7.3.5 Emergency contraception
Refer to FSRH Decision making algorithms for Emergency Contraception
|1st choice||Copper intrauterine device (where service available) [within 120 hours of unprotected sexual intercourse (UPSI) or up to 5 days after predicted day of ovulation]|
|ellaOne® (ulipristal) 30mg tablet (if IUD not available and within 120 hours of UPSI)|
Dose: 1 tablet to be taken as soon as possible following UPSI, but no later than 120 hours
|Levonorgestrel 1.5 mg tablet (if IUD not available and within 72 hours of UPSI)|
Dose: 1.5 mg for 1 dose, taken as soon as possible after UPSI, preferably within 12 hours but no later than after 72 hours, alternatively 3 mg for 1 dose, taken as soon as possible after UPSI, preferably within 12 hours but no later than after 72 hours.
- Refer to FSRH decision making algorithms for emergency contraception (EC).
- Health professionals should discuss individual need for EC and inform women about the different methods with regard to efficacy, adverse effects, interactions, medical eligibility and need for additional contraceptive precautions.
- NICE recommend that all eligible women presenting within 120 hours of UPSI or up to 5 days after earliest expected date of ovulation should be offered a copper IUD as it is the most effective method.
- Oral EC taken after ovulation is ineffective.
- If IUD insertion is not available locally then consider referral to a service which can provide insertion of IUD. Oral emergency contraception should be provided in the interim. Where IUD insertion is not available or not acceptable to the woman, ulipristal 30mg tablet or levonorgestrel 1.5mg tablet can be offered. Evidence suggests that ulipristal is more effective than levonorgestrel even on day 1 after intercourse and has sustained efficacy to day 5. This may be of particular relevance for women presenting mid cycle around the time of ovulation. Refer to FSRH decision making algorithms to help decide on the best choice for the individual patient.
- The MHRA have issued advice on the risk factors for uterine perforation with intra-uterine contraception, including copper intra-uterine devices and levonorgestrel-releasing intra-uterine systems. Uterine perforation most often occurs during insertion, but might not be detected until a later stage. The risk is increased when the device is inserted up to 36 weeks postpartum or in patients who are breastfeeding. Patients should be informed of the signs and symptoms of uterine perforation. For more information see MHRA.
- The effectiveness of levonorgestrel 1.5mg tablet decreases significantly with time so should be taken as soon as possible.
- Ulipristal 30mg tablet provides prescribers with a licensed option for use in women presenting up to 120 hours after UPSI, if insertion of a copper IUD is not feasible, note: ulipristal may have reduced efficacy in women taking drugs that affect gastric pH, i.e. antacids, H2 antagonists and proton pump inhibitors.
- Levonorgestrel 1.5mg tablet and EllaOne® (ulipristal) can also be purchased in community pharmacies.
- Levonelle® One Step (over-the-counter levonorgestrel 1.5mg) is considerably more expensive than the prescription only medicine (POM) preparations and should not be prescribed.
- If vomiting occurs within 2 hours of taking levonorgestrel 1.5mg tablet or 3 hours of taking ulipristal 30mg tablet, a replacement dose can be given.
- Can oral EC be used more than once in a cycle?
- If a woman has already taken levonorgestrel EC once or more in a cycle, EC providers can offer her levonorgestrel EC again after further UPSI in the same cycle.
- If a woman has already taken ulipristal EC once or more in a cycle, EC providers can offer her ulipristal EC again after further UPSI in the same cycle.
- If a woman has already taken ulipristal EC, levonorgestrel EC should not be taken in the following 5 days.
- If a woman has already taken levonorgestrel EC, ulipristal EC could theoretically be less effective if taken in the following 7 days.
- Concomitant use of ulipristal and EC containing levonorgestrel is not recommended.
- Women who require EC while using enzyme-inducing drugs should be advised that an intrauterine device is the preferred option. Those who prefer to take a hormonal EC may be advised to double the dose of oral levonorgestrel, i.e. 2 tablets of levonorgestrel 1.5mg [off label]. Ulipristal acetate is metabolised by cytochrome P450 and its efficacy may be reduced by enzyme-inducing drugs. Increasing the dose of ulipristal is not recommended as there is no evidence that this is effective.
- There is no evidence that levonorgestrel is teratogenic. It does not work if a woman is already pregnant. Before levonorgestrel is prescribed or sold, pregnancy can usually be excluded on the basis of the menstrual history; pelvic examination and/or pregnancy testing is only indicated if pregnancy is suspected on clinical grounds.
- The relative lack of experience with ulipristal means that its effects on the fetus and any teratogenic potential, through inadvertent use during pregnancy, are not fully known. However the limited data available do not suggest any safety concern.
- If EC has been required due to missed pills:
- Women should continue their pill without delay after using levonorgestrel EC. Additional contraceptive precautions will be required, depending on method of both emergency and regular contraception. Refer to FSRH guide on missed pills.
- Regular hormonal contraception should not be started for 5 days after using ulipristal EC, as efficacy of ulipristal EC may otherwise be reduced. A reliable barrier method should be used until the next menstrual period.
- Women presenting for EC should be encouraged to consider regular contraceptive options, if not already using. Women may opt for LARC methods and this will require bridging with POP. Guidance regarding quick-start and bridging can be found on the Faculty of Sexual and Reproductive Healthcare website.
- Ulipristal is not suitable for use by women who have severe asthma controlled by oral glucocorticoids.