Resident Editor: Anne Montgomery, MD

Faculty Editors: Meg Autry, MD, and Miranda Dunlop, MD

Emergency contraception is indicated to prevent pregnancy after unprotected or inadequately protected sexual intercourse. It is most effective if patients know about it ahead of time and take it as soon as possible after intercourse, so be sure to discuss this along with routine contraception at regular visits. 

Oral emergency contraception

• Progestin-only pills are the most commonly used form of emergency contraception.
  • 1 pill with 1.5mg levonorgestrel (Plan B One-Step, Next Choice One Dose, Take Action, My Way)
  • Available over-the-counter without age restriction; cost $30-60 per pill.
  • Effective up to 3 days after intercourse.
• A progesterone receptor modulator (Ella) is also available.
  • 1 pill with 30mg ulipristal acetate
  • Requires a prescription; >$50 per pill.
  • Effective up to 5 days after intercourse; studies suggest ulipristal is more effective than the levonorgestrel regimen[MA1] , particularly for obese women.
•  Combined OCPs are no longer recommended for use as EC. 
• There are no recognized contraindications to the use of oral EC, though body weight may influence the effectiveness of oral EC. 
  • The most common side effects are headache and nausea. 
  • Consider screening for STIs if your patient is at risk. 
• Exposure to levonorgestrel or ulipristal has no adverse effect on pregnancies that do occur and no adverse effect on future fetal development. 

Copper IUD

• The copper IUD (Paraguard) is the most effective form of EC available.
  • Can be placed up to 5 days after unprotected intercourse; studies have shown a 0.09% pregnancy rate when placed even up to 10 days after intercourse.
  • Contraindicated in the current pregnancy, current PID, and in the setting of Gyn malignancy; otherwise, well-tolerated. 
    • Consider screening for STIs if your patient is at risk. 
• Used less commonly than oral EC due to lack of awareness and need for placement by a trained professional.
• Ideal because it provides ongoing contraception.

Routine contraception

• Because some forms of EC work by delaying ovulation, it is possible for women who have taken EC to become pregnant during the same menstrual cycle. 
  • Prompt initiation of routine contraception is therefore key. 
• After the use of levonorgestrel-based EC, routine hormonal contraception can be started right away, but a barrier method is needed for the first 7 days.
• After use of the ulipristal regimen, women should wait 5 days or until the next menstrual cycle to start routine hormonal contraception and should use a barrier method in the interim.
• Long-acting reversible contraception (IUDs, implants) can be started as soon as pregnancy is ruled out. 

Resources for patients

• 1-888-NOT-2-LATE OR 1-866-EN-TRES-DIAS
• not-2-late.com

References

Committee on Practice Bulletins – Gynecology. Emergency contraception. Practice bulletin no. 152. Obstet Gynecol 2015;126:e1-11.

Office of Population Research at Princeton University. The emergency contraception website. http://ec.princeton.edu. Accessed April 15, 2018.

Raymond EG and K Cleland. Emergency Contraception. N Engl J Med 2015 ;372 :1342-8.