Ms. Li, 35 years old, chief complaint: vaginal bleeding for 10 days after taking emergency contraception orally.
Present Illness: The patient had intercourse 12 days ago and found herself in the periovulatory period without taking any contraceptive measures. She took 1 tablet of levonorgestrel emergency contraceptive pill 10 days ago, started vaginal bleeding since then, in small amounts, continuing till now, with no abdominal pain. No fever.
Medical History: Healthy. Drug allergy history: None
Menstrual History: 5-7/28-30 days, moderate flow, no dysmenorrhea. Last menstrual period: June 22, 2024, same color and quality as before. Obstetric history: G4P2, no contraception.
Gynecological Examination: External genitalia: married, vagina: clear, small amount of dark red blood. Cervix: smooth. After iodine disinfection, internal examination: Uterus: anteverted, normal size, mobile, no tenderness, no abnormality palpable in both adnexal areas.
Auxiliary Examination: Urine HCG: negative; Pelvic ultrasound: endometrial thickness 7mm, left ovary mixed echo 17*17mm.
Preliminary Diagnosis: Western Medicine Diagnosis: abnormal uterine bleeding
Ms. Li’s concern: Is bleeding after taking emergency contraception orally an indication of successful contraception? Does she need treatment?
About emergency contraception:
1. It refers to a medication used as a contraceptive remedy after unprotected sexual intercourse or contraceptive failure. Emergency contraception needs to be taken as required within 72 hours after the event. Emergency contraception mainly consists of two types, one is pure progestin, represented by levonorgestrel, commonly known as Mifepristone; the other is anti-progestin acting ulipristal acetate.
Highly effective synthetic progestogens lower the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which play a crucial role in the growth of the follicles. If their levels decrease, follicle development is affected, and the pituitary gland doesn’t release the pre-ovulatory LH peak, inhibiting ovulation.
2. Does the medication work if ovulation has already occurred before taking it?
Levonorgestrel can also prevent fertilization and implantation by affecting tubal motility and endometrial growth. The contraceptive effectiveness of emergency contraception is approximately 80-90%, and with correct use of levonorgestrel, the pregnancy rate is only 4%. Even with proper usage, there is still a possibility of failure. If contraception fails, don’t rush into terminating the pregnancy. Current data suggest that contraceptive and emergency contraceptive pills do not increase the risk of fetal abnormalities.
3. To understand if bleeding after taking emergency contraception orally indicates successful contraception, let’s first look at the adverse reactions of emergency contraception.
Menstrual changes: The most common reaction is early or delayed menstruation in the same month. Levonorgestrel is a highly effective progestin that can lead to menstrual cycle changes due to hormonal fluctuations in the body. For levonorgestrel, the drug peaks around 1-2 hours after intake, and the concentration decreases to half around 11 hours, with no residual effects in the body after 3 days.
After taking emergency contraception, the medication can cause shedding of the endometrium or delay ovulation, leading to irregular vaginal bleeding. The timing of bleeding is associated with the phase of the menstrual cycle during drug intake. Vaginal bleeding typically occurs about 1 week before or after the expected period. The use of combined estrogen-progestin preparations and levonorgestrel emergency contraception pills is associated with a higher rate of early menstruation compared to the anti-progestin drug ulipristal acetate; if the period is delayed by 1 week, a pregnancy test should be done to confirm the cause of the emergency contraception failure.
Therefore, experiencing vaginal bleeding after taking emergency contraception does not indicate successful contraception. Confirmation through testing is required to determine successful contraception. A pregnancy test should be done 14 days or more after the last unprotected sexual activity, by analyzing urine or blood for human chorionic gonadotropin (HCG), with a negative result confirming successful contraception.
Other adverse reactions may include nausea, vomiting, headache, dizziness, etc. These generally resolve within 24 hours and if vomiting occurs within 2 hours of intake, a dose should be repeated for efficacy.
Does irregular vaginal bleeding need treatment?
Irregular vaginal bleeding after taking emergency contraception does not pose a risk to the body and may not require treatment. However, such bleeding may indicate a serious condition like ectopic pregnancy. If women taking the medication exhibit other symptoms related to ectopic pregnancy, such as lower abdominal pain, they should undergo a pregnancy test and other relevant medical examinations and treatment. In case of persistent abnormal bleeding, some women should seek prompt medical attention.
4. How is a normal menstrual period calculated after taking emergency contraception?
In most cases, a normal menstrual period following emergency contraception usually occurs within about 7 days before or after the expected menstrual onset. This means that menstruation may arrive earlier or be delayed. A delay in menstruation is more common because emergency contraception can affect ovulation. However, some individuals taking emergency contraception may experience irregular bleeding, which requires further examination at a hospital to rule out other causes.
Once again, after taking emergency contraception, if contraception fails, it usually doesn’t affect the embryo, and there is no need to terminate the pregnancy due to this single factor.
Regarding whether Ms. Li needs treatment?
Her usual menstrual cycle is 28-30 days, and with her last menstrual period on June 22, 2024, she visited on July 14, stopped emergency contraception 2 days ago and has been bleeding for 10 days. Considering the abnormal bleeding caused by emergency contraception, but with normal vital signs on examination except for bleeding and no other positive signs, based on the amount of bleeding and the pelvic ultrasound results, my suggestion is symptomatic treatment to stop bleeding, and seek prompt medical attention if bleeding continues after returning home.
Reminder: Emergency contraception should only be used as a remedial measure after unprotected intercourse and not as a regular method. It is not recommended to use emergency contraception as a routine contraceptive method! With various contraceptive methods available such as condoms, short-acting oral contraceptives, subdermal implants, long-acting contraceptive injections, there is always an option suitable for you!
References:
[1] Xie Xing, Kong Beihua, Duan Tao. Obstetrics and Gynecology (Ninth Edition). People’s Medical Publishing House. 2018.
[2] Cheng Linan. The safety of emergency contraception. Practical Journal of Obstetrics and Gynecology, 2014, 30(07): 488-490.
