Definitions of the grades of recommendation, based on levels of evidence (A-C, Good Practice Point), are provided at the end of the "Major Recommendations" field.
When Is Emergency Contraception Indicated?
- The clinician should summarise evidence of effectiveness and the need for emergency contraception (EC) in each woman's individual circumstance to allow her to make an informed choice regarding its use (Good Practice Point).
Table. Recommendations for Emergency Contraception Use in Commonly Occurring Situations
| Situation |
Indications for Emergency Contraception |
| Potential Failures of Various Contraceptive Methods |
| Combined pills (21 active tablets) |
If three or more 30 to 35 microgram EE or two or more 20 microgram EE pills have been missed in the first week of pill taking (i.e., Days 1 to 7) and UPSI occurred in Week 1 or the pill-free week |
| Progestogen-only pill (POP) |
If one or more POPs have been missed or taken >3 hours late (>12 hours late for Cerazette®) and UPSI has occurred in the 2 days following this |
| Intrauterine contraception |
If complete or partial expulsion is identified or mid-cycle removal of an IUD/IUS is deemed necessary and UPSI has occurred in the last 7 days |
| Progestogen-only injectables |
If the contraceptive injection is late (>14 weeks from the previous injection for medroxyprogesterone acetate or >10 weeks for norethisterone enantate) and UPSI has occurred |
| Barrier methods |
If there has been failure of a barrier method |
| Use of Liver Enzyme Inducers |
| Liver enzyme inducing drugs (including St. John's Wort) |
An additional barrier method is recommended if oral contraceptives, progestogen implants or contraceptive patch and liver enzyme-inducers are taken concurrently. EC is indicated if there is UPSI or barrier method failure during, or in the 28 days following, use of liver enzyme-inducers |
EC, emergency contraception; EE, ethinylestradiol; IUD, intrauterine device; IUS, intrauterine system; POP, progestogen-only pill; UPSI, unprotected sexual intercourse.
What Regimens of Oral Hormonal Emergency Contraception Are Available?
- Levonorgestrel (LNG) should be given as a single 1.5 mg dose as soon as possible after unprotected sexual intercourse (UPSI), and within 72 hours (Grade A).
How Effective Is Emergency Contraception and How Can Efficacy Be Optimised?
- Women should be given written and verbal information regarding the failure rates of oral and intrauterine EC to allow them to make informed choices and to increase compliance and efficacy (Grade A).
- LNG EC may be considered between 73 and 120 hours after UPSI, but women should be informed of the limited evidence of efficacy, that such use is outside product licence, and the alternative of an IUD (Good Practice Point).
- Women can be advised that LNG EC can be used more than once in a cycle if clinically indicated (Good Practice Point).
- An intrauterine device (IUD) (or advice on how to obtain one) should be offered to all women attending for EC even if presenting within 72 hours of UPSI (Good Practice Point).
- IUDs with banded copper on the arms and containing at least 380 mm2 of copper have the lowest failure rates and should be the first-line choice, particularly if the woman intends to continue the IUD as long-term contraception (Grade A).
- Ideally, an emergency IUD should be fitted at first presentation, but insertion can be offered later, at the woman's convenience. In this case, LNG EC should be given in the interim (Good Practice Point).
- If facilities are unavailable for emergency IUD insertion, local referral mechanisms should facilitate timely access to a specialist who can provide this service (Good Practice Point).
- A copper IUD can be inserted up to 5 days after the first episode of UPSI. If the timing of ovulation can be estimated, insertion can be beyond 5 days of UPSI, as long as it does not occur beyond 5 days after ovulation (Grade C).
Are There Any Contraindications to Emergency Contraception?
- The World Health Organization Medical Eligibility Criteria for Contraceptive Use advises that there are no medical contraindications to the use of hormonal EC (Grade C).
What Drug Interactions Are Relevant to Emergency Contraceptive Use?
- Women using liver enzyme-inducing drugs should be advised that an IUD is the preferred option for EC (Grade A).
- Women who are using liver enzyme-inducing drugs who are given 0.75 mg tablets of LNG (Levonelle-2) should be advised to take a total of 2.25 mg (three tablets) as a single dose, as soon as possible and within 72 hours of UPSI. This use is outside the product licence (Grade C).
- Women who are using liver enzyme-inducing drugs who are given 1.5 mg tablets of LNG (Levonelle One Step or Levonelle 1500) should be advised to take a total of 3 mg (two tablets) as a single dose, as soon as possible and within the 72 hours of UPSI. This use is outside the product licence (Good Practice Point).
- Women using non-liver enzyme-inducing antibiotics (short- or long-term) should follow the normal LNG regimen (1.5 mg within 72 hours of UPSI) (Grade C).
- There are no drugs that are known to affect emergency IUD use (Grade C).
What Clinical Examinations and Investigations Are Required Before Providing Emergency Contraception?
- A sexual history should be taken from all women attending for EC to assess risk of sexually-transmitted infections (STIs) (Grade C).
- Prior to emergency IUD insertion, women at higher risk of STIs (age <25 years, change in sexual partner, or more than one partner in the last year) should be offered testing for Chlamydia trachomatis (as a minimum) (Grade C).
- For women assessed as being at higher risk of STIs, if results of testing are not available at the time of emergency IUD insertion, the use of prophylactic antibiotics may be considered (Good Practice Point).
What Are the Side Effects of Emergency Contraception?
- Women who experience vomiting within 2 hours of administration of LNG EC should be advised to return as soon as possible for a repeat dose (Good Practice Point).
- Women should be advised that a small increase in pelvic infection occurs in the 20 days following IUD insertion, but the risk is the same as for the non-IUD-using population thereafter (Grade A).
What Aftercare and Follow-Up Is Required?
- Women should be given information and counselling on use of their future contraceptive method of choice (Good Practice Point).
- LNG EC does not provide contraceptive cover for the remainder of the cycle and effective contraception or abstinence must be advised (Grade B).
- Women should be advised to have a pregnancy test if their expected menstruation is more than 7 days late, or lighter than usual (Grade B).
- An emergency IUD can be removed at any time after the next menstruation if no UPSI has occurred since menses or if hormonal contraception was started within the first 5 days of that cycle (Grade C).
Who Can Supply Emergency Contraception?
- Patient group directions (PGDs) can be developed to allow nurses and other health care professionals to supply and administer contraceptives. PGDs may include use outside the terms of the product licence provided such use is justified by current best practice; the PGD clearly describes the status of use outside the licence; and the documentation includes the reason why such use is necessary (Grade C).
Emergency Contraception and Young People
- If a young person is assessed for competency, this should be documented in case notes as being 'Fraser ruling competent' (advice understood, will have or continue to have sex, advised to inform parents, in best interest) (Grade C).
Should Emergency Contraception Be Supplied in Advance of Need?
- Advance provision of LNG can be offered to women to increase early use when required (Grade A).
Definitions:
Grades of Recommendation based on levels of evidence as follows:
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point: Where no evidence exists but where best practice is based on the clinical experience of the Expert Group
