Choices in emergency contraception

How to select the best emergency contraceptive method for patients.

The use of emergency contraception began in the 1960s, when the new and relatively high-dose combined oral contraceptives, unlicensed for use in this way, found a role in preventing pregnancy in rape victims, as postcoital or ‘emergency’ contraception.

Since then, emergency contraception has evolved through several forms to become a licensed, easily available, safe and effective way of preventing unwanted pregnancies after unprotected sexual intercourse (UPSI).

However, despite emergency contraception being free from various sources such as GPs, walk-in centres, family planning clinics and young people’s clinics, and the hormonal options being available to buy OTC on patient group directions from pharmacies and online pharmacies, unwanted pregnancy remains a problem.

Although numbers are falling, 184,571 abortions were performed in 2014 for women in England and Wales, of which more than 98% were funded by the NHS1 – an avoidable burden for the individual and for society as a whole.

Contraceptive options

Since the introduction of ulipristal acetate (UPA) in 2009, there are now three relatively effective options available in emergency contraception:

  • 1.5mg levonorgestrel (LNG)
  • 30mg UPA
  • IUD

LNG is licensed for use up to 72 hours after UPSI, but has a continuing, although diminishing, protective effect even after 72 hours. Historically, this was a ‘better than nothing’ reason to use LNG when the patient presented after 72 hours and would not accept an IUD, which can be used up to five days after UPSI or ovulation.

However, UPA is now licensed for emergency contraception up to 120 hours (five days) following UPSI. Taken as a single oral 1.5 mg dose as soon after UPSI as possible, it is believed to work by inhibition or delay of ovulation, but also possibly through altering tubal motility, interfering with fertilisation or implantation.2

Further, UPA has been shown to prevent significantly more unplanned pregnancies than LNG when given within nought to 72 hours,3 making it the oral treatment of choice for most women.

An IUD is effective up to five days after UPSI, or after ovulation, and can remain in situ, offering continuing contraception for up to 10 years, depending on the type of IUD.

Cost and contraindications

Cost comparison of all three methods is difficult – an emergency IUD offers long-term contraception, so its cost cannot be directly compared with that of LNG or UPA.

Although UPA is more expensive per item to the NHS than LNG, in one study,4 UPA had advantages in its prolonged efficacy, and all costs are less than the estimated cost of unintended pregnancy (£948), regardless of the outcome, or the cost of an induced abortion at the time of the study (£672).

There are few absolute contra-indications to the three forms of emergency contraception (see table 1).

Table 1 Comparison of different emergency contraception methods

Method and dosage

Effectiveness after UPSI


LNG 1.5mg immediately, single dose

Up to 72 hours

Reducing with time after 12 hours
97.8%3 efficacy taken nought to 24 hours after UPSI
85% efficacy after 25 to 48 hours
58% efficacy after 49 to 72 hours5

UPA 30mg immediately, single dose

Up to 120 hours

Static throughout the 120 hours


Up to 120 hours after UPSI or ovulation

Over 99%
Constant for up to five to 10 years

Table 2 Availability, costs and contraindications



Cost per pack



  • Free from GP or clinic on FP10
  • Free to under 24s on pharmacist or clinic PGD
  • Purchase OTC from pharmacy if over 16 and do not qualify for free supply
  • From online pharmacies (needs doctor- reviewed questionnaire)



To patient:


  • C/I in acute porphyria
  • Reduced efficacy in women taking enzyme-inducing drugs (off-licence double dose has been used)
  • Caution in past ectopic pregnancy; severe malabsorption syndromes; active trophoblastic disease (until return to normal of urine- and plasma-gonadotrophin concentration) - seek specialist advice


  • Free from GP or clinic on FP10
  • From online pharmacies (after a doctor reviewed questionnaire)



To patient:


  • Avoid in severe liver impairment
  • Reduced efficacy in women taking enzyme-inducing drugs (off-licence double dose has been used)
  • Caution in uncontrolled severe asthma; as a progesterone receptor binder with high affinity it reduces effectiveness of combined hormonal and progestogen-only contraceptives (additional precautions, eg barrier methods, required for 14/7 for combined and parenteral progestogen-only hormonal contraceptives , 16/7 for Qlaira®) and 9/7 for oral progestogen-only contraceptives. Not advised for repeated use within a menstrual cycle


  • Free from GP or clinic where it needs to be inserted by trained healthcare professional


(depending on device used)

  • Not recommended before 28 days after giving birth
  • Severe anaemia, recent STI, unexplained uterine bleeding, distorted/small uterine cavity, genital malignancy, active trophoblastic disease, PID, immunosuppression; copper allergy, Wilson's disease

Women of all ages can use an emergency IUD, but it is not normally recommended before 28 days after giving birth (LNG or UPA can be used until this time), cannot be used in women allergic to copper, and is used with caution in women with a history of recent uterine infection or other pathology.

Most women can use UPA, although the manufacturer advises against its use in severe liver disease, severe asthma or when taking certain prescribed medicines or complementary medicines which may affect efficacy.

Most women can use LNG, although if the patient is taking certain prescribed or complementary medicines, they may need advice about efficacy and dosage.

A shared decision

Women seek emergency contraception for a variety of reasons, from omitting to use any effective contraception at all, to the contraception they do use failing (most commonly, condoms coming off or tearing, and forgetting to take their oral contraceptive pill).

More subtle factors, such as changing their mind about trying for a pregnancy, can also lead a patient to present.

Counselling about future contraception is as important as discussing the type of emergency contraception to use and will inform the patient’s decision.

Factors such as timing, accessibility, age, medical history, efficacy of choice, medical contraindications and personal preference – for example, many women dislike the thought of an IUD or fear it may be painful – will lead to a shared decision on what is right for this patient on this occasion.


Timing is the main factor, with LNG now the least effective choice, but easiest to access. The IUD offers best efficacy and can be used at any point up to five days after UPSI, or after ovulation. It is the only choice which offers continuing contraception, but it is not accessible without a skilled clinician in a clinic, as opposed to the oral methods, which can be accessed 24 hours a day.

Contraception case scenarios


Tansy is 17 years old and has been in a relationship with her boyfriend Tom for six months.

She is on a progesterone-only pill, but cannot remember taking it in the past couple of days. They also always use condoms, but it came off when they had sex that afternoon.

It is now 10pm and she is starting to panic, so she visits the out-of-hours walk-in centre for advice. She says that pregnancy would be a disaster as they are both planning to go to college.

She is otherwise well, but gives a vague history of abdominal pain and discharge 18 months ago, when staying with her friend in London. She went to a walk-in clinic there, where she was told this was a probable episode of pelvic inflammatory infection. She thinks it was treated as chlamydia with azithromycin, and her symptoms completely settled soon after this.

  • What are her options?
  • Which option would most reduce her risk of pregnancy?
  • What should she use as continuing contraception?


Maria, who is 32 years old, admits to a one-night stand when drunk at a party, with a man she does not know and using no contraception, 70 hours ago.

She says she is really here to discuss possible STIs because she now feels ‘uncomfortable down there’, although she has no specific symptoms other than a thicker than usual discharge.

She has assumed it is too late for any emergency contraception. Maria has had two previous terminations, she says, owing to problems remembering to take her contraceptive pills.

  • Could Maria use any of the three options?
  • What would offer her the most reliable way to avoid an unwanted pregnancy?
  • What factor would most affect your shared discussion about the best continuing contraception for her?


Shani, aged 24, comes to see you because she has had four or possibly more episodes of UPSI during this menstrual cycle.

She is not certain but thinks they were on days eight, 10, 11 and then yesterday, day 17, of her usually regular 27-day cycle.

A friend got something for her after the UPSI on day eight, but she does not know which ‘morning-after pill’ it was and she cannot afford to do that again.

Her life is rather chaotic – she drinks very heavily and has used cannabis and cocaine. She has one child, cared for now by her mother.

She had a hospital admission last year when, after a relationship ended, she took an overdose of paracetamol and alcohol.

She was jaundiced and had a degree of liver damage, although she says she feels more in control of her life now. She has no regular boyfriend.

  • Are all options for emergency contraception open to her?
  • Is emergency contraception going to be effective, given all the UPSI this month?
  • What statement most fits your approach when discussing her contraception?
  • Dr Jenkins is a GP in Bristol and long-term conditions clinical lead at Bristol CCG.

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  1. DH. Abortion Statistics, England and Wales: 2014
  2. Glasier A. N Engl J Med 1997; 337: 1058-64
  3. Glasier A, Cameron S, Fine P et al. Lancet 2010; 375: 555-62
  4. Thomas CM, Schmid R, Cameron S. J Fam Plann Reprod Health Care 2010; 36(4): 197-201
  5. CMO Update 35 (2003)

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