Current guidance taken and adapted from the faculty of sexual and reproductive health care regarding appropriate
This guidance has been taken from the FSRH guidance, available here
Please follow the FSRH Emergency Contraception decision-making algorithms to help you to advise the patient about the best emergency contraception option(s). Below are some notes to help you in your interpretation of this.
Why might someone request Emergency Contraception (EC)?
Women who do not wish to conceive should be offered EC after unprotected sexual intercourse (UPSI) that has taken place on any day of a natural menstrual cycle.
Women who do not wish to conceive should be offered EC after:
- UPSI from Day 21 after childbirth (unless the criteria for lactational amenorrhoea are met).
- UPSI from Day 5 after abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease (GTD).
Women who do not wish to conceive should be offered EC after UPSI if their regular contraception has been compromised or has been used incorrectly.
What information do you need from the patient to inform the choice of EC?
- Date of first day of last menstrual period (LMP)
- Patient’s shortest menstrual cycle (calculating from day 1 of period to day 1 of the following period in her shortest cycle)
- Earliest possible date of ovulation (calculated by subtracting 14 days from shortest cycle length, and adding this number of days to the LMP). (eg shortest cycle length 30 days so earliest ovulation day in cycle is 30-14=day 16. LMP 18.1.18 so earliest date of ovulation = 1.2.18 (16 days from the LMP). Note that women who have had UPSI in the 6 days prior their estimated date of ovulation are at highest risk of conceiving.
- Time and date of last UPSI? How many hours ago this was from now?
- Other UPSI in this cycle? If yes, were any episodes > 5 days ago?
- Other EC in this cycle? If yes, what and when?
- Has the patient been using any other contraception recently?
- PMH (particularly asthma), and DH (enzyme inducers, recent use of progestogen containing contraception)
- Weight/ BMI
- Consideration of STI risk/ advice about screening
- Future contraception needs/ risk of further UPSI
Emergency Contraception options:
There are three choices of EC:
- Copper Coil (Cu-IUD)
- Levonorgestrel (Levonelle) 1500mg
- Ullipristal (EllaOne)
The copper coil (Cu-IUD) is the most effective method of EC and should be considered for all patients requesting EC.
Please use the FSRH EC decision making algorithm ‘Emergency Copper Intrauterine Device vs Oral Emergency Contraception’ to guide the best choice for your patient which can be found on page ix of the FSRH Emergency Contraception Guideline.
A Cu-IUD can be inserted either
- up to 5 days after the first UPSI in a natural menstrual cycle
- or up to 5 days after the earliest likely date of ovulation (whichever is later, see above).
Link for Yuno sexual health website Yuno Sexual Health | Local Sexual Health Clinic and Free STI Tests | Yuno sexual health
Patients should be referred to Yuno for emergency coils. Complete the referral form as accurately as possible to ensure that the patient receives an appropriately timed appointment. If there has been UPSI within the last 5 days, please also administer oral EC at the time of referral.
Oral Emergency Contraception
Give this if:
- You are referring the patient for an emergency IUD and there has been UPSI within the last 5 days (in case it is technically not possible to fit the IUD when they are seen at Unity)
- Emergency IUD is contraindicated or unacceptable, and there has been UPSI in the last 5 days
Please use the FSRH EC decision making algorithm ‘Oral EC: Levonorgestrel EC (LNG-EC) vs Ullipristal Acetate (UPA-EC) to guide the best choice of oral EC for your patient found on page x of the FSRH Emergency Contraception Guideline.
Ullipristal acetate EC (EllaOne, UPA-EC, )
- License as EC for up to 120 hours after UPSI
- Progesterone receptor blocker (effectiveness reduced if patient has been using progestogen containing contraception recently). Works by postponing ovulation.
- First line oral EC, as it is more effective than LNG-EC
- UPA-EC is preferred oral EC choice if
- Patient is > 70kg or BMI > 26
- Patient has had UPSI 96-120 hours ago
- UPSI < 5 days ago, and took place < 5 days prior to anticipated ovulation date
- Not recommended for women with severe asthma managed with glucocorticoids
- Unlikely to be effective if taken after ovulation, but oral EC should be offered irrespective of where the patient is in her cycle.
- May be less effective if patient is taking an enzyme inducer, or has recently taken contraception containing progestogen. IUD would be most effective option in these situations.
- Can be used more than once in a menstrual cycle. No evidence that it may disrupt an existing pregnancy or cause foetal abnormalities.
Levonorgestrel EC (Levonelle, LNG-EC, 1500mg)
- Licensed as EC up to 72 hours after UPSI
- Can be used off license up to 120 hours, though evidence suggests ineffective if taken > 96 hours after UPSI
- Unlikely to be effective if taken after ovulation, but oral EC should be offered irrespective of where the patient is in her cycle.
- Can be used more than once in a menstrual cycle. No evidence that it may disrupt an existing pregnancy or cause foetal abnormalities.
- Give double dose (3mg, two tablets) if BMI > 26 or weight > 70kg, or taking enzyme inducer. Effectiveness not known.
If one oral method of EC has been used in this menstrual cycle already, try to give the same method again (as one method may impact on the efficacy of the other).
Remember to advise the patient to do a pregnancy test 3 weeks after UPSI, irrespective of EC choice
Remember to consider/ advise about STI risk and screening
Testing needs to be completed at least 10-14 days after UPSI to provide a reliable result.
Remember to consider future contraception
The Cu-IUD provides ongoing contraception, but LNG-EC and UPA-EC do not.
Starting contraception after taking LNG EC
Hormonal contraception (combined oral or progestogen only pills) can be started immediately (‘quick starting’). You may consider providing a one month supply in OOH if the risk of further UPSI is high. Advise the patient to use extra protection until the method becomes effective (after 7 days for COCP, and after 2 days for the POP). Advise the patient to do a pregnancy test 3 weeks after taking EC.
Starting contraception after taking LNG EC
Women must wait 5 days after UPA-EC before starting hormonal contraception (the progestogen content of oral contraception may reduce effectiveness of the UPA-EC if taken sooner). Advise the woman to abstain/use condoms during these 5 days. She can then start the COCP or POP after 5 days, but will need to abstain or use additional precautions until they are effective (a further 7 days for the COCP or a further 2 days for the POP). Again, she needs to do a pregnancy test 3 weeks after UPSI.