Restarting Contraception After Emergency Contraception

Oral emergency contraception delays ovulation but does not protect for the rest of the cycle. Ongoing contraception must therefore begin promptly. The timing depends on the emergency method used. After levonorgestrel and the Yuzpe regimen, most methods can start the next day. After ulipristal acetate, hormonal methods wait 5 days, because a progestin taken sooner lowers its effect. After a copper IUD, any hormonal method can start at once.

Why the wait after ulipristal acetate. Ulipristal acetate acts at the progesterone receptor. A progestin competes with it and may allow ovulation to proceed.

Why not to delay. Ovulation can follow delay by a few days, so a patient without cover is at risk for the rest of the cycle.

Return to fertility. Immediate. Protection from ongoing methods depends on timing and backup.

Eligibility. Judge the ongoing method by its own eligibility, which is unchanged by emergency contraception. Emergency contraception itself is category 1 in most groups and category 2 for cardiovascular disease, angina, migraine and severe liver disease.

History. Which emergency method was used, hours since it was taken, date of the last menstrual period, method preference, breastfeeding, weeks since birth, enzyme inducers and weight.

Pregnancy exclusion. The patient is reasonably certain not to be pregnant when there has been no unprotected intercourse since the last normal menses and menses are not overdue. A test is not needed before one recent episode. Quick start of hormonal methods with backup is acceptable. Test again 3 weeks after the episode.

Counselling points for the clinician. Explain the wait after ulipristal acetate and the backup period. Obtain consent and protect confidentiality. Offer condoms for dual protection.

Special groups.

• Breastfeeding: progestin-only methods from 6 weeks after birth; combined methods are avoided until 6 months.

• Postpartum without breastfeeding: combined methods not before 21 days.

• Obesity and enzyme inducers: prefer IUDs and injectables.

Timing and backup.

Regimen details.

• Combined pill: take the first active pill on the stated day. Missed pills follow the usual rules, with 7 days of backup after 3 or more missed pills in week 1 or 2.

• Injectable: 150 mg intramuscularly every 13 weeks, up to 4 weeks late.

• Device lifespans: etonogestrel 68 mg single-rod implant 3 years; levonorgestrel 75 mg two-rod implant 5 years for the 5-year system and 3 years for other systems; levonorgestrel 52 mg IUD 5 years; copper T 380A up to 12 years.

• Switching overlap: stop condoms only after the backup period ends.

Follow up. Test 3 weeks after the episode. Review the method at the next menses or by 4 weeks.

Expected effects. Bleeding changes with the new method, nausea and breast tenderness. Bleeding in the first days may be a withdrawal bleed from the emergency dose.

Antiemetic regimen. Ondansetron 4 mg by mouth as one dose, repeated once after 8 hours if needed. Maximum 12 mg in 24 hours, for no more than 2 days. Limit to 8 mg in 24 hours in severe liver disease. No kidney adjustment is needed. Avoid in congenital long QT syndrome. In pregnancy use only when the benefit is clear. Short courses are acceptable in breastfeeding.

Pregnancy during quick start. A positive test needs assessment for ectopic pregnancy when pain or bleeding is present. The hormones do not harm the pregnancy, and the method is stopped.

Common errors. Starting a progestin within 5 days of ulipristal acetate, omitting backup, giving combined methods to breastfeeding patients under 6 months after birth, and forgetting the 3-week test.

Referral and escalation. Refer for severe lower abdominal pain, fainting, heavy bleeding or a positive pregnancy test with pain or bleeding.