Emergency contraception can be used after episodes of unprotected sexual intercourse (UPSI). This includes situations where the contraceptive method is not protective, such as damaged condoms or multiple missed pills.
There are three options for emergency contraception:
- Levonorgestrel should be taken within 72 hours of UPSI
- Ulipristal should be taken within 120 hours of UPSI
- Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation
The copper coil is the most effective. It is also not affected by BMI, enzyme-inducing drugs or malabsorption, all of which can significantly reduce the effectiveness of oral methods.
With oral emergency contraception, the sooner it is taken, the more effective it is. Oral emergency contraception is unlikely to be effective after ovulation has occurred; however, it is offered after UPSI on any day of the menstrual cycle. The woman needs to take a pregnancy test if her period is delayed.
Oral emergency contraception does not protect against further episodes of UPSI. The FSRH guidelines (2017) state that both levonorgestrel and ulipristal can be used more than once in a menstrual cycle.
Other things to consider when starting emergency contraception:
- Reassure about confidentiality
- Sexually transmitted infections
- Future contraception plans
- Safeguarding, rape and abuse
Intrauterine Device
The copper coil can be used as an emergency contraception up to 5 days after unprotected intercourse, or within 5 days after the earliest estimated date of ovulation. Ovulation occurs 14 days before the end of the cycle, so if a woman’s shortest cycle length is 28 days, the earliest estimated date of ovulation is day 14. It would be day 12 for a 26-day cycle, or day 16 for a 30-day cycle.
The copper coil is toxic to the ovum and sperm, and also inhibits implantation. It is the most effective emergency contraception, being over 99% effective. The FSRH guidelines (2017) advised offering the copper coil first line for emergency contraception.
Insertion may lead to pelvic inflammatory disease, particularly in women that are high risk of sexually transmitted infections. Consider empirical treatment of pelvic infections where the risk is higher.
The coil should be kept in until at least the next period, after which it can be removed. Alternatively, it can be left in long-term as contraception.
Levonorgestrel
Levonorgestrel is a type of progestogen. It works by preventing or delaying ovulation. It is the same hormone found in the intrauterine system (hormonal coil). It is not known to be harmful to the pregnancy if pregnancy does occur.
The combined pill or progestogen-only pill can be started immediately after taking levonorgestrel. Extra contraception (i.e. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.
Levonorgestrel is licensed for use up to 72 hours post intercourse. The dose listed in the BNF is:
- 1.5mg as a single dose
- 3mg as a single dose in women above 70kg or BMI above 26
Nausea and vomiting are common side effects. If vomiting occurs within 3 hours of taking the pill, the dose should be repeated.
Other side effects include:
- Spotting and changes to the next menstrual period
- Diarrhoea
- Breast tenderness
- Dizziness
- Depressed mood
Levonorgestrel is not known to be harmful when breastfeeding, and breastfeeding can continue (unlikely ulipristal). The NICE CKS advise that breastfeeding is avoided for 8 hours after taking the dose to reduce the exposure to the infant.
Ulipristal
Ulipristal acetate is a selective progesterone receptor modulator (SERM) that works by delaying ovulation. The common brand name is EllaOne. It is more effective than levonorgestrel. It is not known to be harmful if pregnancy does occur; however, there is limited data on this.
Wait 5 days before starting the combined pill or progestogen-only pill after taking ulipristal. Extra contraception (ie. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.
It is given as a single dose (30mg) to prevent pregnancy after unprotected intercourse. Ulipristal is licensed for use up to 120 hours after intercourse.
Nausea and vomiting are common side effects. If vomiting occurs within 3 hours of taking the pill, the dose should be repeated.
Other side effects include:
- Spotting and changes to the next menstrual period
- Abdominal or pelvic pain
- Back pain
- Mood changes
- Headache
- Dizziness
- Breast tenderness
There are several notably restrictions with ulipristal:
- Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded)
- Ulipristal should be avoided in patients with severe asthma
Last updated August 2020