Society of Family Planning Clinical Recommendation: Emergency contraception

Contraception 121 (2023) 109958

Contents lists available at ScienceDirect

Contraception

journal homepage: www.elsevier.com/locate/contraception

Review article

Society of Family Planning Clinical Recommendation: Emergency

contraception

✩ , ✩✩

Jennifer Salcedo

a , ∗

, Kelly Cleland

, Deborah Bartz

, Ivana Thompson

Department of Obstetrics and Gynecology, New York Medical College, Valhalla, NY, United States

American Society for Emergency Contraception, Lawrenceville, NJ, United States

Department of Obstetrics and Gynecology, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, United States

Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States

a r t i c l e i n f o

Article history:

Received 19 October 2022

Received in revised form 30 December 2022

Accepted 10 January 2023

Keywords:

Emergency contraception

Emergency contraceptive pills

Intrauterine device

Levonorgestrel

Postcoital contraception

Ulipristal acetate

a b s t r a c t

Emergency contraception (EC) refers to several contraceptive options that can be used within a few days

after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Cur-

rent EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel

(LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate

(UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects

of emergency contraceptive methods; considerations for the use of EC by speciﬁc patient populations and

in speciﬁc clinical circumstances and current barriers to emergency contraceptive access. Further research

is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects

of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation

of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and

elucidate effective emergency contraceptive pill options by body mass indices or weight.

1. Background

Emergency contraception (EC) refers to contraceptive options

that can be used within a few days after an episode of unpro-

tected or under protected intercourse or sexual assault to reduce

the risk of pregnancy. Current EC options available in the United

States include the copper intrauterine device (IUD), levonorgestrel

(LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way,

Take Action), and oral ulipristal acetate (UPA) (ella). All EC options

are effective, safe, and generally well tolerated. Oral methods are

accessible without a clinic visit [1–4] . EC differs from medication

abortion which is used to end an established pregnancy.

Unprotected or under protected intercourse and sexual assault

are common. Of patients who speciﬁcally seek out EC, approxi-

mately 40% report multiple episodes of unprotected intercourse in

the cycle prior to presentation, and 14% report at least one episode

✩

Conﬂicts of interest : The authors have no conﬂicts of interest to report. The So-

ciety of Family Planning receives no direct support from pharmaceutical companies

or other industries for the production of clinical recommendations.

✩✩

Funding : This research did not receive any speciﬁc grant from funding agencies

in the public, commercial, or not-for-proﬁt sectors.

∗

Corresponding author.

E-mail address: jsalcedo4@nymc.edu (J. Salcedo) .

of unprotected intercourse six or more days prior to seeking EC

[ 5 , 6 ]. Additionally, approximately 19% of women in the United

States report a history of rape or attempted rape in their lifetime,

with ethnic minority women, individuals with a history of military

service, and sexual minority and transgender individuals reporting

higher rates [7–9] .

Patients present to various settings to inquire about or access

EC, including emergency departments, clinics, urgent care centers,

and pharmacies. Health care providers working in such settings

should be knowledgeable about EC options and facilitate the pro-

vision of these methods in a time-sensitive manner. Many patients

face geographic, logistical, ﬁnancial, and sociocultural barriers to

safe abortion care, making EC a critical resource to help patients

avoid unintended pregnancies.

2. Clinical questions

2.1. What options are available for EC?

2.1.1. Emergency contraceptive pills (ECPs)

Dedicated oral ECPs containing UPA 30 mg or LNG 1.5 mg, both

as a single dose, are available in the United States and Europe.

UPA can be effectively used up to 120 hours after unprotected in-

tercourse while oral LNG can be effectively used up to 96 hours

https://doi.org/10.1016/j.contraception.2023.109958

J. Salcedo et al. Contraception 121 (2023) 109958

(and possibly up to 120 hours) after unprotected intercourse [10] .

In a few countries, oral mifepristone in doses of 10 to 25 mg is

available commercially as EC [11] . The Yuzpe method is a form of

EC that comprises two doses of combined oral contraceptive pills

containing 10 0 to 120 mcg ethinyl estradiol (EE) and 0.5 to 0.6 mg

LNG per dose [12] . Given the resulting nausea from this high dose

of EE, as well as the availability of other more convenient prod-

ucts marketed speciﬁcally for EC, the Yuzpe method is likely used

infrequently in current clinical practice.

2.1.1.1. Mechanism. ECPs work by preventing or delaying ovula-

tion and are ineffective after ovulation has occurred. Two stud-

ies demonstrated that when LNG ECPs are taken on or before the

day of ovulation, no pregnancies occurred. However, when taken

after the day of ovulation, the number of pregnancies expected

without EC occurred (based on the cycle timing of the individu-

als in the study) [ 13 , 14 ]. In a crossover pharmacodynamic study,

34 women were treated with UPA ECPs or placebo when the lead-

ing follicle was at least 18 mm. Follicular rupture failed to occur

among all women treated with UPA ECPs before the luteinizing

hormone surge began, in 79% after the surge began but before the

peak, and in 8% of women treated after the luteinizing hormone

peak [15] . In another study, researchers measured pregnancy rates

among women who took UPA ECPs within 120 hours of unpro-

tected intercourse and were classiﬁed as preovulatory or postovu-

latory. The observed pregnancy rate in the preovulatory group was

signiﬁcantly lower than expected with 77.6% of expected pregnan-

cies prevented ( p < 0.0 0 01), while the rate in the postovulatory

group was as expected with 36.4% of expected pregnancies pre-

vented ( p = 0.281) [16] . Although the United States Food and Drug

Administration (FDA) recently addressed the labeling of LNG ECPs,

approved labeling for UPA ECPs states that these products can in-

terfere with implantation [ 17 , 18 ]. Two newer systematic reviews

do not support this assertion [19–21] .

2.1.1.2. Eﬃcacy. In clinical trials, pregnancy rates following UPA

ECP use within 120 hours of intercourse range from 0.9% to

1.8% [22–26] . Similar effectiveness is seen when LNG ECPs are

taken up to 96 hours following unprotected intercourse. It is un-

clear whether protection against unintended pregnancy is provided

when LNG ECPs are taken 96 to 120 hours after unprotected inter-

course [10] . In comparative trials, UPA is more effective than LNG.

In a combined analysis of two randomized trials comparing the ef-

fectiveness of UPA to LNG ECPs, the odds of pregnancy following

UPA were 65% lower when taken in the ﬁrst 24 hours following

unprotected intercourse, and 42% lower up to 72 hours after un-

protected intercourse, compared to LNG [ 2 , 16 , 22 , 24 , 26 ]. This differ-

ence in eﬃcacy is best explained by UPA’s ability to delay ovula-

tion after the luteinizing hormone surge has begun (at which point

LNG ECPs are no longer effective) before the luteinizing hormone

peak [27] .

2.1.2. IUDs

2.1.2.1. Types. The copper IUD and the LNG 52 mg IUD can be ef-

fectively initiated up to 120 hours after unprotected intercourse as

EC. Copper IUDs have been used for decades as EC, while the LNG

52 mg IUD has recently demonstrated effectiveness as EC [ 4 , 28 ].

2.1.2.2. Mechanism. The primary mechanism of the copper IUD is

interference with sperm maturation and motility [29] . However,

the nearly one hundred percent eﬃcacy of the emergency copper

IUD indicates that if fertilization does occur, postfertilization ef-

fects (such as induction of a foreign-body reaction in the uterus

through alteration of cytokines in the endometrial lining which

can inhibit implantation) may also contribute to its mechanism

of action [27] . LNG IUDs may work as EC by similarly inducing a

foreign-body reaction or through known effects of LNG, such as

thickening of cervical mucus, interference with sperm maturation

and function, and alterations to oviduct transport [29–32] .

2.1.2.3. Eﬃcacy. The copper IUD used as EC is signiﬁcantly more

effective than ECPs, with a pregnancy rate of 0.09% [ 33 , 34 ]. A ran-

domized, noninferiority trial of 638 patients investigated the eﬃ-

cacy of the LNG 52 mg IUD for EC compared to the copper IUD

within 5 days of unprotected intercourse. The trial demonstrated

a 0.5% (95% CI 0.01% to 1.7%) failure rate for the LNG 52 mg IUD

as compared to a 0% (95% CI 0%–1.1%) failure rate for the copper

IUD. The LNG 52 mg IUD was found to be noninferior to the cop-

per IUD for EC [28] . The investigators did not estimate anticipated

pregnancy rates based on cycle timing of unprotected intercourse

in the study. Additional studies investigating the LNG IUD for EC

may further strengthen the external validity of these ﬁndings [35] .

We recommend that the LNG 52 mg IUD be offered as a ﬁrst-line EC

option, along with other EC methods (GRADE 1B). IUD for EC patients

should be counseled regarding the risk of ectopic pregnancy should

an IUD fail, as well as the risks of pregnancy in the setting of an

IUD, such as miscarriage and intrauterine infection [36] .

We recommend that clinicians counsel individuals considering EC

on the following:

◦ The copper IUD is more effective than ECPs (GRADE 1A).

◦ UPA ECPs are more effective than LNG ECPs (GRADE 1A).

◦ LNG and UPA ECPs prevent pregnancy through preovulatory effects

(GRADE 1A).

◦ The LNG 52 mg IUD is noninferior to the copper IUD for EC within

5 days of unprotected intercourse (GRADE 1B).

2.2. What are the indications for EC?

Patients seek EC to reduce their risk of pregnancy after unpro-

tected or under protected intercourse and sexual assault. Such sit-

uations include, but are not limited to: intercourse during which

no contraception was used; intercourse surrounding contraception

failure (such as a broken condom) or incorrect use (such as re-

cently missed oral contraceptive pills); intercourse during which

the contraception used is viewed to have suboptimal effectiveness

(such as a barrier method); sexual assault; suspected contracep-

tive sabotage; and intercourse during fertile days in one’s cycle, as

tracked by calendars or period tracking applications.

The World Health Organization (WHO) identiﬁes several speciﬁc

clinical situations for which EC can be recommended. These clin-

ical scenarios are listed in Table 1 [37] . As detailed in this docu-

ment, the risks of EC use are low. If a patient requests EC outside

of the listed criteria for use, we recommend engaging in a shared

decision-making process to assist the patient in choosing an option

that best meets their goals.

2.3. What clinical considerations may impact the use of EC?

2.3.1. Medical conditions

Given the potential for EC to decrease morbidities associated

with mistimed or unwanted pregnancy, the risk of all currently

available EC methods should be compared to the risks of preg-

nancy in the setting of medical conditions. For patients with hyper-

coagulable conditions or a history of VTE, the estrogen-containing

Yuzpe method has not been found to signiﬁcantly change Factor

VII or antithrombin levels, unlike longitudinal combined oral con-

traceptive use. No cases of venous thromboembolism secondary to

estrogen-containing EC use have been reported [38] .

Acute or chronic illnesses associated with signiﬁcant vomiting

or malabsorption may result in decreased effectiveness of ECPs.

J. Salcedo et al. Contraception 121 (2023) 109958

Table 1

World Health Organization indications for emergency contraception use

Sexual intercourse when no contraceptive has been used

Sexual assault when the person was not protected by an effective contraceptive method

Sexual intercourse where there is concern for contraceptive failure or misuse, including:

Condoms Breakage, slippage, or incorrect use

Combined hormonal

contraceptive pills

Three or more consecutively missed pills or

Three days late during the ﬁrst week of the cycle

Progesterone-only

contraceptive pills

Three or more hours late from usual pill use time or

more than 27 h after the previous pill

Desogestrel-only contraceptive

pills

Twelve or more hours from usual pill use time or

more than 36 h after the previous pill

Norethisterone enanthate

injection

Two or more weeks late for injection

Depot-medroxyprogesterone

acetate injection

Four or more weeks late for injection

Combined injectable

contraceptive

Seven or more days late for injection

Cervical cap or diaphragm Dislodgement, breakage, tearing, or early removal

Withdrawal Failed withdrawal

Spermicide Failure to melt prior to intercourse

Fertility awareness methods Miscalculation of abstinence period, or failure to abstain

or use a barrier on the fertile days

Intrauterine device or implant Device expulsion

Data from selected practice recommendations for contraceptive use. 3rd ed. Geneva: World Health

Organization; 2016.

The UPA prescribing information and the Centers for Disease Con-

trol and Prevention Selected Practice Recommendations for Con-

traceptive Use recommend repeat ECP dosing when vomiting oc-

curs within 3 hours of pill intake, the maximum amount of time

required to achieve peak plasma concentrations in the setting of

recent high-fat food intake [ 18 , 36 ].

Immunosuppressed patients should be considered appropriate

candidates for IUDs for EC, given the current understanding of IUD

mechanisms of action, absence of evidence for systemic inﬂamma-

tion following LNG IUD placement, and evidence for a sterile in-

trauterine inﬂammatory response after IUD insertion in solid organ

transplant and patients with other immunosuppressive conditions.

Additionally, while there are concerns for increased upper genital

tract infection risk with the IUD insertion process, such infections

are rare, and the risk of infection is not increased in immunosup-

pressed patients [39] . Although the CDC US Medical Eligibility for

Contraceptive Use (US MEC) states that IUD insertion is not rec-

ommended unless other methods are not available or acceptable

in patients with complicated solid organ transplant, such as graft

failure, rejection, or cardiac allograft vasculopathy, this recommen-

dation is based on theoretical concern with no published evidence

of increased infectious morbidity with IUD placement in such pa-

tients. Clinicians should pursue a shared decision-making approach

with patients in these circumstances [40–44] .

2.3.2. Weight and BMI

Multiple studies demonstrate no changes in the failure rate for

the copper IUD or the LNG 52 mg IUD for EC based on body weight

or BMI [ 28 , 35 , 45 , 46 ]. However, patient BMI and weight appear to

impact the effectiveness of ECPs, with LNG ECPs being negatively

affected to a greater extent than UPA ECPs. A meta-analysis of oral

EC studies demonstrated that the risk of pregnancy is one and

one-half times greater in users with an overweight BMI (25–29.9

kg/m

) and more than three times greater in users with an obese

BMI ( > 30 kg/m

), compared to nonoverweight users [47] . A meta-

analysis by Festin et al. [48] pooled data from four oral EC studies

and examined data from 6873 EC users. When compared to partic-

ipants with BMI < 25 kg/m

, participants with BMI > 30 kg/m

were eight times more likely to experience pregnancy after EC use.

Despite the demonstrated increased risk of pregnancy, the overall

pregnancy rate in the obese group was low, at only 2.03% [48] . A

study of 1731 oral LNG EC users demonstrated pregnancy rates of

1.4% or less for participants weighing 75 kg or less compared to

pregnancy rates of 6.4% and 5.7% among users weighing 75 to 85

kg and > 85 kg, respectively [49] .

While doubling the dose of LNG ECPs increases the maximum

concentration of serum LNG in individuals with obesity to levels

seen in individuals with normal BMI, it was not shown to decrease

levels of follicular rupture within 5 days to levels seen in individ-

uals with BMI < 25 kg/m

[ 50 , 51 ]. Although the Edelman 2022

study was not designed to evaluate oral LNG EC eﬃcacy, the failure

to decrease levels of follicular rupture in individuals with obesity

to levels seen in individuals with overweight or normal BMI sug-

gests lower eﬃcacy of oral LNG EC in individuals with obesity, even

with a higher dose of 3 mg LNG [51] .

UPA ECPs are more effective than LNG ECPs in all users, includ-

ing those with overweight and obese BMIs [ 2 , 16 , 22 , 24 , 26 ]. Patients

with an overweight BMI have the same failure rate as patients with

a normal BMI with the correct use of UPA for EC [47] . However,

UPA ECP users with obesity are twice as likely to experience preg-

nancy compared to users with a normal BMI. It appears the upper

limit of eﬃcacy for LNG ECPs occurs at a bodyweight of 70 kg and

the upper limit of eﬃcacy for UPA ECPs occurs at a bodyweight of

85 kg, though it is unclear how the data from prior studies trans-

lates from patient weight to BMI [47] . Based on this data, we recom-

mend that clinicians counsel individuals that UPA ECPs, if available,

are more effective than LNG ECPs in overweight and obese persons

and those with bodyweight 70 kg or greater (GRADE 1C).

2.3.3. Medications

As LNG and UPA are substrates of cytochrome P450 3A4 (and

LNG also of P450 3A5), concurrent use with enzyme inducers, such

as efavirenz, carbamazepine, oxcarbazepine, and phenytoin, is ex-

pected to lower the dose of the ECPs, which may decrease their

effectiveness [52] . In women taking the former EC regimen of oral

LNG 0.75 mg (two doses 12 hours apart) concurrent with efavirenz

(a reverse transcriptase inhibitor commonly used in the treatment

of HIV), the AUC12, Cmax, and Cmin of LNG were decreased by

56%, 41%, and 67%, respectively [53] . Similar reductions have been

noted with carbamazepine, phenytoin, oxcarbazepine, and eslicar-

bazepine [52] . While the clinical signiﬁcance of these reductions

is unclear, in 2016 the European Medicines Agency (EMA) rec-

ommended to double the dose of LNG ECPs for patients taking

CYP3A4 inducers in the preceding 4 weeks [52] . However, the ef-

J. Salcedo et al. Contraception 121 (2023) 109958

fectiveness of double dosing LNG ECPs in this setting has not been

evaluated, and it may be inadequate to address the effects of med-

ications that induce CYP3A4 more strongly than efavirenz, such as

rifampin and phenytoin [52] . Lamotrigine, a glucuronidation en-

zyme inducer, also reduces levels of LNG taken orally [ 52 , 53 ]. In

contrast, coadministration of oral LNG with vigabatrin, levetirac-

etam, ticagrelor, solifanacin, and vortioxetine does not decrease

LNG levels [52] .

Only three studies evaluating medication interactions with oral

UPA are available. While erythromycin and ketoconazole do not

lower levels of UPA taken orally, rifampicin, an enzyme inducer,

decreases mean UPA exposure more than 10-fold [ 54 , 55 ]. Simi-

lar but more modest interactions are predicted for carbamazepine,

rifabutin, dabrafenib, and phenobarbital, while stronger interac-

tions are predicted for phenytoin, enzalutamide, and mitotane

[ 52 , 54 , 55 ]. Using modeling, predicted required dose increases for

oral UPA when coadministered with a CYP3A enzyme inducer vary

from 1.3-fold for the weakest inducer to 14.3-fold for the most po-

tent inducers, rifampicin, and mitotane [52] . While current UPA

ECP labeling recommends avoiding use in patients who have taken

CYP3A4 inducers in the past 4 weeks, this interval may be insuf-

ﬁcient for such medications with long half-lives, such as enzalu-

tamide, phenobarbital, and mitotane [ 18 , 52 ].

While neither UPA nor oral LNG inhibits CYP450 enzyme ac-

tivity, both may inhibit P-glycoprotein (P-gp) at emergency con-

traceptive doses, thereby elevating levels of P-gp substrates, such

as digoxin, colchicine, and fexofenadine, resulting in potential

morbidity related to supratherapeutic levels of such medications

[ 18 , 56 ]. A case report of a supratherapeutic international normal-

ized ratio not associated with hemorrhage, noted in a patient on

warfarin taking two doses of 0.75 mg LNG for EC, may be illustra-

tive of such interaction [57] .

We recommend advising patients currently or recently taking cy-

tochrome P450–3A4 and P450–3A5 inducers or glucuronidation en-

zyme inducers that ECPs may be less effective and that IUD placement

for EC should be considered (GRADE 1C).

2.4. What are counseling considerations regarding repeated use of

EC, use by an unknowingly pregnant individual, and use with other

hormonal contraceptives?

2.4.1. Repeated use of EC in the same cycle

There are no speciﬁc safety concerns regarding the repeated or

frequent use of LNG ECPs [12] . Additionally, there is no evidence

for the increased incidence of ectopic pregnancy (relative to in-

trauterine pregnancy) with repeated LNG ECP use [58] . Further,

weekly dosing of UPA has not been associated with serious side ef-

fects, although headache and nausea were reported in almost 70%

of participants in one study [59] . While no reports of serious ad-

verse events have been noted with the use of UPA ECPs, recent re-

ports of rare but serious liver injury in women using lower daily

dosing for the treatment of uterine ﬁbroids calls for additional

study of the safety of frequent UPA dosing [60] . In September 2020,

the EMA concluded that UPA use for the treatment of uterine ﬁ-

broids should no longer be marketed in the European Union due to

eight case reports of serious liver injuries (four requiring transplan-

tation) out of more than 765,0 0 0 patients included in postmarket-

ing surveillance [61] . In such cases, the hepatotoxicity is thought to

be an idiosyncratic drug-induced liver injury (DILI) potentially also

impacted by UPA’s high lipophilicity and long half-life, inhibition of

breast cancer resistance protein in liver cells, and bile salt export

pump inhibition [62] . Such reactions are related more to host fac-

tors than to toxic properties of the medication itself, and are thus

less dose-dependent and more varied in latency, presentation, and

course than intrinsic DILI (such as acetaminophen-associated DILI)

[63] . In contrast, Yoon et al. [64] compared more than 20,0 0 0 pa-

tients taking UPA for ﬁbroids to those taking gonadotropin releas-

ing hormone agonists and did not ﬁnd a difference in the incidence

of severe or toxic liver disease between the groups. In that study

the rate of severe liver disease and hepatic failure in patients using

UPA was 0.04% and no liver transplantations were performed.

The daily dosing of 5 to 10 mg UPA is associated with com-

plete ovulation inhibition in approximately 80% of individuals, as

observed with the use of a contraceptive vaginal ring releasing 1.5

to 2.5 mg of UPA daily (unavailable in the United States) [59] . How-

ever, in a contraceptive study of women administered UPA 30 mg

orally every ﬁve to seven days, ovulation was observed in more

than 70% of cycles, likely explained by the half-life of UPA being

only 32 hours [59] . Repeat dosing of UPA ECPs in the same cycle

is not recommended by the manufacturer [18] . Given the poten-

tial morbidity of mistimed or unwanted pregnancy, and the fact

that individuals may take ECPs at times in the cycle when they are

not at signiﬁcant risk of pregnancy, repeated dosing should not be

withheld. Patients should be counseled that repeat dosing of UPA

appears safe but the contraceptive effectiveness of multiple UPA

doses within the same cycle remains unclear.

2.4.2. EC use by an unknowingly pregnant patient

For patients who take LNG ECPs while unknowingly pregnant,

or who conceive as a result of LNG ECP failure, there is no

concern for associated pregnancy-related morbidity. Meta-analyses

have not demonstrated an association between embryonic expo-

sure to contraceptive hormones and fetal malformations generally,

or genital malformations speciﬁcally [ 65 , 66 ]. More limited but sim-

ilarly reassuring data are available regarding inadvertent exposure

to UPA in pregnancy. One case of optic nerve atrophy has been

documented in a pregnancy with UPA exposure, a condition which

was determined by an independent Data Safety Monitoring Board

not to be attributable to UPA in utero exposure [67] . No other

pregnancy or delivery complications have been reported in associ-

ation with UPA ECP use. The miscarriage rate associated with UPA-

exposed pregnancies (13.8%) is not higher than the 20% reported

in the general population [ 67 , 68 ] . Similarly, the incidence of ec-

topic pregnancy (1.1%) is similar to that in the general population

of pregnant individuals of 0.8% to 2% [ 67 , 69 , 70 ]. More pregnancies

following ECP exposure end in abortion than in the general popu-

lation, consistent with differences in pregnancy intention between

the 2 populations [67] . Given such ﬁndings, pregnancy testing is

unnecessary prior to ECP use, unless a patient is concerned about

their pregnancy status for other reasons.

For patients seeking copper or LNG IUDs for EC who also re-

port episodes of unprotected intercourse in the current cycle more

than ﬁve days before planned IUD insertion, the potential presence

of a preimplantation fertilized ovum should be considered. Several

studies demonstrate that pregnancy is uncommon in such situa-

tions following IUD placement. In a study of same-day LNG IUD

placement for routine contraception, 0.4% of patients who did not

meet checklist criteria supported by the CDC for reasonable cer-

tainty of not being pregnant received a diagnosis of pregnancy in

the weeks following IUD insertion [71] . In another study, one out

of 40 patients (2.5%) who presented for EC and reported additional

unprotected intercourse 6 to 14 days prior to IUD insertion had a

positive pregnancy test within the subsequent 2 weeks [6] . A study

of 134 patients who had a copper IUD placed 6 to 14 days after un-

protected demonstrated 0 pregnancies two to four weeks after IUD

placement [46] .

Although uncommon, pregnancies in patients with an IUD have

elevated risks of adverse pregnancy outcomes compared to pa-

tients who conceive without an IUD. Such elevated risks include

miscarriage, preterm delivery, and septic abortion. These risks are

decreased in patients who undergo IUD removal during the preg-

nancy but remain elevated relative to baseline risks without an IUD

J. Salcedo et al. Contraception 121 (2023) 109958

[72] . There is currently insuﬃcient data to reach conclusions about

any speciﬁc risks of an LNG IUD on a developing fetus [72] . Similar

considerations pertain to patients who receive an IUD for EC with

unprotected intercourse limited to the previous ﬁve days in whom

the IUD fails, resulting in pregnancy. Given the risks of pregnancy

in the setting of an IUD, pregnancy testing should be performed

prior to IUD insertion for EC and patients counseled regarding the

risks of pregnancy in the case a preimplantation fertilized ovum is

present at the time of IUD placement for EC or in the case of IUD

EC failure.

2.4.3. Use with other hormonal contraceptives

Initiating regular contraceptive use immediately following ECPs

increases uptake and continuation of the regular contraceptive

method [ 73 , 74 ]. There is no mechanism by which LNG, a progestin,

would decrease the effectiveness of subsequently initiated hor-

monal contraception. Similarly, initiation of regular hormonal con-

traception immediately following LNG ECP use will not decrease

the effectiveness of LNG as an ECP. We recommend routine hor-

monal contraception be initiated as soon as desired following LNG ECP

use, with abstinence or a nonhormonal contraceptive method used

as back-up for 7 days or until the next menstrual period/withdrawal

bleed, whichever occurs ﬁrst (GRADE 1A).

UPA does not appear to decrease subsequent oral contraceptive

pill eﬃcacy. UPA had no signiﬁcant effect on the contraceptive on-

set of a 75 mg desogestrel progestin-only pill, with regard to des-

ogestrel’s impact on cervical mucus or ovulation inhibition [75] .

Administration of UPA mid-cycle, followed the next day by initi-

ation of a daily 30 mcg EE/150 mcg LNG-containing combined hor-

monal contraceptive pill was associated with ovarian quiescence in

most women by seven days, with a minority of women taking ad-

ditional days (up to 14) to reach quiescence [76] . All women who

ovulated did so after 11 days of combined oral contraceptive pill

use [76] . No studies to date have investigated the potential for de-

layed effectiveness of routine contraceptive effects when UPA is

closely followed by the use of nonoral hormonal contraceptives. Af-

ter resuming or initiating regular contraception following ECP use,

the Centers for Disease Control and Prevention Selected Practice

Recommendations for Contraceptive use recommends abstinence

or barrier method use for seven days, or until the next menses,

whichever occurs ﬁrst [36] .

In contrast, the effectiveness of UPA in delaying ovulation for EC

use is reduced by subsequent administration of hormonal contra-

ceptive pills. When a combined oral contraceptive pill containing

30 mcg of EE and 150 mcg of LNG was administered 2 days follow-

ing UPA, more subjects demonstrated evidence of ovulation (follic-

ular rupture) within 5 days (27% vs 3%) [77] . Similarly, administra-

tion of 75 mg desogestrel the day following UPA is associated with

evidence of ovulation within ﬁve days in 45% of subjects, compared

to 3% of subjects who took only UPA [75] . The mean time to ovu-

lation was 8 days in the UPA only group, compared to four days in

the group taking UPA followed by desogestrel [75] . Consequently,

extrapolation of decreased UPA effectiveness to coadministration

with other progestin-only pills and nonoral routes of progestin ad-

ministration should be done with caution [75] .

Whether the effectiveness of UPA is similarly decreased when

used following missed doses of routine short-term hormonal con-

traception followed by resumption of the routine contraception is

unclear. Additionally, individuals who delay reinitiating their rou-

tine hormonal contraception following UPA use may be at elevated

risk of ovulation and consequent pregnancy compared to those

who resume hormonal contraception immediately following UPA

use. In a study of women who missed combined oral contracep-

tive pill doses (as part of a 21/7 regimen of 30 mcg EE/150 mcg

LNG) on days ﬁve, six, and seven, and took UPA the morning of day

eight, those who resumed their combined oral contraceptive pill

the same evening demonstrated decreased evidence of subsequent

ovulation during that pill pack compared to those who waited ﬁve

days to restart contraceptive pills [78] . No women who completed

the study ovulated in the ﬁve days after taking UPA, regardless of

when the contraceptive pill was restarted [84] . Given that ovarian

activity is suppressed during combined oral contraceptive pill use

and that time is required after missed pills for recovery of ovarian

activity, restarting contraceptive pills soon after missing pills and

taking UPA would be unlikely to result in ovulation [ 78 , 79 ]. Some

may argue that individuals who miss only a few contraceptive pills

are not indicated to use EC at all. However, given that an individ-

ual may intermittently miss doses throughout a cycle, providing a

patient with a speciﬁc risk assessment for conception after missed

doses is challenging [78] .

Concerns that initiating routine hormonal contraception in the

days following UPA use may decrease UPA’s effectiveness must be

weighed against the risk of subsequent pregnancy if routine con-

traception is not established or reestablished. This risk-beneﬁt ratio

is expected to vary by individual and situation based on the risk

of pregnancy from the index exposure, risk of subsequent preg-

nancy in the short-term, contraceptive access, and individual pref-

erences. Following UPA ECPs, we recommend generally delaying initi-

ation of routine hormonal contraception for ﬁve days and abstinence

or a nonhormonal contraceptive method used as back-up for an addi-

tional seven days or until the next menstrual period/withdrawal bleed.

However, the speciﬁc timing of routine hormonal contraceptive initia-

tion should be individualized through shared decision-making (GRADE

1B).

2.5. What follow-up and additional services should be offered to

individuals seeking EC?

2.5.1. Urine pregnancy testing (at time of provision and at follow-up)

EC reduces the risk of pregnancy after unprotected intercourse

but does not completely resolve this risk. EC is associated with

pregnancy rates ranging from 0.09% to 2.6% [ 24 , 28 , 33 ]. If an EC

user experiences menses within two weeks of EC use, they can

be reassured of their nonpregnant status. If this does not occur,

a pregnancy test is recommended three weeks after EC use. Addi-

tionally, pregnancy testing should be considered one month fol-

lowing LNG IUD placement for EC given the potential for men-

strual changes with this method [28] . If pregnancy is detected, the

patient should present for pregnancy localization and pregnancy

options discussion. While pregnancy testing should be performed

prior to IUD insertion for EC, ECPs should not be withheld or de-

layed for pregnancy testing. We recommend against withholding or

delaying ECPs for pregnancy testing (GRADE 1B). We recommend of-

fering urine pregnancy testing for post-EC pregnancy assessment as

needed (GRADE 1C).

2.5.2. Sexually transmitted infection (STI) screening and treatment

In 2018, one in ﬁve adults in the United States had a STI [80] .

Given the prevalence of STIs, people who report unprotected or un-

der protected intercourse should be offered screening for STIs [81] .

Active mucopurulent discharge and current chlamydia or gonor-

rhea infections are contraindications to IUD placement [36] . How-

ever, asymptomatic individuals with chlamydia or gonorrhea infec-

tion at the time of IUD placement may not be at elevated risk of

pelvic inﬂammatory disease when such infections are recognized

and appropriately treated compared to individuals undergoing IUD

insertion in the absence of such infections [82] . Patients with in-

cidentally positive tests noted following IUD insertion should be

treated according to current CDC guidelines and the IUD may re-

main in place if desired [36] . The placement of an IUD for EC

should not be withheld or delayed for STI screening in the absence

of active mucopurulent discharge, regardless of the patient’s STI

J. Salcedo et al. Contraception 121 (2023) 109958

risk. Empiric treatment for gonorrhea, chlamydia, and trichomo-

niasis should be given to persons reporting sexual assault. Such

individuals should be offered Hepatitis B and HPV vaccinations

based on their vaccination status [81] . HIV postexposure and pre-

exposure prophylaxis should be considered within a framework

of shared decision-making [81] . We recommend offering or refer-

ring persons requesting EC for sexually transmitted infection screening,

postexposure prophylaxis, pre-exposure prophylaxis, and treatment as

indicated (GRADE 1C).

2.5.3. Intimate partner violence and human traﬃcking screening

People who experience intimate partner violence or who are

being human traﬃcked are likely to experience unprotected or

under protected intercourse [ 83 , 84 ]. People who present for EC

should be screened for intimate partner violence and sex traﬃck-

ing and provided local resources and referrals as desired. We rec-

ommend screening persons who use EC for intimate partner violence

and human traﬃcking as indicated (GRADE 1C).

2.5.4. Ongoing contraception

Unprotected intercourse is common and EC users frequently

have more than one episode of unprotected intercourse prior to

presenting for EC [ 5 , 6 ]. Discussing or initiating ongoing contracep-

tion at the time of presentation for EC may help EC users meet

their fertility goals. It is important to recognize that people are

ﬂuid in their reproductive intentions [85] . Acceptance of EC does

not commit a person to avoiding pregnancy for any duration out-

side of the initial EC use. At EC encounters, health care providers

should assess users for interest in ongoing contraception and pro-

vide contraception management or referrals as desired by the pa-

tient. We recommend offering or referring persons who use EC for on-

going contraception as desired (GRADE 1C).

2.6. How can clinicians support EC use in special populations?

2.6.1. Use by gender diverse individuals (particularly those taking

testosterone)

Clinicians should educate all patients at risk for pregnancy, in-

cluding gender diverse individuals, regarding EC and provide ad-

vance prescription of ECPs if desired. Although gender diverse

patients may experience amenorrhea secondary to gonadotropin

releasing hormone agonist or testosterone use, they remain at

risk for pregnancy if having receptive intercourse with a sperm-

producing partner. Such patients may be unaware of their preg-

nancy risk. In addition to the general risks of unintended preg-

nancy, in gender diverse individuals unintended pregnancy may

also be associated with gender dysphoria and with fetal risks as-

sociated with in utero testosterone exposure. While there are no

published studies regarding EC use in gender diverse populations,

expert consensus based on other hormonal contraceptives does not

prompt concern about the loss of eﬃcacy of EC or testosterone

when used concurrently [86] . As with all patients, clinicians should

use a trauma-informed approach when counseling gender diverse

individuals interested in an IUD [87] .

2.6.2. Use while breastfeeding, lactating, or chest feeding

ECPs are an effective complement for individuals relying on the

lactational amenorrhea method (LAM) for contraception. In a study

of Egyptian women comparing standard LAM education to LAM

and EC education with advanced provision of one pack of LNG

ECPs, 44% of women in the EC group used the LNG ECPs, of which

88% did so correctly (when at least one requirement of LAM had

expired and intercourse occurred before initiating a regular contra-

ceptive method) [88] . Signiﬁcantly more women in the EC group

initiated regular contraception within or shortly after the ﬁrst 6

months postpartum (30% vs 7.3%) and fewer pregnancies occurred

in the EC group (0.8% vs 7.3%) [88] . There were no signiﬁcant differ-

ences between groups in duration of lactation, pattern of breast-

feeding, or resumption of menstruation [88] . The most common

LNG side effect was nausea without vomiting, which occurred in

approximately 30% of women [88] . We recommend clinicians pro-

vide EC counseling and advanced prescription of ECPs to individuals

relying on the lactational amenorrhea method (GRADE 1B).

Similar to progestin-only regular contraceptives, LNG ECPs have

not been shown to objectively affect the health or development of

nursing infants or to subjectively impact the volume of breast milk

produced [ 88 , 89 ]. After a single 1.5 mg dose of LNG, levels peak

in breast milk after approximately four hours and reach a max-

imum concentration of approximately 4.1 to 10.7 ng/mL, with a

mean terminal half-life of 26 hours [90] . The amount of LNG ex-

creted in milk over the ﬁrst 24 hours is 0.09% of the dose and de-

creases rapidly over time, with only 0.01% of the dose recovered

in breast milk over the 49 to 72 hours interval [90] . The estimated

mean amount of progestin absorbed by a nursing infant intaking

800 mL/day of breast milk is 1.6 mcg in the ﬁrst 24 hours, 0.3 mcg

in the second 24 hours, and 0.2 mcg in the third 24-hour interval

[90] . We recommend that clinicians counsel individuals that breast-

feeding does not need to be disrupted because of LNG ECP use (GRADE

1A).

The copper IUD does not pose concerns for breastfed infants.

Insertion of a copper IUD does not impact lactation performance

and does not result in elevated levels of copper in breast milk

compared to individuals who did not receive a copper IUD [ 91 , 92 ].

Health care providers should be attentive to the overall small but

increased risk of uterine perforation associated with IUD insertion

in breastfeeding individuals compared to individuals who are not

breastfeeding [92] .

Little information is available on the use of UPA ECPs while

breastfeeding. Currently, package labeling recommends avoiding

use while breastfeeding, while the CDC Medical Eligibility Crite-

ria for Contraceptive Use recommends expressing and discarding

breast milk for 24 hours after dosing [ 18 , 36 ]. It is estimated that

following a 30 mg dose, a fully breastfed infant would receive ap-

proximately 4.1 mcg/kg of UPA and its active metabolite over the

ﬁrst 24 hours and a total of 5.2 mcg/kg over ﬁve days. This ex-

posure would result in an approximate adjusted dosage of 0.8% of

the medication and active metabolite on the ﬁrst day and a total

of 1% of the maternal dose over a ﬁve-day period [93] . No stud-

ies have addressed infant outcomes in the setting of UPA ECP use

and there are no published reports of associated harm. Given the

established beneﬁts of breastfeeding, the low level of infant expo-

sure, and no evidence of harm, it is reasonable for individuals to

continue breastfeeding without interruption if desired in the set-

ting of shared decision-making.

2.7. What are the barriers to EC use?

2.7.1. IUDs

IUD insertions require an in-person visit with a trained

provider. While many clinicians in obstetrics and gynecology are

well-trained and comfortable with long-acting reversible contra-

ception (LARC) provision, many other health care professionals are

uncomfortable placing an IUD [94] . There is limited awareness of

the copper IUD as an EC option and very few obstetrics and gy-

necology and primary care clinics offer the copper IUD as EC [95] .

Additional effort s should be made to increase health care provider

and oﬃce staff knowledge and training in IUD provision for EC.

To effectively place IUDs upon patient request, a clinic or insti-

tution must stock devices for same-day placement. Unfortunately,

many clinics do not have a readily available stock of IUD de-

vices and instead employ a two-visit IUD insertion approach mod-

eled after outdated STI screening and pregnancy testing protocols

J. Salcedo et al. Contraception 121 (2023) 109958

or based on diﬃculties with device reimbursement [96] . Approx-

imately half of the patients who must return for a subsequent

visit for IUD placement do not return [97] . Additionally, IUD de-

vices can cost upwards of $80 0-$90 0 for self-funded patients, with

additional charges associated with insertion and removal [ 98 , 99 ].

While the Affordable Care Act has resulted in many insurers cov-

ering the cost of IUD placement without co-pay for patients, the

cost may still be a barrier for uninsured and underinsured patients

[100] . Same-day copper and LNG 52 mg IUD insertions for pa-

tients with a negative urine pregnancy test are safe and associated

with low pregnancy rates [ 45 , 46 ]. Clinics should develop same-day

IUD insertion protocols that balance their ability to meet patient

needs and clinic ﬁnancial responsibilities. Professional organiza-

tions should continue to advocate for private and public funding

of IUDs for EC and routine use.

2.7.2. ECPs

LNG ECPs have been approved for sale over-the-counter with-

out age or gender restrictions since 2013. However, individuals

trying to purchase the product in pharmacies can encounter a

lack of availability, additional security measures (locked cabinets,

locked exterior packaging), unnecessary requests for identiﬁca-

tion to enforce outdated age restrictions, and unaffordable cost

($40–50 at most pharmacies) [ 101 , 102 ]. Individuals seeking UPA

ECPs encounter additional challenges due to the requirement for

a prescription. Clinicians and pharmacists are frequently unfamil-

iar with UPA [ 103 , 104 ]. Additionally, many pharmacies do not rou-

tinely stock UPA and may provide inaccurate information regarding

its mechanism of action or differences from LNG ECPs [ 105 , 106 ].

Further, the nuanced clinical guidance related to the initiation

of routine hormonal contraception following UPA use may deter

providers from offering it instead of LNG ECPs [36] . In addition to

these barriers, nine states have policies that restrict access to ECPs

by excluding ECPs from contraceptive coverage mandates or allow-

ing pharmacists to refuse to provide it [107] .

Pharmacists play a key role in timely EC access. Pharmacists are

positioned to advocate for stocking UPA ECPs, ensuring that LNG

ECPs are stocked and available over the counter without additional

security measures, and educating pharmacy staff members about

EC. An informational guide for pharmacy staff is available from

the American Society for Emergency Contraception [108] . Several

states currently allow pharmacists to dispense ECPs without a pre-

scription, either through a collaborative practice agreement with a

physician or through a state-approved protocol [109] . Telemedicine

visits for the provision of EC counseling, prescription of ECPs, and

facilitation of in-person visits for EC IUD placement may also de-

crease barriers to EC access for care in which clinician contact is

required or helpful [110] .

2.7.3. Populations most negatively impacted by barriers to EC access

Barriers to accessing EC may be ampliﬁed for individuals from

marginalized communities, those living in rural areas, and young

people. In parts of the country that are more geographically dis-

persed, individuals who need EC may be far from a pharmacy. Ad-

ditionally, individuals from rural or isolated areas may experience

conﬁdentiality or privacy concerns related to familiarity with phar-

macy staff and lack of alternatives if ECPs are not in stock or diﬃ-

cult to obtain where initially sought. According to the National Sur-

vey of Family Growth, from 2006 to 2017, women of reproductive

age living in rural areas were signiﬁcantly less likely to have used

EC than those living in urban areas, with reported ever use of ECPs

increased from six percent to 15% in rural areas compared with

11% to 27% in urban areas during this time-period [111] . While

EC should be routinely offered following sexual assault involving a

risk of pregnancy, this is often not the case in emergency depart-

ments, particularly for individuals seeking care within religiously

aﬃliated hospital systems [ 81 , 112 ].

Young people also face unique challenges in accessing EC. The

complicated regulatory history of LNG ECPs in the United States

involved several different age restrictions over the years. Although

these restrictions have not been in place since 2013 (2014 for

generics), pharmacy staff may still ask for identiﬁcation [101] . Ad-

ditionally, young people may have conﬁdentiality concerns when

accessing EC through parents’ health insurance and may lack trans-

portation to a health care provider or pharmacy. Young people

and others with limited ﬁnancial resources may ﬁnd EC cost pro-

hibitive, and only 11 states currently have laws that require in-

surance plans to cover over-the-counter EC without a prescription

[113] .

Gender diverse individuals face additional barriers when seek-

ing reproductive health care generally and EC speciﬁcally [114] .

Clinicians may not recognize that transgender and gender nonbi-

nary patients are at risk of pregnancy or may be reluctant to offer

EC to patients on testosterone due to concerns about interactions.

Additionally, clinicians may be uncomfortable offering IUD place-

ment. Gender diverse individuals may also anticipate and experi-

ence unwanted questions, judgment, and stigma when attempting

to purchase ECPs at a pharmacy [86] .

2.8. Is there a role for ECPs as a primary contraceptive method?

In one study , almost 70% of abortion clients and 50% of fam-

ily planning clients would deﬁnitely or probably be interested in a

postcoital contraceptive pill as routine contraception [115] . Patients

who reported recently engaging in unprotected intercourse, those

reporting that obtaining a prescription for contraception in the

past was “not very easy,” and African American women (compared

to non-Hispanic white women) expressing higher levels of interest

[115] . Top reasons for interest included not needing to remember

to take a daily pill, liking the idea of only taking hormones when

needed, and having infrequent intercourse. In contrast, top reasons

for lack of interest included desiring a more effective method, not

wanting to remember to use a method pericoitally, and dislike of

altered menstrual cycles [115] . Additional reasons for interest in a

routine postcoital contraceptive pill include the ability to conceal

use and lack of coital interruption (as compared to the use of a

coitally-dependent nonhormonal method) [116] .

The use of LNG ECPs as a solitary primary contraceptive method

is associated with effectiveness that compares reasonably with

coitally-dependent methods, such as barrier methods, withdrawal,

and periodic abstinence, that have typical use failure rates on

the order of 14% to 40% [117] . However, given that individuals in

studies of LNG ECPs as a primary contraceptive method are usu-

ally selected based on relatively low intercourse frequency, direct

comparison of method effectiveness is challenging [118] . Addition-

ally, the use of ECPs as a supplement to nonhormonal methods,

planned periodic abstinence, and withdrawal may increase overall

contraceptive effectiveness [119] . No studies have speciﬁcally eval-

uated routine postcoital use of UPA ECPs and concerns about de-

laying ovulation to later in the cycle may limit its effectiveness for

this purpose.

A 2014 Cochrane review calculated a pooled Pearl Index of 5.4

per 100 person-years (95% CI 4.1–7) for the postcoital use of 0.75

mg LNG [120] . A study that speciﬁcally included US individuals

taking 0.75 mg LNG within 24 hours of intercourse who expected

to have intercourse 1 to 4 days per month noted a higher Pearl

Index of 22.4 (95% CI 4.6–65.4) [121] . In a more recent study eval-

uating use of LNG 1.5 mg within 24 hours of intercourse, the Pearl

Index was noted to be 7.5 for solitary use in all users, and 11. 0

for solitary use in women under 35 years old [122] . Oral LNG use

J. Salcedo et al. Contraception 121 (2023) 109958

pre-coitally may be more effective than postcoital use, as it may

concurrently affect both cervical mucus and ovulation [120] .

The main side effect reported in oral LNG EC studies is bleed-

ing abnormalities, which have been associated with high discon-

tinuation rates in some studies. Other common side effects include

nausea, breast tenderness, weakness, dizziness, headache, abdomi-

nal bloating or pain, pelvic pain, decreased libido, depression, and

vomiting [ 118 , 122 ]. There is no consistent evidence of a relation-

ship between bleeding abnormalities and the frequency of pill in-

take or total dose of LNG [120] . The side effect of irregular bleeding

may be problematic for individuals who wish to use ECPs in con-

junction with natural family planning methods that rely on cycle

regularity [123] . Despite high rates of reported bleeding abnormal-

ities and other side effects, a signiﬁcant majority of study partici-

pants express favorable views of the method [ 118 , 122 ]. The current

cost, access, and packaging of LNG ECPs in the United States may

make routine ECP use challenging or prohibitive.

We recommend offering regular pericoital use of LNG ECPs for in-

dividuals who desire this method either alone or as a supplement to

nonhormonal coitus-dependent methods, such as periodic abstinence,

barrier methods, or withdrawal (GRADE 1B).

3. Clinical recommendations

Please see Appendix 1 for a key to interpreting GRADE.

• We recommend that the LNG 52 mg IUD be offered as a ﬁrst-

line EC option, along with other EC methods (GRADE 1B).

• We recommend that clinicians counsel individuals considering

EC on the following:

◦ The copper IUD is more effective than ECPs (GRADE 1A).

◦ UPA ECPs are more effective than LNG ECPs (GRADE 1A).

◦ LNG and UPA ECPs prevent pregnancy through pre-ovulatory

effects (GRADE 1A).

◦ The LNG 52 mg IUD is noninferior to the copper IUD for EC

within ﬁve days of unprotected intercourse (GRADE 1B).

• Based on this data, we recommend that clinicians counsel indi-

viduals that UPA ECPs, if available, are more effective than LNG

ECPs in overweight and obese persons and those with body-

weight 70 kg or greater (GRADE 1C).

• We recommend advising patients currently or recently taking

cytochrome P450–3A4 and P450–3A5 inducers or glucuronida-

tion enzyme inducers that ECPs may be less effective and that

IUD placement for EC should be considered (GRADE 1C).

• We recommend routine hormonal contraception be initiated as

soon as desired following LNG ECP use, with abstinence or a

nonhormonal contraceptive method used as back-up for seven

days or until the next menstrual period/withdrawal bleed,

whichever occurs ﬁrst (GRADE 1A).

• Following UPA ECPs, we recommend generally delaying initia-

tion of routine hormonal contraception for ﬁve days and absti-

nence or a nonhormonal contraceptive method used as back-

up for an additional seven days or until the next menstrual

period/withdrawal bleed. However, the speciﬁc timing of rou-

tine hormonal contraceptive initiation should be individualized

through shared decision-making (GRADE 1B).

• We recommend against withholding or delaying ECPs for preg-

nancy testing (GRADE 1B).

• We recommend offering urine pregnancy testing for post-EC

pregnancy assessment as needed (GRADE 1C).

• We recommend offering or referring persons requesting EC

for sexually transmitted infection screening, postexposure pro-

phylaxis, pre-exposure prophylaxis, and treatment as indicated

(GRADE 1C).

• We recommend screening persons who use EC for intimate

partner violence and human traﬃcking as indicated (GRADE

1C).

• We recommend offering or referring persons who use EC for

ongoing contraception as desired (GRADE 1C).

• We recommend clinicians provide EC counseling and advanced

prescription of ECPs to individuals relying on the lactational

amenorrhea method (GRADE 1B).

• We recommend that clinicians counsel individuals that breast-

feeding does not need to be disrupted because of LNG ECP use

(GRADE 1A).

• We recommend offering regular pericoital use of LNG ECPs for

individuals who desire this method either alone or as a supple-

ment to nonhormonal coitus-dependent methods, such as peri-

odic abstinence, barrier methods, or withdrawal (Grade 1B).

4. Recommendations for future research

• Effectiveness of the copper IUD compared to the 52 mg LNG

IUS for EC.

• Effective dosing of LNG and UPA ECPs for individuals with ele-

vated BMI or body weight.

• Effective dosing of LNG ECPs for individuals concurrently or re-

cently using CYP3A4 inducers.

• Clinically relevant medication interactions with UPA ECPs .

• Effects of initiation or reinitiation of various methods of regular

hormonal contraception on the effectiveness of UPA ECPs.

• Effects on ovulation of repeat dosing of UPA ECPs at different

times during the same menstrual cycle.

• Effects of UPA on lactation and breastfeeding infants.

• Acceptability of EC methods to gender diverse individuals.

Sources

A series of clinical questions was developed by the authors

and reviewed by the Society of Family Planning Clinical Affairs

Committee. A search of the medical literature was performed us-

ing the PubMed program of the National Library of Medicine and

the Cochrane Library of Clinical Trials from the beginning of the

databases through April 9, 2022. Search terms included but were

not limited to LNG, UPA, copper IUD, LNG IUD, sexually trans-

mitted infection, breastfeeding, mechanism of action, safety, ef-

fectiveness, transgender, and gender diverse, in combination with

EC, ECPs, postcoital contraception, and pericoital contraception. We

then hand-searched the references of these manuscripts for addi-

tional relevant publications. We reviewed relevant product labels

and statements from the American College of Obstetricians and Gy-

necologists and United States Centers for Disease Control and Pre-

vention. A comprehensive systematic review was not performed.

Intended audience

This Clinical Recommendation is intended for Society of Fam-

ily planning members, reproductive health service clinicians, repro-

ductive health researchers, and policy makers.

Disclaimer

This publication is designed as a resource to assist clinicians in

providing family planning care. It should not be considered inclu-

sive of all proper treatments or serve as the standard of care. It is

not intended to substitute for the independent professional judg-

ment of the treating clinician. Variations, taking into account indi-

vidual circumstances, may be appropriate. This publication reﬂects

the best available evidence at the time of publication, recognizing

J. Salcedo et al. Contraception 121 (2023) 109958

that continued research or major changes in the practice environ-

ment may impact future recommendations and should be evalu-

ated for incorporation into care. Any updates to this document can

be found on https://www.societyfp.org/clinical-guidance/ . The So-

ciety and its contributors provide the information contained in this

publication "as is" and without any representations or warranties,

express or implied, of any kind, whether of accuracy, reliability, or

otherwise.

Author contributions

This Clinical Recommendation was prepared by Jennifer Sal-

cedo, MD, MPH, MPP; Kelly Cleland, MPA, MPH; Ivana Thompson,

MD, MSCI, and Deborah Bartz, MD, MPH and was reviewed and ap-

proved by the Clinical Affairs Committee on behalf of the Board of

Directors of the Society of Family Planning.

Supplementary materials

Supplementary material associated with this article can be

found, in the online version, at doi: 10.1016/j.contraception.2023.

109958 .

References

[1] Trussell J, Ellertson C, von Hertzen H, Bigrigg A, Webb A, Evans M, et al.

Estimating the effectiveness of emergency contraceptive pills. Contraception

2003;67(4):259–65

[2] von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Barfai G, et al. Low dose

mifepristone and two regimens of levonorgestrel for emergency contracep-

tion: a WHO multicentre randomised trial. Lancet 2002;360(9348):1803–10

[3] Glasier A. The rationale for use of ulipristal acetate as ﬁrst line in emer-

gency contraception: biological and clinical evidence. Gynecol Endocrinol

2014;30(10):688–90

[4] Cleland K, Raymond EG, Westley E, Trussell J. Emergency contraception re-

view: evidence-based recommendations for clinicians. Clin Obstet Gynecol

2014;57(4):741–50

[5] BakenRa A, Gero A, Sanders J, Simmons R, Fay K, Turok DK. Pregnancy risk by

frequency and timing of unprotected intercourse before intrauterine device

placement for emergency contraception. Obstet Gynecol 2021;138(1):79–84

[6] Sanders JN, Howell L, Saltzman HM, Schwarz EB, Thompson IS, Turok DK. Un-

protected intercourse in the 2 weeks prior to requesting emergency intrauter-

ine contraception. Am J Obstet Gynecol 2016;215(5):592.e1–592.e5

[7] ACOG Committee Opinion No. 777: sexual assault. ObstetGynecol

2019;133(4):e296–302

[8] Rothman EF, Exner D, Baughman AL. The prevalence of sexual assault against

people who identify as gay, lesbian, or bisexual in the United States: a sys-

tematic review. Trauma Violence Abuse 2011;12(2):55–66

[9] Norris AL, Orchowski LM. Peer victimization of sexual minority and transgen-

der youth: a cross-sectional study of high school students. Psychol Violence

2020;10(2):201–11

[10] Piaggio G, Kapp N, von Hertzen H. Effect on pregnancy rates of the delay

in the administration of levonorgestrel for emergency contraception: a com-

bined analysis of four WHO trials. Contraception 2011;84(1):35–9

[11] International Consortium for Emergency Contraception. EC pill types and

countries of availability, by brand, https://toolkits.knowledgesuccess.org/

toolkits/emergency-contraception/emergency-contraceptive-pills-registration-

status-country

; 2022 [accessed December 29, 2022].

[12] Jatlaoui TC, Riley H, Curtis KM. Safety data for levonorgestrel, ulipristal

acetate and Yuzpe regimens for emergency contraception. Contraception

2016;93(2):93–112

[13] Novikova N, Weisberg E, Stanczyk FZ, Croxatto HB, Fraser IS. Effectiveness of

levonorgestrel emergency contraception given before or after ovulation - a

pilot study. Contraception 2007;75(2):112–18

[14] Noé G, Croxatto HB, Salvatierra AM, Reyes V, Villarroel C, Muñoz C, et al.

Contraceptive eﬃcacy of emergency contraception with levonorgestrel given

before or after ovulation. Contraception 2011;84(5):486–92

[15] Brache V, Cochon L, Jesam C, Maldonado R, Salvatierra AM, Levy DP, et al. Im-

mediate pre-ovulatory administration of 30 mg ulipristal acetate signiﬁcantly

delays follicular rupture. Hum Reprod 2010;25(9):2256–63

[16] Li HWR, Lo SST, Ng EHY, Ho PC. Eﬃcacy of ulipristal acetate for emergency

contraception and its effect on the subsequent bleeding pattern when admin-

istered before or after ovulation. Hum Reprod 2016;31(6):1200–7

[17] Duramed pharmaceuticals Inc. Plan B one-step (levonorgestrel) tablet, 1.5

mg, for oral use [package insert], https://www.accessdata.fda.gov/drugsatfda _

docs/label/20 09/021998lbl.pdf

; 20 09 [accessed December 29, 2022].

[18] Watson Pharma Inc. Ella (ulipristal acetate) tablet [package insert], https://

www.accessdata.fda.gov/drugsatfda _ docs/label/2010/022474s0 0 0lbl.pdf

; 2010

[accessed December 29, 2022].

[19] Endler M, Li RHW. Gemzell Danielsson K. Effect of levonorgestrel emer-

gency contraception on implantation and fertility: a review. Contraception

2022;109:8–18

[20] Li HWR, Resche-Rigon M, Bagchi IC, Gemzell-Danielsson K, Glasier A. Does

ulipristal acetate emergency contraception (ella®) interfere with implanta-

tion? Contraception 2019;100(5):386–90

[21] Li D, Wilcox AJ, Dunson DB. Benchmark pregnancy rates and the assessment

of post-coital contraceptives: an update. Contraception 2015;91(4):344–9

[22] Creinin MD, Schlaff W, Archer DF, Wan L, Frezieres R, Thomas M, et al. Pro-

gesterone Receptor Modulator for Emergency Contraception: a randomized

controlled trial. Obstet Gynecol 2006;108(5):1089–97

[23] Fine P, Mathé H, Ginde S, Cullins V, Morfesis J, Gainer E. Ulipristal acetate

taken 48-120 h after intercourse for emergency contraception. ObstetGynecol

2010;115(2):257–63

[24] Glasier AF, Cameron ST, Fine PM, Logan SJS, Casale W, van Horn

J, et al. Ulipristal acetate versus levonorgestrel for emergency con-

traception: a randomised non-inferiority trial and meta-analysis. Lancet

2010;375(9714):555–62

[25] Hamoda H, Ashok PW, Stalder G, Flett GMM, Kennedy E, Templeton A. A ran-

domized trial of mifepristone (10 mg) and levonorgestrel for emergency con-

traception. Obstet Gynecol 2004;104(6):1307–13

[26] Dada OA, Godfrey EM, Piaggio G, von Hertzen H. Nigerian Network for Re-

productive Health Research and Training. A randomized, double-blind, non-

inferiority study to compare two regimens of levonorgestrel for emergency

contraception in Nigeria. Contraception 2010;82(4):373–8

[27] Gemzell-Danielsson K, Berger C, Lalitkumar PGL. Emergency contraception -

mechanisms of action. Contraception 2013;87(3):300–8

[28] Turok DK, Gero A, Simmons RG, Kaiser JE, Stoddard GJ, Sexsmith CD, et al.

Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception.

N Engl J Med 2021;384(4):335–44

[29] Ortiz ME, Croxatto HB. Copper-T intrauterine device and levonorgestrel in-

trauterine system: biological bases of their mechanism of action. Contracep-

tion 2007;75(6 Suppl):S16–30

[30] Black T, Goldstuck N, Spence A. Post-coital intrauterine device insertion - a

further evaluation. Contraception 1980;22(6):653–8

[31] Guillebaud J, Kubba A, Rowlands S, White J, Elder M. Post-coital contraception

with danazol, compared with an ethinyloestradiol-norgestrel combination or

insertion of an intra-uterine device. J Obstet Gynaecol 1983;3(Suppl 2):S64–8

[32] Tamburrino L, Marchiani S, Minetti F, Forti G, Muratori M, Baldi E.

The CatSper calcium channel in human sperm: relation with motility

and involvement in progesterone-induced acrosome reaction. Hum Reprod

2014;29(3):418–28

[33] Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J. The eﬃcacy of intrauter-

ine devices for emergency contraception: a systematic review of 35 years of

experience. Hum Reprod 2012;27(7):1994–2000

[34] Goldstuck ND, Cheung TS. The eﬃcacy of intrauterine devices for emergency

contraception and beyond: a systematic review update. Int J Womens Health

2019;11:471–9

[35] Turok DK, Sanders JN, Thompson IS, Royer PA, Eggebroten J, Gawron LM. Pref-

erence for and eﬃcacy of oral levonorgestrel for emergency contraception

with concomitant placement of a levonorgestrel IUD: a prospective cohort

study. Contraception 2016;93(6):526–32

[36] Curtis K, Jatlaoui T, Tepper N, Zapata L, Horton L, Jamieson D, et al. U.S.

Selected Practice Recommendations for Contraceptive Use, 2016. MMWR

Recomm Rep 2016;65(4):1–66

[37] Selected practice recommendations for contraceptive use. 3rd ed. Geneva:

World Health Organization; 2016

[38] Webb A, Taberner D. Clotting factors after emergency contraception. Adv Con-

tracept 1993;9(1):75–82

[39] Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine de-

vices and pelvic inﬂammatory disease: an international perspective. Lancet

1992;339(8796):785–8

[40] Gordon C, Harken T. Controversies in family planning: intrauterine

device placement in solid organ transplant patients. Contraception

2019;100(3):250–2

[41] Juliato CRT, Stahlschmidt P, Fernandes A, Monteiro I, Bahamondes L. A case

series on the use of levonorgestrel 52 mg intrauterine system after organ

transplant. Contraception 2018;98(3):252–4

[42] Morrison CS, Sekadde-Kigondu C, Sinei SK, Weiner DH, Kwok C, Kokonya D. Is

the intrauterine device appropriate contraception for HIV-1-infected women?

BJOG 2001;108(8):784–90

[43] Huguelet PS, Sheehan C, Spitzer RF, Scott S. Use of the levonorgestrel 52-mg

intrauterine system in adolescent and young adult solid organ transplant re-

cipients: a case series. Contraception 2017;95(4):378–81

[44] Kim CR, Martinez-Maza O, Magpantay L, Magyar C, Gornbein J, Rible R, et al.

Immunologic evaluation of the endometrium with a levonorgestrel intrauter-

ine device in solid organ transplant women and healthy controls. Contracep-

tion 2016;94(5):534–40

[45] Boraas CM, Sanders JN, Schwarz EB, Thompson I, Turok DK. Risk of pregnancy

with levonorgestrel-releasing intrauterine system placement 6-14 days after

unprotected sexual intercourse. Obstet Gynecol 2021;137(4):623–5

[46] Thompson I, Sanders JN, Schwarz EB, Boraas C, Turok DK. Copper in-

trauterine device placement 6–14 days after unprotected sex. Contraception

2019;100(3):219–21

[47] Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, et al. Can we

identify women at risk of pregnancy despite using emergency contraception?

J. Salcedo et al. Contraception 121 (2023) 109958

Data from randomized trials of ulipristal acetate and levonorgestrel. Contra-

ception 2011;84(4):363–7

[48] Festin MPR, Peregoudov A, Seuc A, Kiarie J, Temmerman M. Effect of BMI and

body weight on pregnancy rates with LNG as emergency contraception: anal-

ysis of four WHO HRP studies. Contraception 2017;95(1):50–4

[49] Kapp N, Abitbol JL, Mathé H, Scherrer B, Guillard H, Gainer E, et al. Effect of

body weight and BMI on the eﬃcacy of levonorgestrel emergency contracep-

tion. Contraception 2015;91(2):97–104

[50] Edelman AB, Cherala G, Blue SW, Erikson DW, Jensen JT. Impact of obesity on

the pharmacokinetics of levonorgestrel-based emergency contraception: sin-

gle and double dosing. Contraception 2016;94(1):52–7

[51] Edelman AB, Hennebold JD, Bond K, Lim JY, Cherala G, Archer DF, et al. Dou-

ble dosing levonorgestrel-based emergency contraception for individuals with

obesity: a randomized controlled trial. Obstet Gynecol 2022;140(1):48–54

[52] le Corvaisier C, Capelle A, France M, Bourguignon L, Tod M, Goutelle S. Drug

interactions between emergency contraceptive drugs and cytochrome induc-

ers: literature review and quantitative prediction. Fundam Clin Pharmacol

2021;35(2):208–16

[53] Carten ML, Kiser JJ, Kwara A, Mawhinney S, Cu-Uvin S. Pharmacokinetic inter-

actions between the hormonal emergency contraception, levonorgestrel (Plan

B), and efavirenz. Infect Dis Obstet Gynecol 2012;2012:137192

[54] Pohl O, Osterloh I, Gotteland JP. Effects of erythromycin at steady-state con-

centrations on the pharmacokinetics of ulipristal acetate. J Clin Pharm Ther

2013;38(6):512–17 .

[55] Pohl O, Zobrist RH, Gotteland JP. The clinical pharmacology and pharmacoki-

netics of ulipristal acetate for the treatment of uterine ﬁbroids. ReprodSci

2015;22(4):476–83

[56] Matyanga CMJ, Dzingirai B. Clinical pharmacology of hormonal emergency

contraceptive pills. Int J Reprod Med 2018;2018:2785839

[57] Ellison J, Thompson AJ, Greer I. Apparent interaction between warfarin and

levonorgestrel used for emergency contraception. BMJ 20 0 0;321(7273):1382

[58] Zhang J, Li C, Zhao WH, Xi X, Cao SJ, Ping H, et al. Association between lev-

onorgestrel emergency contraception and the risk of ectopic pregnancy: a

multicenter case-control study. Sci Rep 2015;5:8487

[59] Jesam C, Cochon L, Salvatierra AM, Williams A, Kapp N, Levy-Gompel D, et al.

A prospective, open-label, multicenter study to assess the pharmacodynam-

ics and safety of repeated use of 30 mg ulipristal acetate. Contraception

2016;93(4):310–16

[60] Medicines and Healthcare products Regulatory Agency UK. Esmya (ulipristal

acetate): suspension of the licence due to risk of serious liver injury,

https://www.gov.uk/drug- safety- update/esmya- ulipristal- acetate- suspension-

of- the- licence- due- to- risk- of- serious- liver- injury

; 2021 [accessed 29 De-

cember 2022].

[61] Donnez J, Arriagada P, Marciniak M, Larrey D. Liver safety parameters of

ulipristal acetate for the treatment of uterine ﬁbroids: a comprehensive re-

view of the clinical development program. Vol. 17. Expert Opin Drug Saf

2018;17(12):1225–32

[62] Gatti M, Poluzzi E, de Ponti F, Raschi E. Liver Injury with ulipristal acetate: ex-

ploring the underlying pharmacological basis. Drug Saf 2020;43(12):1277–85

[63] Donnez J. Liver injury and ulipristal acetate: an overstated tragedy? Vol. 110 .

Fertil Steril 2018;110(4):593–5

[64] Yoon EL, Yuk JS. Use of ulipristal acetate and risk of liver disease: a nation-

wide cohort study. J Clin Endocrinol Metabolism 2021;106(6):1773–82

[65] Bracken MB. Oral contraception and congenital malformations in offspring:

a review and meta-analysis of the prospective studies. Obstet Gynecol

1990;76(3 Pt 2):552–7

[66] Raman-Wilms L, in Tseng AL, Wighardt S, Einarson TR, Koren G. Fetal gen-

ital effects of ﬁrst-trimester sex hormone exposure: a meta-analysis. Obstet

Gynecol 1995;85(1):141–9

[67] Levy DP, Jager M, Kapp N, Abitbol JL. Ulipristal acetate for emergency contra-

ception: postmarketing experience after use by more than 1 million women.

Contraception 2014;89(5):431–3

[68] Zinaman MJ, Clegg ED, Brown CC, O’connor J, Selevan SG. Estimates of human

fertility and pregnancy loss. Fertil Steril 1996;65(3):503–9

[69] Cleland K, Raymond E, Trussell J, Cheng L, Zhu H. Ectopic pregnancy

and emergency contraceptive pills: a systematic review. Obstet Gynecol

2010;115(6):1263–6

[70] Barnhart KT. Ectopic pregnancy. N Eng J Med 2009;361(4):379–87 .

[71] Castaño PM, Westhoff CL. Experience with same-day placement of the

52 mg levonorgestrel-releasing intrauterine system. Am J Obstet Gynecol

2020;222(4) S883.e1-S883.e6

[72] Brahmi D, Steenland MW, Renner RM, Gaﬃeld ME, Curtis KM. Preg-

nancy outcomes with an IUD in situ: a systematic review. Contraception

2012;85(2):131–9

[73] Westhoff C, Kerns J, Morroni C, Cushman LF, Tiezzi L, Murphy PA. Quick start:

novel oral contraceptive initiation method. Contraception 2002;66(3):141–5

[74] Nelson AL, Katz T. Initiation and continuation rates seen in 2-year experience

with same day injections of DMPA. Contraception 2007;75(2):84–7

[75] Brache V, Cochon L, Duijkers IJM, Levy DP, Kapp N, Monteil C, et al. A

prospective, randomized, pharmacodynamic study of quick-starting a deso-

gestrel progestin-only pill following ulipristal acetate for emergency contra-

ception. Hum Reprod 2015;30(12):2785–93

[76] Cameron ST, Berger C, Michie L, Klipping C, Gemzell-Danielsson K. The ef-

fects on ovarian activity of ulipristal acetate when ‘quickstarting’ a combined

oral contraceptive pill: a prospective, randomized, double-blind parallel-arm,

placebo-controlled study. Hum Reprod 2015;30(7):1566–72

[77] Edelman AB, Jensen JT, McCrimmon S, Messerle-Forbes M, O’Donnell A,

Hennebold JD. Combined oral contraceptive interference with the ability of

ulipristal acetate to delay ovulation: a prospective cohort study. Contracep-

tion 2018;98(6):463–6

[78] Banh C, Rautenberg T, Duijkers I, Borenzstein P, Monteil C, Levy-Gompel D,

et al. The effects on ovarian activity of delaying versus immediately restart-

ing combined oral contraception after missing three pills and taking ulipristal

acetate 30 mg. Contraception 2020;102(3):145–51 .

[79] Zapata LB, Steenland MW, Brahmi D, Marchbanks PA, Curtis KM. Effect of

missed combined hormonal contraceptives on contraceptive effectiveness: a

systematic review. Contraception 2013;87(5):685–700

[80] Tuddenham S, Hamill MM, Ghanem KG. Diagnosis and treatment of sexually

transmitted infections: a review. JAMA 2022;327(2):161–72

[81] Workowski K, Bachmann L, Chan P, Johnston CM, Muzny CA, Park I, et al.

Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm

Rep 2021;70(4):1–187

[82] Jatlaoui TC, Simmons KB, Curtis KM. The safety of intrauterine contracep-

tion initiation among women with current asymptomatic cervical infec-

tions or at increased risk of sexually transmitted infections. Contraception

2016;94(6):701–12 .

[83] Decker MR, Mack KP, Barrows JJ, Silverman JG. Sex traﬃcking, violence vic-

timization, and condom use among prostituted women in Nicaragua. Int J Gy-

naecol Obstet 2009;107(2):151–2

[84] Orchowski LM, Yusufov M, Oesterle D, Bogen KW, Zlotnick C. Intimate partner

violence and coerced unprotected sex among young women attending com-

munity college. Arch Sex Behav 2020;49(3):871–82

[85] Wolgemuth T, Judge-Golden C, Callegari L, Zhao X, Mor M, Borrero S. As-

sociations between pregnancy intention, attitudes, and contraceptive use

among women veterans in the ECUUN study. Womens Health Issues

2018;28(6):480–7

[86] American Society for Emergency Contraception. Emergency contraception for

transgender and nonbinary patients, https://www.americansocietyforec.org/

reports- and- factsheets

; 2021 [accessed 29 December 2022].

[87] Bonnington A, Dianat S, Kerns J, Hastings J, Hawkins M, de Haan G, et al. So-

ciety of Family Planning clinical recommendations: contraceptive counseling

for transgender and gender diverse people who were female sex assigned at

birth. Contraception 2020;102(2):70–82

[88] Shaaban OM, Hassen SG, Nour SA, Kames MA, Yones EM. Emergency con-

traceptive pills as a backup for lactational amenorrhea method (LAM)

of contraception: a randomized controlled trial. Contraception 2013;87(3):

363–369 .

[89] Shaaban OM, Abbas AM, Mahmoud HR, Yones EM, Mahmoud A, Zakherah MS.

Levonorgestrel emergency contraceptive pills use during breastfeeding; ef-

fect on infants’ health and development. J Matern Fetal Neonatal Med

2019;32(15):2524–8

[90] Gainer E, Massai R, Lillo S, Reyes V, Forcelledo ML, Caviedes R, et al.

Levonorgestrel pharmacokinetics in plasma and milk of lactating women

who take 1.5 mg for emergency contraception. Hum Reprod 2007;22(6):

1578–1584

[91] National Library of Medicine (US). Intrauterine Copper Contraceptive [Inter-

net]. (2021). Available from: https://www.ncbi.nlm.nih.gov/books/

[92] Berry-Bibee EN, Tepper NK, Jatlaoui TC, Whiteman MK, Jamieson DJ, Cur-

tis KM. The safety of intrauterine devices in breastfeeding women: a system-

atic review. Contraception 2016;94(6):725–38

[93] Drugs and Lactation Database (LactMed) [Internet]. Bethesda (MD): national

Institute of Child Health and Human Development; 2006–. Ulipristal. 2022.

[94] Davis SA, Braykov NP, Lathrop E, Haddad LB. Familiarity with long-acting re-

versible contraceptives among obstetrics and gynecology, family medicine,

and pediatrics residents: results of a 2015 National Survey and Implica-

tions for Contraceptive Provision for Adolescents. J Pediatr Adolesc Gynecol

2018;31(1):40–4

[95] Schubert FD, Bishop ES, Gold M. Access to the copper IUD as post–

coital contraception: results from a mystery caller study. Contraception

2016;94(5):561–6

[96] Castleberry NM, Stark L, Schulkin J, Grossman D. Implementing best practices

for the provision of long-acting reversible contraception: a survey of obstetri-

cian-gynecologists. Contraception 2019;100(2):123–7

[97] Bergin A, Tristan S, Terplan M, Gilliam ML, Whitaker AK. A missed opportu-

nity for care: two-visit IUD insertion protocols inhibit placement. Contracep-

tion 2012;86(6):694–7

[98] Bellows BK, Tak CR, Sanders JN, Turok DK, Schwarz EB. Cost-effective-

ness of emergency contraception options over 1 year. Am J Obstet Gynecol

2018;218(5):508.e1–508.e9

[99] Amico JR, Heintz C, Bennett AH, Gold M. Access to IUD removal: data from a

mystery-caller study. Contraception 2020;101(2):122–9

[100] Tschann M, Soon R. Contraceptive Coverage and the Affordable Care Act. Ob-

stet Gynecol Clin North Am 2015;42(4):605–17

[101] Cleland K, Bass J, Doci F, Foster AM. Access to emergency contraception in

the over-the-counter era. Womens Health Issues 2016;26(6):622–7

[102] Vega A, Choi YJ, Tschann M, Salcedo J. Over-the-counter access to lev-

onorgestrel emergency contraception in South Texas: does Over-the-counter

mean ready to buy? Contraception 2021;104(3):271–4

[103] Batur P, Cleland K, McNamara M, Wu J, Pickle S. Emergency contraception:

a multispecialty survey of clinician knowledge and practices. Contraception

2016;93(2):145–52

[104] Castleberry NM, Stark L, Schulkin J, Grossman D. Oral and IUD emergency

J. Salcedo et al. Contraception 121 (2023) 109958

contraception provision among a national sample of obstetrician–gynecolo-

gists. Contraception 2020;102(6):406–8

[105] Shigesato M, Elia J, Tschann M, Bullock H, Hurwitz E, Wu YY, et al. Pharmacy

access to ulipristal acetate in major cities throughout the United States. Con-

traception 2018;97(3):264–9

[106] Bullock H, Salcedo J. Emergency contraception: do your patients have a plan

B? Obstetd Gynecol Clin North Am 2015;42(4):699–712

[107] Guttmacher Institute. Emergency Contraception, https://www.guttmacher.org/

state-policy/explore/emergency-contraception

; 2022 [accessed 29 December

2022].

[108] American Society for Emergency Contraception. Emergency contraception: a

guide for pharmacies and retailers, https://www.americansocietyforec.org/ _

ﬁles/ugd/7f2e0b _ fc23debfbd29451685a17bec4cb8518f.pdf

; 2020 [accessed 29

December 2022].

[109] Raﬁe S, Stone RH, Wilkinson TA, Borgelt L, El-Ibiary SY, Ragland D. Role of the

community pharmacist in emergency contraception counseling and delivery

in the United States: current trends and future prospects. Integr Pharm Res

Pract 2017;6:99–108

[110] Stifani BM, Madden T, Micks E, Moayedi G, Tarleton J, Benson LS. Society of

Family planning clinical recommendations: contraceptive care in the context

of pandemic response. Contraception 2022;113:1–12

[111] Milkowski C, Ziller E, Ahrens K. Rural-urban residence and emergency contra-

ception use, access, and counseling in the United States, 2006-2017. Contra-

cept X 2021;3:10 0 061 .

[112] Chandramani A, Dussault N, Parameswaran R, Rodriguez J, Novack J, Ahn J,

et al. A needs assessment and educational intervention addressing the care

of sexual assault patients in the emergency department. J Forensic Nurs

2020;16(2):73–82

[113] Coursolle A, McCaman Taylor L. Coverage of over-the-counter drugs in med-

icaid. National Health Law Program 2022. https://healthlaw.org/resource/

coverage- of- over- the- counter- drugs- in- medicaid/;2022

[accessed 29 Decem-

ber]

[114] Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the trans-

masculine spectrum. Am J Obstet Gynecol 2020;222(2):134–43

[115] Foster DG, Biggs MA, Grossman D, Schwarz EB. Interest in a pericoital

pill among women in family planning and abortion clinics. Contraception

2013;88(1):141–6

[116] Raymond EG, Shochet T, Drake JK, Westley E. What some women want?

On-demand oral contraception. Contraception 2014;90(2):105–10

[117] Hatcher R. Contraceptive Technology. 21st ed; 2018 .

[118] Eﬃcacy and side effects of immediate postcoital levonorgestrel used repeat-

edly for contraception. United Nations Development Programme/United Na-

tions Population Fund/World Health Organization/World Bank Special Pro-

gramme of Research, Development and Research Training in Human Repro-

duction, Task Force on on Post = Ovulatory Methods Fertility Regulation. Con-

traception 20 0

0;61(5):303–8 .

[119] Shelton JD. Repeat emergency contraception: facing our fears. Contraception

2002;66(1):15–17

[120] Halpern V, Raymond EG, Lopez LM. Repeated use of pre- and postcoital hor-

monal contraception for prevention of pregnancy. Cochrane Database Syst Rev

2014;2014(9):CD007595

[121] Taylor DJ, Lendvay A, Halpern V, Bahamondes LG, Fine PM, Ginde SY, et al. A

single-arm study to evaluate the eﬃcacy, safety and acceptability of pericoital

oral contraception with levonorgestrel. Contraception 2014;89(3):215–21

[122] Festin MPR, Bahamondes L, Nguyen TMH, Habib N, Thamkhantho M, Singh K,

et al. A prospective, open-label, single arm, multicentre study to evaluate

eﬃcacy, safety and acceptability of pericoital oral contraception using lev-

onorgestrel 1.5 mg. Hum Reprod 2016;31(3):530–40

[123] Cahill EP, Blumenthal PD. Pericoital contraception. Curr Opin Obstet Gynecol

2018;30(6):400–6