Table 3 Survey questions for EOC knowledge and their sources, answers, references for the answers, and scores
Survey question | Source of question | Answer | Possible score | Number of correct answersb (n/total) |
|---|---|---|---|---|
What are emergency oral contraceptives (EOCs)a that are commercially available in Thailand? | –/–/P/S | Levonorgestrel | 0–1 | 337/421 |
What are the tradenames of the EOCs that are commercially available in Thailand? | G/–/–/S | Postinor®, Madonna®, Maple Forte® | 0–3 | 155/421 |
What are the indications of the EOCs? | –/I/P/S | We decided not to include the scores of this question, because all answer choices are defined as unplanned unprotected sex | N/A | –/421 |
What is the dosage form of the EOCs? | –/–/–/S | Film-coated tablets | 0–1 | 291/421 |
What is the EOCs’ mechanism of action? | G/I/P/S | Preventing the ovulation EOCs act by inhibiting or postponing ovulation (Gemzell-Danielsson et al., 2013). Levonorgestrel must be taken within a window period after the selection of follicle but before the luteinizing hormone surge (Gemzell-Danielsson et al., 2013). In addition, the conception rate of taking EOCs after ovulation does not differ from the placebo (Endler et al., 2022). This indicates the insignificant of other proposed mechanisms of actions of EOCs. Other studies also defy other mechanisms of action of levonorgestrel. For example, a study shows that gene expression in the endometrium does not change after taking levonorgestrel EOCs (Vargas et al., 2012). Another study shows that taking levonorgestrel EOCs after ovulation does not prevent implantation (Endler et al., 2022) | 0–1 | 22/421 |
How do you access the information on EOCs? | –/–/P/S | There is no correct answer to this question. More than 50% of pharmacist access EOC information from package inserts and practice guidelines | 0 | –/419 |
What is the strength of the EOCs? | G/I/P/S | 0.75 mg, 1.5 mg | 0–2 | 229/421 |
What is the total dose of the EOCs for one coitus? | G/I/P/S | 1.5 mg | 0–1 | 359/421 |
EOCs can be taken two tablets every …… hour apart | G/I/P/S | 12 h (2 points) or 24 h (1 point) Levonorgestrel EOCs are approved as two doses of 0.75 mg, 12 h apart, or a single dose of 1.5 mg. However, Tmax, Cmax, and AUC derived from taking levonorgestrel 12 h and 24 h apart are not significantly different (Johansson et al., 2002). In addition, a randomized controlled trial in 2071 women showed that taking 0.75 mg of levonorgestrel 120 h after coitus, either 12 h or 24 h apart, is effective (Wai Ngai et al., 2005) | 0–2 | 375/421 |
The dose of EOCs must be adjusted when the users are heavier than …… kg | G/I/P/S | There is not enough evidence for the answer Although there is a recommendation to double the dose of EOCs in patients who weigh more than 70 kg or have a BMI of more than 26 kg/cm2 or 30 kg/cm2, the recommendation is questionable (Gemzell-Danielsson et al., 2015; Kardos, 2020) | 0–1 | 220/421 |
If the dose of EOCs must be adjusted when the users are heavier, the dose should be adjusted to ……. mg/coitus | G/I/P/S | There is not enough evidence for the answer | 0–1 | 214/421 |
The EOCs should not be used for more than how many boxes (dose/coitus) per month? | G/I/P/S | There is not enough evidence for the answer | 0–1 | 66/421 |
What is the maximum number of EOCs in boxes that can be taken continuously? | G/I/P/S | There is not enough evidence for the answer | 0–1 | 132/421 |
What is the maximum number of EOCs in boxes that can be taken in a lifetime? | –/–/P/– | There is not enough evidence for the answer | 0–1 | 263/421 |
Is a pregnancy test required before using EOCs? | –/–/P/S | No | 0–1 | 268/421 |
EOCs are used before or after coitus? | G/–/P/S | After only EOCs are approved for postcoital use. In addition, there are no studies investigating the effectiveness of 1.5 mg of levonorgestrel before intercourse (Halpern et al., 2014; Raymond et al., 2011) | 0–1 | 312/421 |
The first dose of EOCs should be taken within how many hours after coitus? | G/I/P/S | 72 | 0–1 | 210/421 |
The first dose of EOCs should be taken, as late as possible, within how many hours after coitus? | G/I/P/S | 120 (Wai Ngai et al., 2005) | 0–1 | 350/421 |
The earlier the first dose of EOCs, the better the contraception efficacy. Is this true? | G/I/P/S | True (Matyanga & Dzingirai, 2018) | 0–1 | 406/421 |
What is the restriction period for another coitus, in hours, after the use of EOCs? | G/–/P/– | There is no restriction | 0–1 | 223/421 |
What is the efficacy of 0.75 mg EOCs/coitus? | –/I/P/S | The Pearl Index of this method is reported as 22.4 (Taylor et al., 2014). Therefore, an efficacy rate of approximately 78% can be expected | 0 | The answer wasd 52 ± 23% (-/413) |
What is the efficacy of 1.5 mg EOCs/coitus? | –/I/P/S | The Pearl Index of this method is reported as 6.8 (United Nations Development Programme et al., 2000). Therefore, an efficacy rate of approximately 93% can be expected | 0 | The answer wasd 81 ± 11% (–/414) |
What is the efficacy of combined oral contraceptive pills? | –/I/P/S | The Pearl Index of this method is reported as 0.29–2.86 (Trussell & Portman, 2013). Therefore, an efficacy rate of approximately 97% can be expected | 0 | The answer wasd 92 ± 10% (–/416) |
What is the efficacy of condoms? | –/I/P/S | The Pearl Index of this method is reported as 1.26 (Zhao et al., 2014). Therefore, an efficacy rate of approximately 99% can be expected | 0 | The answer wasd 92 ± 12% (–/415) |
What is the efficacy of the lactational amenorrhea method? | –/I/P/S | The pregnancy rate of this method is reported as 0.5–1.5 (Trussell, 2009). Therefore, an efficacy rate of approximately 98% can be expected | 0 | The answer wasd 73 ± 26% (–/416) |
Are EOCs effective after ovulation? | G/I/P/S | No (Noé et al., 2011) | 0–1 | 65/421 |
If vomiting occurs after taking EOCs, another tablet must be taken when taking EOCs and vomiting are how many hours apart? | –/–/P/– | 2 h The time to maximum concentration of levonorgestrel is approximately 2 h (Johansson et al., 2002; Kives et al., 2005; Kook et al., 2002) | 0–1 | 196/421 |
The more frequently the EOCs are taken, the less the EOCs are efficient. Is this true? | –/I/P/– | No The probability of contraception failure over time is well-discussed by Trussel in 2009 (Trussell, 2009) | 0–1 | 136/421 |
EOCs can be active for how many hours after the dose is complete? | G/–/P/S | 72 h We cannot speculate on the effective duration of levonorgestrel after its oral absorption from its precoital study, since there are no studies investigating the effectiveness of 1.5 mg levonorgestrel before intercourse (Halpern et al., 2014; Raymond et al., 2011). However, an in vitro study shows that levonorgestrel can inhibit sperm migration in cervical mucous for 12 h after the dose (Kovacs et al., 2000). In addition, a pharmacokinetics study suggests that after completing the doses of levonorgestrel, contraception can be achieved for at least 3 days (Tremblay et al., 2001) | 0–1 | 124/421 |
After the use of EOCs, if side effects occur, they usually occur for how many hours? | G/–/–/– | There is not enough evidence for the answer A pharmacokinetics study suggests that after completing the doses of levonorgestrel, plasma levonorgestrel can remain above its effective level for longer than 4.5 days (Tremblay et al., 2001). However, there is no study supporting the window period for levonorgestrel side effects after its last dose | 0–1 | 30/421 |
What is the relationship between nausea and EOCs? | –/I/–/S | A side effect that does not require cessation of EOCs Nausea is one of the common but not serious adverse events reported during the use of levonorgestrel EOCs (Leelakanok & Methaneethorn, 2020) | 0–1 | 401/421 |
What is the relationship between hypertension and EOCs? | –/–/–/–c | A side effect that requires cessation of levonorgestrel (American Pharmacist Association, 2018) | 0–1 | 86/421 |
What is the relationship between ectopic pregnancy and EOCs? | –/I/P/S | Not enough evidence to support such a relationship/unrelated The evidence on the association between levonorgestrel and ectopic pregnancy is still conflicting (Leelakanok & Methaneethorn, 2020). WHO states that people with a history of ectopic pregnancy can still use progestin-only contraception or a levonorgestrel intrauterine device (Altshuler et al., 2015) | 0–1 | 45/421 |
What is the relationship between breast tenderness and lactation and EOCs? | –/–/P/S | A side effect that does not require cessation of EOCs Breast tenderness and lactation are common but not serious adverse events reported during the use of levonorgestrel EOCs (Leelakanok & Methaneethorn, 2020) | 0–1 | 257/421 |
What is the relationship between diabetes mellitus and EOCs? | –/–/–/– | A side effect that requires cessation of levonorgestrel (American Pharmacist Association, 2018) | 0–1 | 20/421 |
What is the relationship between breast cancer and EOCs? | –/I/P/S | Contraindication Progestin-only contraception or levonorgestrel intrauterine device is contraindicated in people with breast cancer (Altshuler et al., 2015). It is prudent to assume that people with breast cancer should also not use levonorgestrel EOCs | 0–1 | 265/421 |
What is the relationship between infertility and EOCs? | –/I/P/S | Not enough evidence to support such a relationship/unrelated Levonorgestrel as an EOC does not affect the menstrual cycle or endometrial receptivity to implantation. In addition, the evidence does not support that levonorgestrel causes miscarriage or teratogenicity (Endler et al., 2022) | 0–1 | 208/421 |
What is the relationship between severe hepatic diseases and EOCs? | –/–/–/– | Contraindication (American Pharmacist Association, 2018; Vrettakos & Bajaj, 2022) | 0–1 | 32/421 |
What is the relationship between thromboembolism and EOCs? | –/–/–/S | A side effect that requires cessation of EOCs Thromboembolism is one of the serious adverse events reported during the use of levonorgestrel EOCs (Leelakanok & Methaneethorn, 2020). WHO also recommended that the risk for thromboembolism in progestin-only contraception or levonorgestrel intrauterine device users outweigh the benefits of contraception (Altshuler et al., 2015) | 0–1 | 50/421 |
What is the relationship between acne and EOCs? | –/–/P/S | A side effect that does not require cessation of EOCs Acne is one of the common but not serious adverse events reported during the use of levonorgestrel EOCs (Leelakanok & Methaneethorn, 2020) | 0–1 | 283/421 |
Vaginal bleeding can occur within how many days after the use of EOCs? | –/–/P/– | 1–7 days Two studies found that their participants had vaginal spotting 2 to 3 days after levonorgestrel usage (Hapangama et al., 2001; Okewole et al., 2007) | 0–1 | 240/421 |
Vaginal bleeding can occur for how many days after the use of EOCs? | –/–/P/– | 1–7 days One study reported that intermenstrual bleeding lasted for an average of 2.4 days (range 1–7) (Gainer et al., 2006) | 0–1 | 249/421 |
What causes the bleeding after the use of EOCs? | –/–/P/– | Bleeding after EOC use is a side effect (Gainer et al., 2006) | 0–1 | 221/421 |
What are the differences between vaginal bleeding after the use of EOCs and menstruation? | –/–/P/– | Vaginal bleeding is lesser in amount, thickness, and darkness (Gainer et al., 2006; Okewole et al., 2007) | 0–3 | 17/421 |
After the use of EOCs, the menstruation cycle can be early or delayed for how many days? | G/I/P/S | Two days early to 2 days late, in general In one study, more than 50% of the participants had menses within 2 days after taking levonorgestrel (von Hertzen et al., 2002) | 0–1 | 45/421 |
Using EOCs during pregnancy can cause teratogenicity. Is this true? | G/I/P/S | No | 0–1 | 124/421 |
Using EOCs during pregnancy can cause abortion. Is this true? | G/I/–/S | No | 0–1 | 178/421 |
What is the relationship between levonorgestrel and CYP450? | –/–/P/S | Levonorgestrel is a CYP3A4 substrate (Sunaga et al., 2021) | 0–1 | 133/421 |
Patients using EOCs can be immunized with the COVID-19 vaccine. Is it true? | G/–/P/– | Yes Venous thrombosis was reported as an adverse event in users of RNA‐based, non‐replicating viral vector, and protein subunit COVID-19 vaccine (Graña et al., 2022). In addition, thromboembolism can be a serious side effect of levonorgestrel. However, the risk of thromboembolism in levonorgestrel users is the lowest (Leelakanok & Methaneethorn, 2020). Besides, levonorgestrel poses a lower risk of thromboembolism than COCs (Rott, 2019). Together with the fact that pregnancy poses higher risks for thromboembolism than using COCs and the risk for thromboembolism in COVID-19 patients is higher than people receiving COVID-19 vaccines (Lee et al., 2022), people using COCs are recommended to receive COVID-19 vaccine (Lee et al., 2022). Therefore, it is prudent to assume that EOCs can be immunized with the COVID-19 vaccine | 0–1 | 373/421 |
Patients using EOCs can be immunized with the Human Papilloma Virus vaccine. Is it true? | –/–/–/– | Yes The vaccine is not known to cause serious adverse events. This vaccine should not be used in pregnant women. The only contraindication of the vaccine is a history of allergy to vaccine components (World Health Organization, 2017). Therefore, it is prudent to assume that EOCs can be immunized with the Human Papilloma Virus vaccine | 0–1 | 303/421 |
Patients using EOCs can be immunized with the Hepatitis B virus vaccine. Is it true? | –/–/–/– | Yes The vaccine is not known to cause serious adverse events. The only contraindication of the vaccine is a history of allergy to vaccine components (World Health Organization, 2019). Therefore, it is prudent to assume that EOCs can be immunized with the Hepatitis B virus vaccine | 0–1 | 299/421 |
Can combined oral contraceptive pills be used as EOCs? | –/–/P/S | Yes COC pills can be used as EOCs as in the Yuzpe regimen. However, this question is not included in scoring, since the question was not clear enough to make the participants understand whether COC can be used regularly (i.e., taking a tablet of COC) as EOC or COC must be used specifically (as in the Yuzpe regimen) | N/A | –/421 |
Have you ever heard of EOC abuse? | –/–/P/– | There is no correct answer to this question. Pharmacists have heard that EOCs are used for abortion, acne treatment, alopecia, delaying menstruation, hormone replacement in transgender, melasma, menstrual stimulation, and weight reduction | N/A | –/420 |