Emergency Contraception: What, When and How?

Emergency contraception interventions are intended to prevent an unplanned pregnancy after unprotected or inadequately protected intercourse. Contraceptive failure or failure to use contraception are common indications for use.

CLINICAL ACTIONS:

  • Offer emergency contraception (EC) to all women who have had unprotected or inadequately protected intercourse and who do not desire pregnancy
    • There are no exclusionary health conditions –women who have contraindications to oral contraceptives can be given EC
  • Offer EC to all reproductive-aged women who have sustained sexual assault
  • No clinical examination or pregnancy testing is necessary
  • Treatment should be initiated as soon as possible, and should be made available up to 5 days after unprotected or inadequately protected intercourse
  • If menses are delayed by a week or more, a woman who has received EC should have a pregnancy test and clinical evaluation
  • EC may be used more than once even in the same menstrual cycle
  • Regular contraception should be started immediately after EC and women should abstain or use barrier contraception for 14 days or until onset of next menses
    • Those receiving uripristal acetate should delay starting hormonal contraception until 5 days after use

SYNOPSIS:

All of the methods below are effective only before a pregnancy is established. Hormonal EC does not pose a risk to an established pregnancy and is not associated with embryonal developmental abnormalities. Adverse effects for all of the oral methods include nausea and headache as well as irregular bleeding. Adverse effects for the copper IUD include perforation, changes in menses or dysmenorrhea. Pregnancy rates after EC range from 0-2.2%, and may be impacted by body weight.

KEY POINTS:

  • Uripristal acetate, a selective progesterone receptor modulator, is given as a single 30 mg dose
    • Requires a prescription
    • Efficacy may be reduced in women with BMI ≥30
    • Effective up to 5 days after unprotected intercourse
    • FDA approved for EC
  • Progestin only EC, either 1 tablet Levonorgestrel in a single dose (1.5 mg) or as a split dose (1 dose of 0.75 mg of levonorgestrel followed by a second dose of 0.75 mg of levonorgestrel 12 hours later)
    • May be less effective in women with BMI ≥25
    • 1 tablet formulation available over the counter without age restriction
    • 2 tablet formulation available over the counter to women ≥17 years with photo ID
    • Effective for up to 3 days after unprotected intercourse
    • FDA approved for EC
  • Copper IUD insertion
    • Requires office visit and insertion by a clinician
    • Efficacy not impacted by body weight
    • Effective up to 5 days after unprotected intercourse
    • Safe and effective but not FDA labeled for use as EC
    • LNG-IUDs “are currently being investigated” (ACOG PB) | Recent RCT suggests LNG-IUD is not inferior to copper IUD (see ‘Learn More – Primary Sources’)
  • Combined progestin-estrogen pills
    • Can use a variety of formulations (see ‘Learn More – Primary Sources’ below for a list of appropriate formulations)
    • Two doses every 12 hours
    • All aim for 100-120 micrograms of ethinyl estradiol and 0.5-0.6 milligrams of levonorgestrel per dose
    • Requires a prescription
    • Effective up to 5 days after unprotected intercourse
    • Safe and effective but not FDA labeled for use as EC

Learn More – Primary Sources:

Practice Bulletin No. 152: Emergency Contraception

CDC Contraceptive Guidance for Health Care Providers

CDC: U.S. Selected Practice Recommendations for Contraceptive Use, 2016 – Recommendations and Reports