Initial Assessment
Confidentiality & Consent
- Reassure about confidentiality
- Explain circumstances requiring breach (e.g., child protection)
- For girls under 16: assess competency using Fraser criteria
- Document assessment in case notes
Risk Assessment
Vulnerable Groups
- Younger than 16 years
- Disadvantaged background
- In or leaving care
- Low educational attainment
Legal Considerations
- Legal age of consent: 16 years in UK
- Sexual activity under 16 is an offence
- Under 13: statutory rape
- Assess for non-consensual sex
Medical Assessment
STI Risk & Testing
- Consider risk of sexually transmitted infections
- Offer STI testing including HIV
- Provide appropriate referrals
When is EC Indicated?
Consider EC if a woman does not wish to conceive and has had unprotected sexual intercourse (UPSI):
General Indications
- On any day of natural menstrual cycle
- After regular hormonal contraception failure
- After contraceptive misuse
- After sexual assault
Postpartum & Post-procedure
- From day 21 after childbirth
- Unless LAM criteria fully met
- From day 5 after miscarriage/abortion
- From day 5 after ectopic pregnancy
- From day 5 after uterine evacuation
History Taking
| Information Needed | Purpose |
|---|---|
| Timing of UPSI | Determine appropriate EC method and timeframe |
| Last menstrual period | Calculate ovulation timing and cycle stage |
| Cycle length | Assess regularity and fertility window |
| Previous EC use | Identify potential cycle disturbances |
| Current medications | Check for drug interactions |
| Medical conditions | Identify contraindications |
Methods of Emergency Contraception
Three Methods Available in UK
- Levonorgestrel - oral progestogen
- Ulipristal acetate - oral progesterone receptor modulator
- Copper IUD - non-hormonal intrauterine device
Comparison of Methods
| Feature | Levonorgestrel | Ulipristal acetate | Copper IUD |
|---|---|---|---|
| Dosage | 1.5 mg single tablet | 30 mg single tablet | Various shapes/sizes |
| Timeframe | 72 hours (up to 96h) | 120 hours (5 days) | 120 hours (5 days) |
| Mode of Action | Inhibits ovulation | Suppresses LH surge | Sperm/ova toxicity |
| Efficacy | Good | Very good | Excellent |
| Post-ovulation | Not effective | Not effective | Effective |
Levonorgestrel Advantages
- Readily available
- Safe to use
- Effective within timeframe
- Widely accessible
Ulipristal Advantages
- Longer timeframe (5 days)
- May be more effective than LNG
- Effective later in cycle
- Single dose convenience
Copper IUD Advantages
- Most effective method
- Works after ovulation
- Provides ongoing contraception
- No hormonal side effects
Method-Specific Considerations
Levonorgestrel (LNG)
Disadvantages & Limitations
- Less effective than copper IUD
- Repeat dose needed if vomiting within 3 hours
- Not effective after ovulation
- Less suitable with liver enzyme-inducing drugs
- Limited effective window
- Possible adverse effects: vomiting, headache, abdominal pain
Ulipristal Acetate (UPA)
Disadvantages & Limitations
- Less effective than copper IUD
- Repeat dose if vomiting within 3 hours
- Not effective after ovulation
- Not suitable with liver enzyme-inducing drugs
- Breastfeeding withheld for 1 week
- Possible adverse effects: vomiting, mood changes, headache, dizziness
Copper Intrauterine Device
Disadvantages & Limitations
- Less readily available than oral methods
- Requires trained professional for fitting/removal
- May be less acceptable to some women
- Possible pelvic discomfort during/after fitting
- May cause heavier, longer, more painful periods
- Risk of expulsion, perforation, infection
Prescribing & Counseling
Essential Discussion Points
- Mode of action and efficacy
- Advantages and disadvantages
- Possible risks and adverse effects
- Follow-up requirements
Key Advice for Patients
Immediate Actions
- Take tablet as soon as possible after UPSI
- If vomiting within 3 hours, take second dose
- Seek medical attention for severe abdominal pain
Menstrual Changes
- Early mild bleeding/spotting may occur
- Do not consider this as start of new cycle
- Period may be earlier/later than normal
- Pregnancy test if period >7 days late
Ongoing Protection
- EC does not protect against STIs
- Use barrier methods for STI protection
- EC intended for occasional use only
- No contraceptive cover for remainder of cycle
Special Populations
| Population | Considerations |
|---|---|
| Adolescents <16 | Fraser competency assessment, child protection considerations |
| Breastfeeding | UPA requires 1 week breastfeeding interruption |
| Liver enzyme inducers | Avoid UPA, consider double-dose LNG or Cu-IUD |
| High BMI | UPA may be more effective than LNG |
| Repeat EC users | Advise regular contraception, assess for cycle disturbance |
Follow-up & Ongoing Care
Pregnancy Testing
- Perform if next period >7 days late
- Test if bleeding lighter than usual
- Consider if UPSI occurred earlier in cycle
- Reliable only if >21 days since UPSI
Regular Contraception Planning
Immediate Needs
- Advise abstinence or barrier methods
- EC provides no ongoing protection
- Increased pregnancy risk with further UPSI
- Consider quick-start regular contraception
Long-term Planning
- EC should not replace regular contraception
- Discuss suitable ongoing methods
- Provide appropriate referrals
- Address repeat EC use concerns
When to Seek Urgent Care
- Severe lower abdominal pain (ectopic risk)
- Heavy vaginal bleeding
- Signs of infection
- Symptoms of pregnancy
- Concerns about IUD placement