiveness is how            indicated.                                       same for emergency or
quickly it is taken after unprotected                                                         nonemergency Cu-IUD insertion. Pain
                                             Levonorgestrel-Only Methods                      with insertion is possible with use of
or underprotected intercourse.34
                                             The most common adverse effect                   the Cu-IUD for EC, and some patients
                                             reported after use of levonorgestrel             may be fearful of pain and/or the
ADVERSE EFFECTS AND                          EC is heavier menstrual bleeding;                required pelvic examination. Events
CONTRAINDICATIONS                            spotting may also be reported.37 The             associated with ongoing use of the
The only contraindication for use of         rate of nausea and vomiting with                 Cu-IUD include expulsion (∼6% in
EC is known pregnancy. According to          levonorgestrel EC is approximately               first year) and heavy menstrual
the CDC Medical Eligibility Criteria for     half that with the Yuzpe method, and             bleeding and/or painful periods
Contraceptive Use, pregnancy is an           the routine use of antiemetics is not            (∼12%). Contraindications for Cu-
absolute contraindication for                indicated. If vomiting does occur                IUD use include anatomic features
insertion of a Cu-IUD (category 4).35        within 3 hours of use, the dose should           that prevent insertion, Wilson
ECPs are not indicated for use in            be taken again. Repeated use of                  disease, and signs of active cervical
patients with documented or                  levonorgestrel EC is associated with             and/or pelvic infection.35 Of note,
suspected pregnancy; however,                the same adverse effects as 1-time               negative STI test results are not
according to CDC Medical Eligibility         use. A Cochrane Review of the subject            required before the insertion of an
Criteria, no harms to the woman,             found no serious adverse effects in              IUD. However, if an adolescent has
pregnancy, or fetus of inadvertent           trials of repeated use.38                        not been screened for gonorrhea and
ECP use during pregnancy are known                                                            Chlamydia according to screening
to exist.35 Use of ECPs will not disrupt     Yuzpe and Estrogen-Containing                    guidelines,42 screening can be
a pregnancy that is implanted in the         Methods                                          performed at the time of IUD
uterus, and ECPs are not                     The most common adverse effects                  insertion, and IUD insertion should
abortifacients. Years of use of              that occur during the first 24 to                 not be delayed. The American College
hormonal contraceptives indicate that        48 hours of using estrogen-containing            of Obstetricians and Gynecologists
there is no risk of teratogenicity from      EC methods are nausea (∼50%) and                 Long-Acting Reversible Contraception
use of levonorgestrel EC or the Yuzpe        vomiting (∼20%), which seem to be                Program provides links to resources
method. There have also been no              unaffected by food intake.39–41 The              for clinicians who are interested in
reports of fetal malformations after         severity and incidence of nausea and             obtaining training on IUD insertion

                                Downloaded from www.aappublications.org/news by guest on July 31, 2021
4                                                                                                  FROM THE AMERICAN ACADEMY OF PEDIATRICS
(www.acog.org/About-ACOG/ACOG-                   individuals at risk of pregnancy, it is          average cost of UPA in studied
Departments/Long-Acting-                         important for young men to be                    pharmacies was approximately $50.
Reversible-Contraception).                       counseled on this method as well as              Another study of pharmacy
                                                 on condom use and the regular use of             availability of UPA was conducted in
                                                 other contraceptive methods so that              Massachusetts and reported that 7%
OTHER CLINICAL CONSIDERATIONS                    they can communicate with their at-              of pharmacies surveyed had UPA in
Initiating Contraception After Use of            risk partners about optimal                      stock.44
ECPs                                             contraceptive use.
                                                                                                  Although EC methods are indicated
Although there is no specific                                                                      for use only in patients at risk of
contraindication for repeated use of             ADOLESCENTS AND EC: AWARENESS                    pregnancy, previous AAP policy
EC, it should be emphasized to                   AND ACCESS                                       statements advised that educating
patients that ECPs are intended for              Data from the CDC indicate that the              adolescent male patients is
emergency use and routine use of                 use of EC by female teenagers who                important.45 Evidence suggests that
ECPs to prevent pregnancy is not as              had sexual intercourse at least once             most male teenagers are not
effective as the regular use of other            has increased over the past decade               knowledgeable about EC.45–47 One
forms of contraception. Ongoing                  from 8% in 2002 to 22% in 2011 to                study conducted among an older
hormonal contraceptives may be                   2013.2 This increase is likely related           adolescent and young adult
initiated or resumed immediately                 to regulatory changes that increased             population (ages 18–25 years)
after use of levonorgestrel ECPs or              nonprescription access to                        recruited from a Job Corps site and
the Yuzpe method; however, condoms               levonorgestrel EC during this time.              a free clinic in Los Angeles surveyed
or abstinence should be used in                  Despite the FDA approval of                      male and female participants and
addition for 7 days for back-up                  levonorgestrel for over-the-counter              found that 18% of male participants
protection.25 Initiation of ongoing              access without an age restriction,               reported having a partner who had
hormonal contraceptives after the use            additional access barriers remain. In            previously used EC.48 Significantly
of UPA should be delayed for 5 days              its most recent survey, the American             fewer male than female participants
to minimize the risk of interference             Society for Emergency Contraception              in that study reported having
with UPA activity.25 Prescriptions or            found that only 64% of pharmacies                received information about EC from
a supply of hormonal contraceptives              have ECPs in stock on their shelves,             a health care provider. Another study
can be given at the time of UPA                  and among those that do, nearly half             of a younger convenience sample of
provision; however, patients should              use a lock of some kind requiring                sexually experienced adolescent male
be instructed not to initiate them               employee assistance to obtain it from            participants (ages 13–24 years) in
until 5 days after the dose of UPA. In           the shelf.16 Additionally, despite               Denver reported that only 42% had
addition, as with levonorgestrel or              multiple brand-name and generic                  heard of EC.49 One study explored
the Yuzpe method, patients should be             products on the market, the cost of              how willing young men are to accept
counseled to abstain from intercourse            levonorgestrel ECPs remains at $40 to            an advanced supply of EC in a clinic
or use condoms for 7 days after the              $50, on average. This cost may be                setting and found that a majority who
initiation of ongoing contraception or           prohibitive, so pediatricians are                were offered EC accepted it.46
until the start of their next period,            encouraged to be aware of other                  It is important that information about
whichever occurs first.25                         resources for patients to obtain                 EC be included in all contraceptive
                                                 affordable ECPs, which may include               and STI counseling for adolescents
Assessing for STI Risk                           college health services, school-based            wherever these visits occur: the
The discussion of EC methods with                clinics, or Title X clinics. Insurance           primary care office, the emergency
patients must include the fact that              coverage may help with the cost                  department, specialty clinics, or
none of these methods protect from               barrier; however, coverage may vary              inpatient units. Discussions should
STIs. Because of the cooccurring risk            by plan. In addition to the cost                 include indications for use and how
of STIs, offering STI testing at the visit       barrier, some stores also continue to            patients can access EC in a timely
for EC or encouraging patients to                enforce an unjustified age restriction            fashion. Yet, provider communication
schedule follow-up visits for STI                on purchase.16                                   about EC remains low and differs by
testing or treatment are advisable. In           Access to UPA is also often limited.             patient characteristics. Findings from
addition, follow-up visits are an                One study in Hawaii reported data                a nationally representative sample of
important time to discuss options for            from a secret-shopper study of                   sexually active 15- to 24-year-old
ongoing contraception, abstinence,               pharmacies throughout the state that             women in the 2011–2015 National
and consensual intercourse. Although             found that less than 3% had UPA in               Survey of Family Growth found that
EC is exclusively for use by                     stock at the time of the request.43 The          provider communication about EC

                                     Downloaded from www.aappublications.org/news by guest on July 31, 2021
PEDIATRICS Volume 144, number 6, December 2019                                                                                         5
during a visit for a pelvic examination      medical discourse indicates that                 knowledgeable about the rights of the
or Papanicolaou test was infrequent          personal values of physicians and                adolescent with regard to consent for
(19%) compared with                          pharmacists continue to affect access            contraception in their state and
communication about birth control            to EC, particularly for                          ensure that adolescents are aware of
(67%) and differed by patient                adolescents.59–63 Some physicians                these rights. Pediatricians can also be
characteristics, including race and/or       decline to provide EC to teenagers,              an important source of information
ethnicity and insurance status.50 For        regardless of the circumstance,20 and            for parents to help them
example, a higher proportion of non-         others may provide EC only if sexual             communicate with their adolescents
Hispanic black (25%) and Hispanic            assault has occurred.20,64 These                 and to educate them about the
(27%) women reported receiving               decisions by physicians and                      importance of contraception and
provider counseling about EC than            pharmacists have important adverse               other prevention strategies to reduce
did non-Hispanic white (14%)                 consequences for adolescents in their            risks associated with sexual activity if
women. Reasons for differences in the        ability to access EC.                            their adolescents make the decision
reporting of counseling by race and/                                                          to have sex.
or ethnicity have not been identified         A physician’s decision to provide EC
by research to date. Adolescents with        at a time of need but not in advance
disabilities (both physical and              of need may be related to the                    SUMMARY AND RECOMMENDATIONS
cognitive) and their families should         physician’s beliefs about whether it is
                                                                                              We recommend the following.
be counseled on EC as part of routine        acceptable for teenagers to have
anticipatory guidance,51 especially          sex.20 Often, physicians hold                    1. Pediatricians should be aware that
                                             conflicting values when approaching                  sexual behavior is prevalent
because data suggest that children
                                             reproductive health issues with                     among teenagers and that many
with disabilities have 2 times the risk
                                             teenagers. Physicians may object to                 sexually active teenagers may be
of being sexual assaulted compared
                                             unprotected intercourse or                          the victims of sexual assault.
with children without disabilities.52
                                             intercourse outside of marriage, but                Despite the availability of
Offering advance prescription of ECPs
                                             they may also feel the need to prevent              hormonal and long-acting
is encouraged.
                                             unwanted pregnancy among                            contraceptives, the pregnancy
Laws allowing minors to consent to           teenagers. It is important that                     prevention methods most
birth control services, including EC,        pediatricians are aware of the ways in              commonly used by US teenagers
without parents and rights to                which the underlying beliefs they                   are condoms and withdrawal. EC is
confidentiality vary by state. The            bring to their clinical practice affect             an important back-up method to
Guttmacher Institute regularly               the care that they provide.                         which all teenagers should have
updates information on the general                                                               access.
categories of reproductive health            The AAP has issued a policy
                                                                                              2. Indications for use of EC include
services to which minors can consent         statement on refusal to provide
                                                                                                 unprotected or underprotected
by state.53 Minors in special                information or treatment on the basis
                                                                                                 intercourse, such as failure to use
circumstances, such as those in the          of conscience, stating that
                                                                                                 any form of contraception; sexual
foster care or juvenile justice systems,     pediatricians have a duty to inform
                                                                                                 assault; and imperfect
may face unique barriers to access           their patients about relevant, legally
                                                                                                 contraceptive use (eg, condom
and confidentiality.54 State laws             available treatment options to which
                                                                                                 breakage or slippage and missed
regarding reporting age of consent for       they object and have a moral
                                                                                                 or late doses of oral contraceptive
sexual activity and mandated                 obligation to refer patients to other
                                                                                                 pills, contraceptive patch,
reporting of sexual activity involving       physicians who will provide and
                                                                                                 contraceptive ring, or injectable
minors also vary by state.55                 educate about those services.65
                                                                                                 contraception).
                                             Pediatricians may also encounter                 3. Pediatricians should provide ECPs
PERSONAL BELIEFS FOR PHYSICIANS              situations in which adolescents and                 (levonorgestrel or UPA) or Cu-IUD
AND PHARMACISTS                              their parents differ in their                       insertion to adolescents and young
Despite the fact that hormonal EC will       acceptance of sexual intercourse and                adults who are in immediate need
not disrupt an established pregnancy         contraception. Recognizing the                      of EC. In addition, the AAP
and studies showing that access to EC        importance of parents and families to               recommends that pediatricians
does not make it more likely that            adolescent health and helping                       provide prescriptions and/or
adolescents will engage in more sex          adolescents make decisions with                     a supply of ECPs (with refills and
or less likely that they will use            which they are comfortable can be                   condoms) so adolescents have
condoms or other                             challenging. In these cases, it is                  them on hand in case of future
contraceptives,56–58 public and              important for pediatricians to be                   need (ie, advanced provision).

                                Downloaded from www.aappublications.org/news by guest on July 31, 2021
6                                                                                                  FROM THE AMERICAN ACADEMY OF PEDIATRICS
When a visit is not possible, ECPs               Cu-IUD is not affected by weight.                 coverage of EC without cost
   can safely be prescribed over the                Patients who do not wish to use                   sharing to further reduce cost
   phone without requiring                          a Cu-IUD or do not have access to                 barriers.
   a pregnancy test.                                IUD insertion should be offered EC
4. ECPs are most effective in                       pills regardless of their weight.
                                                                                                  LEAD AUTHORS
   decreasing risk of pregnancy when             8. Repeat episodes of unprotected
   used as soon as possible, but may                                                              Krishna K. Upadhya, MD, MPH, FAAP
                                                    sex during the same cycle after the
   be used up to 120 hours after                    use of ECPs increase the risk of
   unprotected or underprotected                    pregnancy because they work by                COMMITTEE ON ADOLESCENCE, 2016–2017
   intercourse. Adolescents should be               delaying ovulation. Adolescents               Cora C. Breuner, MD, MPH, FAAP,
   instructed to use EC as soon as                  who use ECPs should be counseled              Chairperson
   possible after unprotected                       to abstain or use another method              Elizabeth M. Alderman, MD, FAAP, FSAHM
   intercourse and to then schedule                                                               Laura K. Grubb, MD, FAAP
                                                    to prevent pregnancy until their
                                                                                                  Laurie L. Hornberger, MD, MPH, FAAP
   a follow-up appointment with                     next period. Ongoing hormonal                 Makia E. Powers, MD, MPH, FAAP
   their primary provider to address                contraceptives may be initiated               Krishna K. Upadhya, MD, FAAP
   the need for STI testing and                     immediately after the use of                  Stephenie B. Wallace, MD, FAAP
   ongoing contraception.                           levonorgestrel ECPs or the Yuzpe
5. Advanced provision of ECPs                       method. Ongoing hormonal                      LIAISONS
   increases the likelihood that                    contraceptives should not be                  Liwei L. Hua, MD, PhD – American Academy
   teenagers will use EC when                       initiated sooner than 5 days after            of Child and Adolescent Psychiatry
   needed, reduces the time to use,                 the use of UPA to minimize the                Margo Lane, MD – Canadian Pediatric Society
   and does not decrease condom or                  risk of interference with UPA                 Meredith Loveless, MD – American College of
                                                                                                  Obstetricians and Gynecologists
   other contraceptive use.                         activity. Nonhormonal methods
                                                                                                  Seema Menon, MD – North American Society
   Levonorgestrel ECPs are available                (eg, condoms) may be initiated                of Pediatric and Adolescent Gynecology
   to male and female patients                      immediately after ECP use.                    Lauren B. Zapata, PhD, MSPH – Centers for
   regardless of age without                     9. The AAP recommends that all                   Disease Control and Prevention
   a prescription but may be                        adolescents receive counseling
   expensive when purchased over                    about EC as part of routine
   the counter and are often covered                                                              STAFF
                                                    anticipatory guidance in the
   by insurance with a prescription.                                                              Karen Smith
                                                    context of a discussion on sexual
   UPA is available by prescription                                                               James Baumberger, MPP
                                                    health and family planning
   only. Pediatricians should be                    regardless of current intentions
   aware that the stock of available                for sexual behavior. In addition, it
   ECPs, especially UPA, may vary by                                                                ABBREVIATIONS
                                                    is important that information
   pharmacy and that local patterns                 about EC be included in all                     AAP: American Academy of
   of availability, cost, insurance                 contraceptive and STI counseling                      Pediatrics
   coverage, and sources of low-cost                for adolescents wherever these                  CDC: Centers for Disease Control
   EC in their practice area may affect             visits occur, including emergency                     and Prevention
   the ability of their patients to                 departments, clinics, and hospitals.            Cu-IUD: copper intrauterine device
   obtain recommended services.                     Information provided should                     EC: emergency contraception
6. When a dedicated ECP product or                  include indications for use and                 ECP: emergency contraceptive pill
   Cu-IUD are not options, the use of               options for access, including over-             FDA: US Food and Drug
   combined oral contraceptive pills                the-counter availability and                          Administration
   for EC (Yuzpe method) may be                     advance prescription or supply if               IUD: intrauterine device
   recommended. Adverse effects                     available in the clinic. It is                  STI: sexually transmitted infection
   may include nausea, vomiting, and                important that pediatricians also               UPA: ulipristal acetate
   abdominal pain, and                              provide this counseling to
   coadministration of an antiemetic                adolescents with physical and
   may be considered with this                      cognitive disabilities and their
   method.                                          parents. At the policy level,                 REFERENCES
7. Meta-analyses have suggested that                pediatricians should advocate for                1. Shen J, Che Y, Showell E, Chen K, Cheng
   both levonorgestrel and UPA may                  low-cost or free, nonprescription                   L. Interventions for emergency
   be less effective in individuals                 access to ECPs for teenagers                        contraception. Cochrane Database Syst
   who are overweight. Efficacy of the               regardless of age and insurance                     Rev. 2017;8(8):CD001324

                                     Downloaded from www.aappublications.org/news by guest on July 31, 2021
PEDIATRICS Volume 144, number 6, December 2019                                                                                               7
2. Martinez GM, Abma JC. Sexual activity,        13. Yuzpe AA, Thurlow HJ, Ramzy I, Leyshon           Available at: https://ec.princeton.edu/
        contraceptive use, and childbearing of            JI. Post coital contraception–A pilot            news/HRA_Ella_PR.pdf. Accessed
        teenagers aged 15–19 in the United                study. J Reprod Med. 1974;13(2):53–58            January 7, 2019
        States. NCHS Data Brief. 2015;(209):1–8                                                        23. von Hertzen H, Piaggio G, Ding J, et al;
                                                      14. Meyer JL, Gold MA, Haggerty CL.
     3. Martinez G, Copen CE, Abma JC.                    Advance provision of emergency                   WHO Research Group on Post-ovulatory
        Teenagers in the United States: sexual            contraception among adolescent and               Methods of Fertility Regulation. Low
        activity, contraceptive use, and                  young adult women: a systematic                  dose mifepristone and two regimens of
        childbearing, 2006–2010 national                  review of literature. J Pediatr Adolesc          levonorgestrel for emergency
        survey of family growth. Vital Health             Gynecol. 2011;24(1):2–9                          contraception: a WHO multicentre
        Stat 23. 2011;(31):1–35                                                                            randomised trial. Lancet. 2002;
                                                      15. Rowan A. Obama administration yields
                                                                                                           360(9348):1803–1810
     4. Kann L, McManus T, Harris WA, et al.              to the courts and the evidence, allows
        Youth risk behavior surveillance -                emergency contraception to be sold           24. Rodrigues I, Grou F, Joly J. Effectiveness
        United States, 2015. MMWR Surveill                without restrictions. Available at:              of emergency contraceptive pills
        Summ. 2016;65(6):1–174                            https://www.guttmacher.org/gpr/2013/             between 72 and 120 hours after
                                                          06/obama-administration-yields-courts-           unprotected sexual intercourse. Am
     5. Trent M, Clum G, Roche KM. Sexual                 and-evidence-allows-emergency-                   J Obstet Gynecol. 2001;184(4):531–537
        victimization and reproductive health             contraception-be-sold. Accessed
        outcomes in urban youth. Ambul                                                                 25. Curtis KM, Jatlaoui TC, Tepper NK, et al.
                                                          January 7, 2019                                  U.S. selected practice
        Pediatr. 2007;7(4):313–316
                                                      16. American Society for Emergency                   recommendations for contraceptive
     6. Helton JJ, Gochez-Kerr T, Gruber E.               Contraception. Inching towards                   use, 2016. MMWR Recomm Rep. 2016;
        Sexual abuse of children with learning            progress: ASEC’s 2015 pharmacy access            65(4):1–66
        disabilities. Child Maltreat. 2018;23(2):         study. Available at: http://
        157–165                                                                                        26. American College of Obstetricians and
                                                          americansocietyforec.org/uploads/3/4/            Gynecologists. Practice Bulletin No. 152:
     7. Casteel C, Martin SL, Smith JB, Gurka             5/6/34568220/asec_2015_ec_access_                emergency contraception. Obstet
        KK, Kupper LL. National study of                  report_1.pdf. Accessed February 13,              Gynecol. 2015;126(3):e1–e11
        physical and sexual assault among                 2017
                                                                                                       27. Cleland K, Zhu H, Goldstuck N, Cheng L,
        women with disabilities. Inj Prev. 2008;      17. Sills MR, Chamberlain JM, Teach SJ. The          Trussell J. The efficacy of intrauterine
        14(2):87–90                                       associations among pediatricians’                devices for emergency contraception:
     8. Lindberg L, Santelli J, Desai S.                  knowledge, attitudes, and practices              a systematic review of 35 years of
        Understanding the decline in                      regarding emergency contraception.               experience. Hum Reprod. 2012;27(7):
        adolescent fertility in the United States,        Pediatrics. 2000;105(4, pt 2):954–956            1994–2000
        2007–2012. J Adolesc Health. 2016;            18. Golden NH, Seigel WM, Fisher M, et al.       28. Wu S, Godfrey EM, Wojdyla D, et al.
        59(5):577–583                                     Emergency contraception:                         Copper T380A intrauterine device for
     9. US Department of Health and Human                 pediatricians’ knowledge, attitudes, and         emergency contraception:
        Services. Healthy People 2020                     opinions. Pediatrics. 2001;107(2):               a prospective, multicentre, cohort
        objectives: family planning. Available at:        287–292                                          clinical trial. BJOG. 2010;117(10):
        https://www.healthypeople.gov/2020/           19. Lim SW, Iheagwara KN, Legano L, Coupey           1205–1210
        topics-objectives/topic/family-planning/          SM. Emergency contraception: are             29. Turok DK, Godfrey EM, Wojdyla D, et al.
        objectives. Accessed September 30,                pediatric residents counseling and               Copper T380 intrauterine device for
        2018                                              prescribing to teens? J Pediatr Adolesc          emergency contraception: highly
    10. Ott MA, Sucato GS; Committee on                   Gynecol. 2008;21(3):129–134                      effective at any time in the menstrual
        Adolescence. Contraception for                20. Upadhya KK, Trent ME, Ellen JM. Impact           cycle. Hum Reprod. 2013;28(10):
        adolescents. Pediatrics. 2014;134(4).             of individual values on adherence to             2672–2676
        Available at: www.pediatrics.org/cgi/             emergency contraception practice             30. Turok DK, Sanders JN, Thompson IS,
        content/full/134/4/e1257                          guidelines among pediatric residents:            et al. Preference for and efficacy of oral
    11. American College of Obstetricians and             implications for training. Arch Pediatr          levonorgestrel for emergency
        Gynecologists. ACOG Committee Opinion             Adolesc Med. 2009;163(10):944–948                contraception with concomitant
        No. 735: adolescents and long-acting          21. Batur P, Cleland K, McNamara M, Wu J,            placement of a levonorgestrel IUD:
        reversible contraception: implants and            Pickle S; EC Survey Group. Emergency             a prospective cohort study.
        intrauterine devices. Obstet Gynecol.             contraception: a multispecialty survey           Contraception. 2016;93(6):526–532
        2018;131(5):e130–e139                             of clinician knowledge and practices.        31. Moreau C, Trussell J. Results from
                                                          Contraception. 2016;93(2):145–152                pooled Phase III studies of ulipristal
    12. Abma JC, Martinez GM. Sexual activity
        and contraceptive use among                   22. Pharma HRA. FDA advisory committee               acetate for emergency contraception.
        teenagers in the United States,                   unanimously recommends approval of               Contraception. 2012;86(6):673–680
        2011–2015. Natl Health Stat Rep. 2017;            HRA pharma’s ulipristal acetate for          32. Glasier A, Cameron ST, Blithe D, et al.
        (104):1–23                                        emergency contraception. 2010.                   Can we identify women at risk of

                                        Downloaded from www.aappublications.org/news by guest on July 31, 2021
8                                                                                                          FROM THE AMERICAN ACADEMY OF PEDIATRICS
pregnancy despite using emergency                contraceptive pills: a randomized trial.         Children With Disabilities. Maltreatment
     contraception? Data from randomized              Obstet Gynecol. 2000;95(2):271–277               of children with disabilities. Pediatrics.
     trials of ulipristal acetate and                                                                  2007;119(5):1018–1025
                                                  42. Workowski KA, Bolan GA; Centers for
     levonorgestrel. Contraception. 2011;                                                          53. Guttmacher Institute. Minors’ access to
                                                      Disease Control and Prevention.
     84(4):363–367                                                                                     contraceptive services. 2018. Available
                                                      Sexually transmitted diseases
 33. Kapp N, Abitbol JL, Mathé H, et al. Effect       treatment guidelines, 2015. MMWR                 at: https://www.guttmacher.org/state-
     of body weight and BMI on the efficacy            Recomm Rep. 2015;64(RR-03):1–137                 policy/explore/minors-access-
     of levonorgestrel emergency                                                                       contraceptive-services. Accessed April
                                                  43. Bullock H, Steele S, Kurata N, et al.
     contraception. Contraception. 2015;                                                               5, 2018
                                                      Pharmacy access to ulipristal acetate
     91(2):97–104                                                                                  54. Dudley TI. Bearing injustice: foster care,
                                                      in Hawaii: is a prescription enough?
 34. US Food and Drug Administration. FDA             Contraception. 2016;93(5):452–454                pregnancy prevention, and the law. Law
     communication on levonorgestrel                                                                   Justice. 2013;28(1):77–115
                                                  44. Brant A, White K, St Marie P. Pharmacy
     emergency contraceptive effectiveness                                                         55. US Department of Health and Human
                                                      availability of ulipristal acetate
     and weight. Available at: https://www.                                                            Services. Statutory rape: a guide to
                                                      emergency contraception: an audit
     fda.gov/Drugs/DrugSafety/Postmarke                                                                state laws and reporting requirements.
                                                      study. Contraception. 2014;90(3):
     tDrugSafetyInformationforPatientsa                                                                2004. Available at: https://aspe.hhs.gov/
                                                      338–339
     ndProviders/ucm109775.htm. Accessed                                                               report/statutory-rape-guide-state-laws-
     January 3, 2019                              45. Committee on Adolescence. Emergency              and-reporting-requirements. Accessed
                                                      contraception. Pediatrics. 2012;130(6):          April 12, 2018
 35. Curtis KM, Tepper NK, Jatlaoui TC, et al.
                                                      1174–1182
     US medical eligibility criteria for                                                           56. Stewart HE, Gold MA, Parker AM. The
     contraceptive use, 2016. MMWR                46. Garbers S, Bell DL, Ogaye K, Marcell AV,         impact of using emergency
     Recomm Rep. 2016;65(3):1–103                     Westhoff CL, Rosenthal SL. Advance               contraception on reproductive health
                                                      provision of emergency contraception             outcomes: a retrospective review in an
 36. US Food and Drug Administration.
                                                      to young men: an exploratory study in            urban adolescent clinic. J Pediatr
     Highlights of prescribing information:
                                                      a clinic setting [published online ahead         Adolesc Gynecol. 2003;16(5):313–318
     ella (ulipristal acetate) tablet. Revised
                                                      of print April 17, 2018]. Contraception.
     March 2015. Available at: www.                                                                57. Gold MA, Wolford JE, Smith KA, Parker
                                                      doi:10.1016/j.contraception.2018.04.005
     accessdata.fda.gov/drugsatfda_docs/                                                               AM. The effects of advance provision of
     label/2015/022474s007lbl.pdf. Accessed       47. Marcell AV, Waks AB, Rutkow L, et al.            emergency contraception on
     January 3, 2019                                  What do we know about males and                  adolescent women’s sexual and
                                                      emergency contraception? A synthesis             contraceptive behaviors. J Pediatr
 37. US Food and Drug Administration.
                                                      of the literature. Perspect Sex Reprod           Adolesc Gynecol. 2004;17(2):87–
     Highlights of prescribing information:
                                                      Health. 2012;44(3):184–193                       96
     Plan B One-Step tablet (levonorgestrel)
     1.5mg for oral use. Revised July 2009.       48. Schrager SM, Olson J, Beharry M, et al.      58. Raine TR, Harper CC, Rocca CH, et al.
     Available at: www.accessdata.fda.gov/            Young men and the morning after:                 Direct access to emergency
     drugsatfda_docs/label/2009/021998lbl.            a missed opportunity for emergency               contraception through pharmacies and
     pdf. Accessed January 3, 2019                    contraception provision? J Fam Plann             effect on unintended pregnancy and
                                                      Reprod Health Care. 2015;41(1):33–37             STIs: a randomized controlled trial.
 38. Halpern V, Raymond EG, Lopez LM.
     Repeated use of pre- and postcoital          49. Richards MJ, Peters M, Sheeder J, Kaul           JAMA. 2005;293(1):54–62
     hormonal contraception for prevention            P. Contraception and adolescent males:       59. Conard LA, Fortenberry JD, Blythe MJ,
     of pregnancy. Cochrane Database Syst             an opportunity for providers. J Adolesc          Orr DP. Pharmacists’ attitudes toward
     Rev. 2010;(1):CD007595                           Health. 2016;58(3):366–368                       and practices with adolescents. Arch
 39. Ellertson C, Webb A, Blanchard K, et al.     50. Liddon N, Steiner RJ, Martinez GM.               Pediatr Adolesc Med. 2003;157(4):
     Modifying the Yuzpe regimen of                   Provider communication with                      361–365
     emergency contraception:                         adolescent and young females during          60. Grimes DA. Emergency contraception:
     a multicenter randomized controlled              sexual and reproductive health visits:           politics trumps science at the U.S.
     trial. Obstet Gynecol. 2003;101(6):              findings from the 2011–2015 National              Food and Drug Administration.
     1160–1167                                        Survey of Family Growth. Contraception.          Obstet Gynecol. 2004;104(2):
                                                      2018;97(1):22–28                                 220–221
 40. Percival-Smith RK, Abercrombie B.
     Postcoital contraception with dl-            51. Murphy NA, Elias ER. Sexuality of            61. Pruitt SL, Mullen PD. Contraception or
     norgestrel/ethinyl estradiol                     children and adolescents with                    abortion? Inaccurate descriptions of
     combination: six years experience in             developmental disabilities. Pediatrics.          emergency contraception in newspaper
     a student medical clinic. Contraception.         2006;118(1):398–403                              articles, 1992-2002. Contraception.
     1987;36(3):287–293                                                                                2005;71(1):14–21
                                                  52. Hibbard RA, Desch LW; American
 41. Raymond EG, Creinin MD, Barnhart KT,             Academy of Pediatrics Committee on           62. Karasz A, Kirchen NT, Gold M. The visit
     et al. Meclizine for prevention of nausea        Child Abuse and Neglect; American                before the morning after: barriers to
     associated with use of emergency                 Academy of Pediatrics Council on                 preprescribing emergency

                                     Downloaded from www.aappublications.org/news by guest on July 31, 2021
PEDIATRICS Volume 144, number 6, December 2019                                                                                                 9
contraception. Ann Fam Med. 2004;2(4):            contraception. Fam Pract. 2005;22(3):            Pediatr Emerg Care. 2014;30(2):
     345–350                                           280–286                                          84–90
 63. Fairhurst K, Wyke S, Ziebland S, Seaman       64. Miller MK, Mollen CJ, O’Malley D,            65. Committee on Bioethics. Policy
     P, Glasier A. “Not that sort of practice”:        et al. Providing adolescent                      statement–Physician refusal to provide
     the views and behaviour of primary                sexual health care in the                        information or treatment on the basis
     care practitioners in a study of                  pediatric emergency department:                  of claims of conscience. Pediatrics.
     advance provision of emergency                    views of health care providers.                  2009;124(6):1689–1693

                                     Downloaded from www.aappublications.org/news by guest on July 31, 2021
10                                                                                                      FROM THE AMERICAN ACADEMY OF PEDIATRICS
Emergency Contraception
         Krishna K. Upadhya and COMMITTEE ON ADOLESCENCE
                            Pediatrics 2019;144;
  DOI: 10.1542/peds.2019-3149 originally published online November 18, 2019;

Updated Information &          including high resolution figures, can be found at:
Services                       http://pediatrics.aappublications.org/content/144/6/e20193149
References                     This article cites 50 articles, 8 of which you can access for free at:
                               http://pediatrics.aappublications.org/content/144/6/e20193149#BIBL
Subspecialty Collections       This article, along with others on similar topics, appears in the
                               following collection(s):
                               Current Policy
                               http://www.aappublications.org/cgi/collection/current_policy
                               Committee on Adolescence
                               http://www.aappublications.org/cgi/collection/committee_on_adoles
                               cence
                               Adolescent Health/Medicine
                               http://www.aappublications.org/cgi/collection/adolescent_health:me
                               dicine_sub
                               Contraception
                               http://www.aappublications.org/cgi/collection/contraception_sub
Permissions & Licensing        Information about reproducing this article in parts (figures, tables) or
                               in its entirety can be found online at:
                               http://www.aappublications.org/site/misc/Permissions.xhtml
Reprints                       Information about ordering reprints can be found online:
                               http://www.aappublications.org/site/misc/reprints.xhtml

                  Downloaded from www.aappublications.org/news by guest on July 31, 2021
Emergency Contraception
        Krishna K. Upadhya and COMMITTEE ON ADOLESCENCE
                           Pediatrics 2019;144;
 DOI: 10.1542/peds.2019-3149 originally published online November 18, 2019;

The online version of this article, along with updated information and services, is
                       located on the World Wide Web at:
         http://pediatrics.aappublications.org/content/144/6/e20193149

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

                  Downloaded from www.aappublications.org/news by guest on July 31, 2021
You can also read