Hormonal Emergency Contraception G16 v5

Trust Guideline for the use of Emergency Contraception (EC)
A clinical guideline recommended

Contraception and Sexual Health, Genito-Urinary
For use in: (GU) Medicine, Obstetrics and Gynaecology and
Emergency Medicine
By: Medical and Nursing staff
For: Prevention of unplanned pregnancy

Division responsible
Women and Children
for document:
Emergency Contraception, Levonelle,
Key words: Levonorgestrel, Ulipristal Acetate, ellaOne,
Intrauterine Device
Name of document author: Dr Charlotte Gatenby
Job title of document
ST4 in Sexual and Reproductive Health
author:
Name of document author’s Line
Richard Smith
Manager:
Job title of document author’s Line
Clinical Director – Obstetrics and Gynaecology
Manager:
Assessed and approved by the: Gynaecology Guidelines Committee (GGC)
Date of approval: 02/10/2021
Ratified by or reported as approved
Clinical Safety and Effectiveness Sub-Board
to (if applicable):
To be reviewed before:
This document remains current after 02/10/2024
this date but will be under review
To be reviewed by: Dr Charlotte Gatenby
Reference and / or Trustdocs
G16 – ID No: 763
ID No:
Version No: 5
Compliance links: (is there any NICE

No
related to guidance)
If Yes – does the strategy/policy

deviate from the recommendations N/A
of NICE? If so, why?
Clinical Guideline for: The Use of Emergency Contraception (EC)

Author/s: Dr Charlotte Gatenby Author/s title: ST4 in Sexual and Reproductive Health
Approved by: GGC Date approved: 02/10/2021 Review date: 02/10/2024
Available via Trust Docs Version: 5 Trust Docs ID: 763 Page 1 of 11
2
Version and Document Control:
Version Date of
Change Description Author
Number Update
Dr Catherine
5 Reviewed and amended
Schunmann
This is a Controlled Document

Printed copies of this document may not be up to date. Please check the hospital
intranet for the latest version and destroy all previous versions.

1) When is EC indicated?
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
 From day 21 after childbirth
 From day 5 after termination, miscarriage, ectopic pregnancy or uterine
evacuation for gestational trophoblastic disease
2) What methods are available and how effective are they? Table 1
Method Class Dose/use Indication Efficacy

(%)
Cu-IUD Intrauterine Retain Cu-IUD until Within 120 hours of first 99%
device pregnancy is UPSI in cycle or within 5
excluded (with next days of earliest
menstrual period) or estimated date of
can be kept for ovulation.
ongoing
contraception
Ulipristal acetate Progesterone 30mg PO single Licensed for use within around
(UPA-EC) receptor dose 120 hours of UPSI 85%,
modulator possibly
more
Levonorgestrel Progestogen 1.5mg PO single Licensed for use within Less than
<72 hours dose 72 hours of UPSI 85%
(LNG-EC) (varying
evidence)
Levonorgestrel Progestogen 1.5mg PO single Unlicensed 65%

72-96 hours oral dose
3) Mode of action
It is estimated that sperm can remain and are viable in the female genital tract for
about 5 days after UPSI. Should ovulation occur within those 5 days, fertilisation
could take place and the patient is at risk of pregnancy. A 2002 judicial review
concluded that pregnancy begins at implantation. It is therefore currently accepted
that any intervention for EC must act to prevent fertilisation or to prevent implantation
rather than by disrupting implantation. Available data demonstrate that the shortest
time from ovulation to implantation is 6 days (although usually longer – over 80% of
pregnancies implant 8-10 days after ovulation). The earliest likely ovulation date is
estimated as the date of the start of the LMP plus the number of days in the shortest
cycle minus 14.
A woman’s fertile period is considered to be the six consecutive days ending with
(and including) the day of ovulation, during which pregnancy risk following a single
episode of UPSI has been estimated to be up to 30%.

The Cu-IUD works primarily via its toxic effect on sperm and ova. If fertilisation does
occur, the local inflammatory reaction resulting from the presence of the Cu-IUD
prevents implantation. A Cu-IUD can be inserted up to 5 days after the first UPSI in a
natural menstrual cycle or 5 days after the earliest likely date of ovulation, whichever
is later. 5 days after ovulation would be Day 19 in a 28 day cycle, before the process
of implantation has begun. It is necessary to establish an accurate last menstrual
period (LMP) date and cycle length in order to insert a Cu-IUD as emergency
contraception using this rule.
Ulipristal (UPA-EC) is a selective progesterone receptor modulator and its primary

method of action is to delay or inhibit ovulation by at least 5 days until sperm from the
UPSI for which EC is being taken are no longer viable. UPA-EC works even after the
start of the LH surge but cannot inhibit ovulation after the LH peak.
Levonorgestrel (LNG-EC) has a similar action, but is ineffective after the start of the
LH surge. The action of LNG-EC declines with increasing time following UPSI,
whereas ulipristal effects are maintained.
After taking oral EC, women continue to be at risk of pregnancy from UPSI later in
the cycle as ovulation has been delayed.
Available evidence suggests that any oral EC administered after ovulation is

ineffective.
4) Broad recommendations
 Women who present for emergency contraception should be seen and

assessed as soon as possible. A baseline pregnancy test is usually useful and a
sexually transmitted infection (STI) risk assessment should be carried out in all
women and this can be repeated at 2 weeks following UPSI if this is with a new
partner.
 Although oral EC may not be effective after ovulation. EC should still be
offered to all women following UPSI that has taken place on any day in a
natural menstrual cycle.
 A careful history should be taken, establishing LMP, average cycle length,

timing and number of episodes of UPSI since LMP and in particular whether UPSI
occurred at a high risk time (days 9-14 of 28 day cycle) and whether the woman is
currently ≤ 5 days after earliest date of ovulation (Day 19 of 28 day cycle)
 Advice about future contraception should be given and, if possible, provided.
5) Key Messages
The Cu-IUD
 Insertion of a copper intrauterine device (Cu IUD) is the most effective method
of EC and should be considered by ALL women who have had UPSI and do
not want to conceive.

 It is the only method that is effective after ovulation has taken place (but is
inserted before the earliest likely date of implantation so that it does not disrupt
a pregnancy that has already implanted – see Table 4 for quick reference
guide to day of ovulation and last possible day of Emergency-IUD insertion for
women with cycle lengths other than 28 days) and has the advantage of
providing immediately effective and ongoing contraception. It is not affected by
other drugs or body mass index (BMI).
 Oral EC should be offered as soon as possible after UPSI if a Cu-IUD is not

appropriate or not acceptable. It is unlikely to be effective if taken > 120 hours
after UPSI or if ovulation has already occurred.
Choosing between UPA-EC and LNG-EC
 UPA-EC is the only oral EC that is likely to be effective if UPSI took place 96-
120 hours ago.
 If UPSI has taken place during the 5 days prior to ovulation, risk of pregnancy
is very high and UPA-EC should be considered first-line oral EC
 The risk of further UPSI in the cycle – the ability of UPA-EC to delay ovulation
may be inhibited if a progestogen is taken in the subsequent 120 hours. It is
therefore recommended that hormonal contraception is not started until 5 days
after UPA-EC whereas hormonal contraception can be started immediately
after LNG-EC. It may be appropriate to prioritise quick starting a reliable,
ongoing hormonal method, particularly if the immediate pregnancy risk is low.
 Recent use of progestogen – the effectiveness of UPA-EC could be

theoretically reduced if a woman has taken a progestogen within the last 7
days (eg attends for EC because of missed pills or expelled IUS)
 BMI – the effectiveness of LNG-EC may be reduced if a woman weighs > 70kg
or has a BMI of 26 or over. UPA-EC may be given or double dose LNG-EC – it
is not known which is more effective.
The following algorithms provide guidance for assessing which women are
suitable for EC-IUD (Algorithm 1) and how to select oral EC (Algorithm 2) for
those women in whom EC-IUD is either unsuitable or unacceptable.


6) Special considerations
Special Considerations – Table 2
Scenario Cu IUD Levonorgestrel Ulipristal Acetate

(Levonelle) (ellaOne)
Breast feeding
Increased
perforation risk Safe to use while
(2/1000). breast feeding.
Unknown safety – advise
Counsel women to avoid breast feeding for
accordingly and 7 days and discard
maintain appropriate expressed milk.
levels of clinical
caution
Multiple doses N/A If further UPSI <12 If further UPSI <12 hours
in a single cycle hours after dose no after dose no additional
additional dose dose needed. Multiple
needed. Multiple doses in the same cycle
doses in the same are acceptable but patient
cycle are acceptable should be warned that
but patient should be they may already be
warned that they may pregnant. UPA-EC should
already be pregnant. not be used within 7 days
LNG-EC should not of using LNG-EC as it
be used within 5 days may interfere with its
of having taken UPA- efficacy.
EC as it may interfere
with its efficacy.
BMI
No effect May be less effective

in women weighing > BMI is not known to affect
70kg or with BMI ≥26. the efficacy of UPA-EC.
3mg recommended
(double dose).
Enzyme
inducing drugs
(see table 3,
page 8 for full
list) No effect IUD is preferred option.
IUD is preferred Ulipristal not
option. If declined, recommended in this
Levonelle dose group.
should be doubled
to 3mg.
Safeguarding Age or parity is not a Assessment of Fraser competence is required and
Age 13 - 16 contraindication to appropriate referrals as per departmental policy.
IUD insertion
Safeguarding Age or parity is not a A child safeguarding issue IS present. Social
Age under 13 contraindication to Services must be informed urgently as a legal
IUD insertion minimum requirement. Senior clinician advice and
discussion necessary.
Enzyme Inducing Drugs – Table 3
Enzyme inducing drugs may affect contraceptive efficacy and may reduce
efficacy of UPA-EC. Women using enzyme inducing drugs should be made
aware of potential interactions and should always be offered Cu-IUD if
appropriate. If this is declined or not appropriate for EC provision a double
dose (3mg) levonogestrel can be offered.
Drug Group Examples of Enzyme inducers

Antiepileptics Carbamazepine, Eslicarbazepine, Oxcarbazepine, Phenobarbital,
Phenytoin, Primidone, Rifinamide, Topiramate
Antiretrovirals Efavirenz and Nevaripine.
Antibiotics Rifampicin, Rifabutin,
Herbal St Johns Wort
Others Aprepitant (Nausea and vomiting esp chemotherapy), Bosentan
(Pulmonary hypertension or systemic sclerosis), Sugammadex
(Neuromuscular blockade reversal agent)
7) Contraindications
 Cu-IUD
The contraindications to insertion of a Cu-IUD for EC are the same as those
for routine insertion (active and/or symptomatic genital tract infection, genital
tract malignancy – see UKMEC 2016)
Importantly, risk of STI, nulliparity, adolescence and previous ectopic
pregnancy are NOT contraindications to use. Women at risk of STI should be
offered screening and appropriate antibiotic cover at the time of insertion.
 UPA-EC
Use of Ulipristal is not recommended in the presence of galactose intolerance,
malabsorption or in those with severe asthma controlled by the use of oral
glucocorticoid therapy. Although use of UPA-EC is not recommended in
women with severe hepatic impairment, pregnancy poses a significant risk
and expert opinion suggests that a single dose of UPA-EC is therefore
acceptable.
 LNG-EC
There are no contraindications to use of LNG-EC
Levonelle (LNG-EC), Upostelle (LNG-EC), Emerres (LNG-EC) and ella One (UPA-
EC) all contain lactose.
8) Accessing Emergency Intrauterine Contraception
Women can be referred to iCaSH, 1a Oak Street, Norwich, NR3 3AE Monday, Friday
0900-1800 for further assessment either by clinician referral on 01603 226 600
(number for clinicians only) or by self-referral on 0300 300 3030. There is also cover
on Saturday mornings but these appointments need to be booked in advance or
discussed with a clinician.
Due to the current social distancing measures, there is no “sit and wait” at iCaSH but
every attempt will be made to process telephone requests for EC in a timely manner.
Outside these hours patients should be given oral EC as an interim measure and the
clinic contacted as soon as possible thereafter to discuss suitability for Cu-IUD
insertion.
9) Auditable outcomes
 Percentage of women presenting for EC who, subject to availability, are

advised that a Cu-IUD is the most effective method – 97%
 Percentage of women whose preferred method is Cu-IUD who are advised of
alternative pathways if the provider is unable to meet their request. – 97%
 Percentage of women prescribed oral EC who are advised about the
importance of starting a reliable method of contraception and are given
information about contraceptive methods – 97%
 Percentage of women resuming or quick starting a hormonal method of
contraception after taking oral EC who are advised to do a pregnancy test no
sooner than 3 weeks after the most recent episode of unprotected sexual
intercourse – 97%
 Percentage of women presenting for EC who have a sexual health risk
assessment and are offered screening at the appropriate interval if indicated –
97%
10) References
1. FSRH Guideline Emergency Contraception Clinical Effectiveness Unit. March 2017.

https://www.fsrh.org/documents/ceu-clinical-guidance-emergency-contraception-march-2017/
Accessed 14.9.2021.
2. Faculty of Sexual and Reproductive Health Care Clinical Effectiveness Unit. (January
2017, updated 2019) “Drug interactions with hormonal contraception.” Available on the
Faculty Website
http://www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdf. Accessed
14.9.2021
3. Faculty of Sexual and Reproductive Health Clinical Guideline: Contraceptive

Choices for Young People (March 2010, amended May 2019)
https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-young-
people-mar-2010/
Accessed 14.9.2021
4.

Quick reference table for insertion of Copper IUD for emergency contraception
according to cycle length – Table 4
No of days in cycle (n)* Day of ovulation (n-14) Last possible day of IUD
insertion for EC (n-14+5)
21 Day 7 Day 12
22 Day 8 Day 13
23 Day 9 Day 14
24 Day 10 Day 15
25 Day 11 Day 16
26 Day 12 Day 17
27 Day 13 Day 18
28 Day 14 Day 19
No of days in cycle (n)* Day of ovulation (n-14) Last possible day of IUD
insertion for EC (n-14+5)
29 Day 15 Day 20
30 Day 16 Day 21
31 Day 17 Day 22
32 Day 18 Day 23
33 Day 19 Day 24
34 Day 20 Day 25
35 Day 21 Day 26
*Note must have a regular cycle length. To assess cycle length and regularity, check this over the
preceding 3 months. Menstrual cycle apps can be very useful. Day 1 of menstruation is day 1 of
cycle.


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Trust Guideline for the use of Emergency Contraception (EC)

A clinical guideline recommended

For: Prevention of unplanned pregnancy

Compliance links: (is there any NICE

If Yes – does the strategy/policy

Clinical Guideline for: The Use of Emergency Contraception (EC)

Version and Document Control:

This is a Controlled Document

Clinical Guideline for: The Use of Emergency Contraception (EC)

Women who do not wish to conceive should be offered EC after unprotected

Method Class Dose/use Indication Efficacy

Levonorgestrel Progestogen 1.5mg PO single Unlicensed 65%

Clinical Guideline for: The Use of Emergency Contraception (EC)

Ulipristal (UPA-EC) is a selective progesterone receptor modulator and its primary

Available evidence suggests that any oral EC administered after ovulation is

 Women who present for emergency contraception should be seen and

 A careful history should be taken, establishing LMP, average cycle length,

Clinical Guideline for: The Use of Emergency Contraception (EC)

 Oral EC should be offered as soon as possible after UPSI if a Cu-IUD is not

Choosing between UPA-EC and LNG-EC

 Recent use of progestogen – the effectiveness of UPA-EC could be

Clinical Guideline for: The Use of Emergency Contraception (EC)

Clinical Guideline for: The Use of Emergency Contraception (EC)

Special Considerations – Table 2

Scenario Cu IUD Levonorgestrel Ulipristal Acetate

No effect May be less effective

Enzyme Inducing Drugs – Table 3

Drug Group Examples of Enzyme inducers

8) Accessing Emergency Intrauterine Contraception

 Percentage of women presenting for EC who, subject to availability, are

1. FSRH Guideline Emergency Contraception Clinical Effectiveness Unit. March 2017.

3. Faculty of Sexual and Reproductive Health Clinical Guideline: Contraceptive

Clinical Guideline for: The Use of Emergency Contraception (EC)

Clinical Guideline for: The Use of Emergency Contraception (EC)

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