Is it really an emergency? It can be! 

Emergency contraception (EC) is contraception after unprotected sex. People commonly think of EC as levonorgestrel (LNG-EC), most commonly known as the "morning-after pill,” or Plan B. However, there are five forms of emergency contraception with dozens of different names. Some are more effective than others, and there are some rules to remember about them, too.

ReproHH Case Vignette: Emergency Contraception

A recent call to the Reproductive Health Hotline (ReproHH) came from a nurse practitioner caring for a patient who had unprotected sex two weeks earlier and took ulipristal acetate (UPA), or Ella, within four days. They then started oral contraceptive pills five days after taking UPA, as recommended. A few days after that, they had unprotected sex again and wanted to know their EC options. The case raised several great questions for ReproHH and the provider to talk through, including:

“Could the patient take Ella again?” Yes. Studies are limited but have not shown significant safety concerns. 

“Would the recent birth control pills make Ella less effective?” No. It would not interfere, and if anything, it may have prevented ovulation, which would make UPA more effective. And if she had been on the pills for more than seven days, she may not have needed UPA, as the birth control is now effective to prevent ovulation. 

“If the patient's BMI is over 30, can I prescribe Ella?” Yes. There is no validated weight cutoff. Both LNG and UPA may be less effective for people who are overweight or obese, and LNG may lose efficacy at a lower weight threshold. 

“If the patient's BMI is over 30, should I prescribe a double dose of Plan B?” No. There is no evidence-based reason to routinely double the dose for patients with higher BMI. A randomized trial found that doubling LNG-EC did not significantly improve outcomes for people with obesity. 

After walking through the case together, the nurse practitioner reported feeling more confident in their ability to advise the patient on their options. 

Increasing Access to Emergency Contraception

This call got our team thinking: What defines EC? Is it primary or secondary prevention? Is it an abortion? 

Simply put, EC decreases the chance of pregnancy after unprotected or underprotected sex. Maybe a condom breaks. Maybe a pill or two of birth control was forgotten. Or, unfortunately, maybe someone was assaulted. It is not meant to end an existing pregnancy; if someone is already pregnant, it won’t work. It is not an abortion. 

There has been a lot of advocacy to get EC on university campuses, make it available over-the-counter (OTC), and reduce barriers to access. Advanced provision—prescribing or providing EC before it is needed—is also highly encouraged. Having EC on hand allows patients to use it promptly after unprotected sex. 

Advanced provision also improves access because the more we prescribe EC, the more it will be stocked. Multiple studies in different geographic areas (Texas, Pennsylvania, and Hawaii) have shown that 5% or less of pharmacies have UPA immediately available. Other studies have also shown that LNG-EC, which is OTC, is not available in many pharmacies. 

So, we need to talk about it more, prescribe it more, prescribe it in advance of need, and advocate that it be OTC. Other encouraging facts about advanced provision include that it quadruples the odds of two or more uses, increases access and use for teens, and does not interfere with the use of routine contraception.

Here is a comprehensive review of the different EC options and some important considerations: 

Adapted from the RHNTC Emergency Contraceptive Methods Table, with updates based on the 2024 CDC U.S. Selected Practice Recommendations and subsequent peer-reviewed evidence.

*If ovulation can be estimated, CDC guidance allows placement >5 days after intercourse if it is within 5 days of ovulation

Here are some starter questions to improve EC access in your practice:

• When someone calls your clinic in need of emergency contraception, what barriers are in place that limit their access? What can you do to make it easier for them? 

• Can you offer same-day access to clinicians who can place IUDs? 

• Do you have a phone-triage protocol that allows a clinician to review the request without requiring an unnecessary in-person visit? 

  • Here is an example phone script you could integrate at your clinical site! 

Finally, here are some tips and tricks to remember about EC: 

• Timing: When taking pills, the sooner the better.  
• Efficacy: IUDs are the most effective EC for everyone and provide protection for future sex. If an IUD is not an option, UPA is more effective for people with elevated BMI and effective for longer after unprotected sex compared to LNG-EC. 
• Availability of pills: LNG-EC is OTC, while UPA is not. Not because it’s not safe, but because the manufacturer has not sought OTC FDA approval (it costs lots of money and time to do this). Both may not be stocked as much as they should, so advanced provision is key to getting them on shelves. And remember, UPA and LGN work better the sooner they are taken.
• Contraindications: Oral EC is extremely safe and has very few medical restrictions. Don't delay EC because of concerns about the contraindications that apply to ongoing combined hormonal contraception—short-term EC use is different. And EC is certainly safer than pregnancy. So when in doubt, don’t be :). 
• Advanced provision: Do it! And add some refills! 
• UPA and progestins: These two don't play well together. Wait at least five days after UPA before starting or restarting hormonal contraception.
• EC is a birth control method: It’s important to honor and validate patients who choose to use it.

Have questions about best practice or expanding access to ECs? We’d love to chat!