Female Reproductive & Breast

Emergency contraception: options and counseling

Clinical Overview and When to Suspect Need for Emergency Contraception

— No contraception used during intercourse

— Condom break, slippage, or incorrect use

— Missed combined oral contraceptive pills (≥2 missed in week 1, or late restart)

— Missed progestin-only pill by >3 hours (traditional norethindrone) or >27 hours from prior dose

— Late depot medroxyprogesterone injection (>15 weeks from last dose)

— Dislodged or removed patch/ring for >48 hours

— Expelled or incorrectly placed IUD

— Failure of withdrawal or fertility-awareness method

— Sexual assault

— Copper IUD (most effective, >99%)

— Levonorgestrel 52 mg IUD (recently shown non-inferior to copper for EC)

— Ulipristal acetate 30 mg PO (UPA, "ella") — Rx only

— Levonorgestrel 1.5 mg PO (LNG, "Plan B") — OTC, no age restriction

— Yuzpe regimen (combined OCPs) — last-line, more nausea

Board pearl: Step 3 stems often hide the EC indication in the social history — "condom broke 3 days ago," "forgot her pill for 4 days," or "assaulted last night." Recognize the window and always offer EC proactively rather than waiting for the patient to ask; this is a standard ambulatory preventive-care competency.

Definition: Emergency contraception (EC) is any method used after unprotected or inadequately protected intercourse to prevent pregnancy, before implantation occurs.

Indications — offer EC whenever any of the following has occurred within the prior 5 days:

Mechanism: All currently available EC methods work primarily by delaying or inhibiting ovulation (oral methods) or by creating a spermicidal/embryotoxic intrauterine environment (copper IUD). None disrupt an established pregnancy — EC is not an abortifacient.

Available US options:

Timing window: LNG up to 72 h (some efficacy to 120 h); UPA up to 120 h; copper/LNG IUD up to 120 h after unprotected sex (and often beyond if pre-ovulatory).

Presentation Patterns and Key History

— Date and time of unprotected intercourse (all of them in the last 5 days — multiple episodes change strategy)

— LMP and cycle regularity — estimate where she is in cycle; mid-cycle exposure carries highest pregnancy risk

— Current contraceptive method and what went wrong

— Prior unprotected sex earlier in this cycle — if >5 days ago, a pre-existing pregnancy must be excluded before UPA or hormonal EC

— Body weight/BMI — efficacy of LNG drops at BMI >26 or weight >70 kg; UPA drops at BMI >35

— Current medications — CYP3A4 inducers (rifampin, phenytoin, carbamazepine, St. John's wort, efavirenz) reduce oral EC efficacy → favor IUD

— Breastfeeding status, allergies, hepatic disease

Key distinction: A negative urine hCG at presentation rules out recognized pregnancy but not a luteal-phase conception from earlier in the same cycle; this is why intercourse >5 days ago still matters for UPA dosing decisions.

Step 3 management: Document time-since-intercourse in hours, BMI, and cycle day in the note — these three data points drive the choice between LNG, UPA, and copper IUD.

Typical encounter: Urgent walk-in, telehealth visit, ED visit, or pharmacy counseling request within hours to days of intercourse. Anxiety, embarrassment, and time pressure dominate — use a nonjudgmental, efficient script.

Essential history (the "EC 7"):

Sexual assault screening: Always ask directly in a private setting. Positive screen triggers parallel pathways — forensic exam, STI prophylaxis, HIV PEP consideration, mental health, mandatory reporting if minor or vulnerable adult.

Pregnancy intention: If she desires pregnancy, EC is obviously inappropriate; this is rare but should be confirmed.

Contraindications to oral EC: Known pregnancy (no benefit, not harmful), severe hepatic disease for UPA, hypersensitivity. No cardiovascular contraindications — unlike combined OCPs, single-dose EC is safe in smokers, hypertensives, and migraineurs.

Physical Exam Findings and Pre-Treatment Assessment

— Patient is choosing IUD as EC — bimanual to assess uterine size/position, speculum to visualize cervix and obtain GC/CT NAAT at insertion

— Sexual assault evaluation — forensic exam per local SANE protocol, evidence collection within 120 h

— Abdominal/pelvic pain, abnormal bleeding, or suspicion of PID or ectopic

— Foreign body retained (broken condom fragment)

CCS pearl: On a CCS case, the correct sequence is: focused history → urine hCG (if IUD planned or pregnancy plausible) → counsel and offer EC options → administer/place → schedule follow-up in 3–4 weeks for pregnancy test and contraception transition. Do not order a "complete pelvic exam" before oral EC — it is a distractor and delays time-sensitive therapy.

Board pearl: Pelvic exam is required before IUD insertion, not before pills.

General principle: Routine pelvic exam is not required before prescribing oral EC. Refusal or inability to undergo exam should never delay EC. This is a Step 3 ambulatory-access pearl — barriers reduce efficacy because EC is time-sensitive.

Vital signs and general exam: Brief assessment for signs of established pregnancy (which would obviate EC), acute abdomen (rule out ectopic if any prior amenorrhea), or trauma if assault is reported.

When pelvic exam IS indicated:

STI risk assessment: Universally offer GC/CT NAAT, syphilis serology, HIV, hepatitis B/C, and trichomonas testing per CDC. Treponemal/HIV testing is especially important if assault occurred.

Pregnancy testing: Urine hCG before EC is not mandatory for oral methods (hormonal EC is not teratogenic and not abortifacient), but is recommended before IUD placement to avoid inserting into an unrecognized intrauterine pregnancy.

Weight and BMI: Document — directly influences choice of regimen (see chunk 7).

Diagnostic Workup — Initial Labs and Pregnancy Testing

— Indication: Before copper or LNG IUD placement; whenever pregnancy is clinically plausible (>2 weeks since unprotected sex, missed period, breast tenderness)

— A positive test means EC is not indicated — counsel on options for the pregnancy

— A negative test does not exclude very-early luteal conception (<10–14 days post-fertilization) — counsel that EC may still fail and a follow-up test is required at 3–4 weeks

— GC/CT NAAT (test-and-treat strategy — placement need not be delayed for results in low-risk patients per CDC; treat presumptively if symptomatic)

— HIV, syphilis, hepatitis serologies if clinically indicated

— No routine CBC, coagulation, or pelvic ultrasound required

— Forensic kit per state SANE protocol

— Baseline HIV, HBsAg, anti-HCV, syphilis RPR, GC/CT, trichomonas

— Toxicology if drug-facilitated assault suspected

— Baseline serum hCG (quantitative) to document pre-exposure status

— Strong CYP3A4 inducers in the last 4 weeks — reduce efficacy of both UPA and LNG → copper IUD preferred

— Concurrent progestin-containing contraception within 5 days before UPA — blunts UPA effect; counsel to delay restart of hormonal contraception until 5 days after UPA

Key distinction: Oral EC is not teratogenic. A patient who is unknowingly already pregnant and takes LNG or UPA has not harmed the pregnancy — important reassurance and a frequent Step 3 ethics-flavored question.

Step 3 management: Always schedule a follow-up pregnancy test 3–4 weeks after EC use; menses delayed >7 days from expected = mandatory testing.

Urine hCG (qualitative):

No routine labs are needed before oral LNG or UPA.

Pre-IUD screening labs:

Sexual assault workup adds:

Drug interactions to verify before UPA or LNG:

Diagnostic Workup — Advanced or Confirmatory Studies

— Persistent amenorrhea or positive hCG at 3–4 week follow-up

— Pelvic pain, abnormal bleeding, or hemodynamic concern → transvaginal ultrasound and quantitative serial β-hCG to evaluate for ectopic vs. early intrauterine pregnancy

— EC failure — confirm pregnancy location and viability before counseling on options

— EC does not increase baseline ectopic risk; however, if a pregnancy occurs despite an IUD in place, the proportion that are ectopic is higher (because the IUD preferentially prevents intrauterine implantation)

— Any pregnancy with an IUD in situ → immediate TVUS to localize, plus discussion of IUD removal (lower miscarriage risk if removed when strings visible, regardless of plan)

— Repeat GC/CT NAAT at 2 weeks if initial was negative and exposure ongoing

— HIV at 4–6 weeks and 3 months (or per 4th-gen Ag/Ab algorithm)

— Syphilis RPR at 6 weeks and 3 months

— Hepatitis B/C per CDC post-exposure schedule

— HIV PEP adherence labs (CBC, CMP at 2 and 4 weeks if on tenofovir-based regimen)

— Psychological screening — PTSD, depression — at each visit for 3 months

Board pearl: Quantitative β-hCG that fails to double in 48 hours in a symptomatic patient after EC failure → high suspicion for ectopic; obtain TVUS once β-hCG >1500–2000 mIU/mL (discriminatory zone).

CCS pearl: Schedule the 3–4 week follow-up visit at the time of the EC encounter — do not rely on the patient to self-refer.

Indications for advanced workup after EC encounter:

Ectopic pregnancy consideration:

STI follow-up testing windows:

Sexual assault follow-up:

Weight-based EC failure workup: If EC fails in a patient with BMI >26 (LNG) or >35 (UPA), document — this is consistent with known efficacy decline and supports counseling toward IUD next time.

Risk Stratification and Choosing Among EC Options

— Copper IUD: pregnancy rate <0.1% — most effective EC method known

— LNG 52 mg IUD: ~0.3% (recent RCT data)

— Ulipristal acetate 30 mg PO: ~1.4%

— Levonorgestrel 1.5 mg PO: ~2.2%

— Yuzpe regimen (ethinyl estradiol + LNG combined pills): ~3–4%, high nausea

— Highest efficacy desired, ongoing contraception wanted, no contraindications: Copper or LNG 52 mg IUD within 120 h

— BMI >26 or weight >70 kg: Prefer IUD; if oral, UPA over LNG

— BMI >35: Oral EC efficacy is markedly reduced — IUD strongly preferred

— Time since intercourse 72–120 h: UPA or IUD (LNG efficacy drops sharply)

— Time since intercourse ≤72 h, BMI <26, no CYP3A4 inducers, IUD declined: LNG (OTC, fastest access)

— On CYP3A4 inducers (rifampin, phenytoin, carbamazepine, St. John's wort): IUD preferred; if oral, double-dose LNG (3 mg) is sometimes used off-label

— Recent (within 7 days) hormonal contraception use or planning to start within 5 days: LNG, not UPA (progestins blunt UPA)

— Breastfeeding: LNG preferred (UPA — discard milk 1 week)

Key distinction: UPA is more effective than LNG, especially at 72–120 h and in patients with higher BMI, but cannot be combined with progestin contraception in the same 5-day window. LNG is more accessible but less effective.

Step 3 management: Offer the most effective method the patient will accept — start with IUD, then UPA, then LNG; do not lead with the least effective option.

Efficacy ranking (most → least effective):

Algorithm by clinical scenario:

Counseling on access: LNG is OTC at any age, no ID needed. UPA requires a prescription. IUDs require same-day or next-day placement — call ahead.

Pharmacotherapy — First-Line Oral Regimens

— Dose: 1.5 mg PO single dose (or 0.75 mg × 2 doses 12 h apart — equivalent)

— Window: ≤72 h ideal; some efficacy to 120 h with declining benefit

— Mechanism: Delays/inhibits ovulation if given before the LH surge; no effect once LH surge has begun

— OTC, no age restriction, no prescription needed

— Side effects: Nausea (~14%), headache, fatigue, irregular bleeding, menses ±7 days from expected

— Repeat dose if vomiting within 3 h

— Resume regular hormonal contraception immediately after LNG

— Dose: 30 mg PO single dose

— Window: Up to 120 h, with sustained efficacy across the window (unlike LNG)

— Mechanism: Selective progesterone receptor modulator — delays ovulation even after the LH surge has started (key advantage over LNG)

— Prescription required (US)

— Side effects: Headache, nausea, abdominal pain, dysmenorrhea

— Repeat dose if vomiting within 3 h

— Wait 5 days before starting/restarting any progestin-containing contraception (progestins displace UPA from the receptor)

— Use back-up barrier for 7 days (14 days for ring/patch; until next menses for pills) after restart

— Breastfeeding: Discard milk for 1 week

— Ethinyl estradiol 100 µg + LNG 0.5 mg, repeat in 12 h

— Add antiemetic (meclizine 50 mg) — nausea ~50%

— Use only if LNG/UPA/IUD unavailable

Board pearl: UPA beats LNG during the fertile window (the 5 days before ovulation) because UPA blocks the LH surge even after it has begun; LNG cannot.

Step 3 management: Provide written instructions, antiemetic if needed, follow-up plan, and transition contraception at the same visit — EC is a bridge, not a method.

Levonorgestrel (LNG, "Plan B One-Step"):

Ulipristal acetate (UPA, "ella"):

Yuzpe regimen (last resort):

Procedures — IUD as Emergency Contraception

— Insert within 120 h of unprotected intercourse (and per some experts, up to 10–14 days if pre-ovulatory based on cycle dating)

— Mechanism: Copper ions are spermicidal and create an inflammatory endometrium hostile to fertilization and implantation

— Efficacy: >99% — the most effective EC method

— Provides ongoing contraception for 10–12 years

— Side effects: Heavier menses, dysmenorrhea (often improves over 3–6 months)

— Contraindications: Pregnancy, distorted uterine cavity, current pelvic infection, Wilson disease, copper allergy, unexplained uterine bleeding, cervical/endometrial cancer

— Recent NEJM 2021 RCT — non-inferior to copper IUD for EC when placed within 5 days

— Efficacy: ~0.3%

— Provides ongoing contraception for 8 years

— Often better tolerated than copper (lighter menses, less cramping)

— Same contraindications as copper minus Wilson/copper allergy; add active breast cancer

— Urine hCG before insertion

— STI testing at insertion (do not delay for results in asymptomatic low-risk patients)

— Bimanual to assess uterine position; sound the uterus

— Counsel on expulsion (2–10%), perforation (1/1000), pain at insertion

— Strings checked at 4–6 weeks

CCS pearl: For a CCS case in which the patient wants long-term contraception and EC, "Place copper IUD" is the single highest-yield order — it accomplishes both in one step.

Key distinction: IUD EC efficacy is independent of BMI, unlike oral methods.

Copper T380A IUD:

Levonorgestrel 52 mg IUD (Mirena/Liletta):

Insertion procedure essentials:

Access barriers: Same-day placement is the goal; if unavailable, bridge with oral EC (UPA preferred if IUD will be placed >5 days later — but note UPA delays IUD placement is not required) and schedule insertion within days.

Special Populations — Renal/Hepatic Impairment and Drug Interactions

— LNG: No dose adjustment; minimal hepatic metabolism issues, but limited data in severe disease

— UPA: Avoid in severe hepatic impairment — metabolized by CYP3A4, no formal dosing data; copper IUD preferred

— Copper IUD: Safe — no systemic absorption

— LNG 52 mg IUD: Safe — minimal systemic levels

— All EC methods are safe across CKD stages including dialysis — no dose adjustment

— IUDs are particularly attractive in CKD patients on teratogenic medications (mycophenolate, ACEi) where pregnancy prevention is critical

— Rifampin, rifabutin

— Phenytoin, carbamazepine, phenobarbital, primidone, oxcarbazepine, topiramate (>200 mg/d)

— Efavirenz, nevirapine, ritonavir-boosted PIs (variable)

— St. John's wort

— Bosentan, modafinil

— Recommendation: Offer copper or LNG IUD; if oral chosen, some experts use double-dose LNG (3 mg) off-label — UPA also reduced

— UPA + recent or imminent progestin (pill, patch, ring, implant, DMPA, LNG IUD) → blunts UPA; either choose LNG EC instead, or delay progestin restart by 5 days

— Antacids/PPIs do not significantly affect oral EC

— LNG efficacy declines at BMI >26 or weight >70 kg

— UPA efficacy declines at BMI >35

— IUD efficacy is BMI-independent — preferred in obesity

Board pearl: A woman with epilepsy on carbamazepine who needs EC → copper IUD, not Plan B.

Step 3 management: Always reconcile the medication list before choosing oral EC; CYP3A4 inducers are an automatic indication to shift toward IUD.

Hepatic impairment:

Renal impairment:

Drug interactions — CYP3A4 inducers reduce oral EC efficacy:

Drug interactions — within EC class:

Obesity:

Special Populations — Adolescents, Assault Survivors, Breastfeeding, and Perimenopause

— LNG is OTC at any age — no parental consent or ID required (US, per FDA 2013)

— Confidentiality: Every state allows minors to consent to contraception including EC; document confidentiality discussion

— Counsel proactively at well-visits — advance prescription of UPA is acceptable

— IUD insertion in nulliparous adolescents is safe and recommended by ACOG and AAP as first-line LARC

— Offer EC routinely — pregnancy from a single assault ~5%

— Pair with: STI prophylaxis (ceftriaxone 500 mg IM + doxycycline 100 mg BID × 7 d + metronidazole 2 g PO), HIV PEP (tenofovir/emtricitabine + dolutegravir × 28 d if within 72 h), hepatitis B vaccination/HBIG if unvaccinated, Tdap if indicated

— Forensic evidence collection within 120 h (SANE)

— Mandatory reporting for minors, vulnerable adults; adult survivor reporting is patient's choice in most states

— LNG: Compatible; preferred — minimal infant exposure

— UPA: Discard breast milk for 1 week (pump and dump)

— Copper IUD: Safe immediately

— LNG IUD: Safe; preferred LARC postpartum

— Pregnancy is still possible until 12 months of amenorrhea (or age 55 without HRT)

— All EC methods remain appropriate; copper IUD attractive for those avoiding hormones

— Postpartum/post-abortion ovulation can occur as early as day 21–25 — EC indicated if unprotected intercourse occurs before contraception is established

Key distinction: EC is not contraindicated at any age — there is no minimum or maximum.

Step 3 management: Assault encounter = EC + STI prophylaxis + HIV PEP + hep B + forensic exam + mental health referral + safety planning, all at the index visit.

Adolescents:

Sexual assault survivors:

Breastfeeding:

Perimenopause:

Recent pregnancy:

Complications and Adverse Outcomes

— Nausea: LNG ~14%, UPA ~12%, Yuzpe ~50% — repeat dose if emesis within 3 h

— Headache, fatigue, dizziness, breast tenderness

— Menstrual disturbance: Next menses may be 7 days earlier or later than expected; any delay >7 days → pregnancy test

— Intermenstrual bleeding/spotting in 10–20%

— No increased risk of VTE, MI, stroke — single-dose hormonal exposure is not comparable to chronic OCP use

— Insertion pain, vasovagal syncope (rare)

— Expulsion 2–10%, highest in first 3 months and in nulliparous patients

— Uterine perforation ~1/1000, higher in lactating and immediately postpartum patients

— Pelvic infection: Slight transient increase in first 20 days post-insertion; baseline thereafter

— Heavy menses/dysmenorrhea (copper); irregular spotting (LNG IUD, usually improves by 6 months)

— No evidence of teratogenicity from LNG or UPA exposure during early pregnancy — reassure

— IUD-in-situ pregnancy: Higher relative ectopic proportion; obtain TVUS to localize

— If IUD pregnancy is intrauterine and strings visible → remove IUD (reduces miscarriage, preterm birth, infection); if strings not visible, individualize

Board pearl: Exposure to LNG or UPA in an already-existing pregnancy is not an indication for termination — these agents are not teratogens.

Step 3 management: Any pelvic pain or abnormal bleeding within 3 weeks of EC use → urine hCG + TVUS to rule out ectopic, regardless of method used.

Oral EC adverse effects (generally mild, self-limited):

IUD-related complications:

EC failure (pregnancy occurs):

Ectopic pregnancy: EC does not increase baseline absolute risk; any patient with pain/bleeding after EC failure deserves prompt ectopic evaluation.

Psychological: Anxiety, decisional regret — provide nonjudgmental follow-up and contraception planning.

When to Escalate Care — Consultation and Inpatient Triage

— Suspected ectopic pregnancy after EC failure (pain, bleeding, hemodynamic instability)

— IUD insertion declined by primary clinician (lack of training) — refer same-day to maintain 120 h window

— Pregnancy with IUD in situ — for removal counseling and management

— Uterine perforation during IUD insertion

— Recurrent EC failure — needs LARC counseling

— Hemodynamic instability — suspected ruptured ectopic

— Sexual assault requiring forensic evaluation and SANE-trained provider

— Severe pelvic infection post-IUD insertion (rare)

— Allergic reaction to medication

— Sexual assault — refer to crisis services, victim advocacy

— Intimate partner violence screen — positive triggers safety planning, hotline referral, possible shelter

— Reproductive coercion (partner sabotaging contraception) — particular concern; offer covert methods (LNG IUD with trimmed strings, DMPA)

— UPA not stocked locally → call ahead; consider mail-order or telehealth with rapid prescription

— Cost barrier → many state Medicaid plans cover; Title X clinics provide free EC

— Mandatory reporting if patient is a minor (per state statute), vulnerable adult, or trafficking victim

CCS pearl: On CCS, do not "admit" a routine EC patient — manage outpatient with same-day prescription/placement and a 3–4 week follow-up. Admission is only for ruptured ectopic or unstable assault victims.

Step 3 management: Time-to-EC is the single most important clinical lever — every system barrier (refusal, lack of training, stockouts) requires immediate workaround, not deferral.

Most EC encounters are managed entirely in primary care, urgent care, or by pharmacist counseling. Escalation is uncommon but the following triggers matter on Step 3:

OB/GYN consultation (urgent, same-day):

Emergency department:

Mental health / social work:

Pharmacy / access escalation:

Public health reporting:

Key Differentials — Same-Category Causes (Contraception-Related Mimics)

— Missed period, breast tenderness, nausea — check hCG before assuming EC is appropriate

— If positive, transition to options counseling (continuation, adoption, abortion per state law and patient values)

— Missed pill scenarios: ACOG provides specific guidance — if missed ≤1 active pill, take it ASAP; ≥2 missed in week 1 or late restart → EC indicated; ≥2 missed in week 2 or 3 → continue active pills, skip placebo, no EC needed

— Late DMPA injection: EC indicated if >15 weeks from last shot and unprotected sex occurred

— Ring/patch removed >48 h: EC indicated; restart and use backup

— Common, often under-recognized; counsel on EC and offer transition to more effective method

— Always screen — patients may not initially disclose

— Implant or IUD recently removed and unprotected sex occurred → standard EC indicated

— Most antibiotics (except rifampin/rifabutin) do not reduce OCP efficacy — EC not routinely needed for amoxicillin courses; this is a frequent patient misconception

Key distinction: Rifampin reduces OCP efficacy → use backup + consider EC if intercourse occurred. Amoxicillin, doxycycline, azithromycin do not — reassure and continue method.

Board pearl: A patient on lamotrigine plus combined OCP — the OCP reduces lamotrigine levels (seizure risk during placebo week), but lamotrigine does not reduce OCP efficacy; EC counseling is the same as the general population.

When a patient presents requesting EC, consider whether the underlying scenario is actually:

Already-established pregnancy:

Contraceptive method failure mistaken for EC need:

Withdrawal/fertility-awareness failure:

Coerced or non-consensual intercourse presenting as "contraceptive failure":

Post-LARC removal pregnancy concern:

Antibiotic-related contraceptive concern:

Key Differentials — Other-Category Causes (Symptoms After EC Use)

— Expected after LNG or UPA — usually within 1 week, resolves by next cycle

— Persistent or heavy bleeding → check hCG, consider TVUS, evaluate for retained products if pregnancy was missed

— Pregnancy until proven otherwise — urine hCG; if negative and >2 weeks late, repeat or quantitative

— Stress-induced anovulation also possible but a diagnosis of exclusion

— Ectopic pregnancy — TVUS + quantitative β-hCG

— Ovarian cyst (LNG can affect follicular dynamics)

— PID — especially within 20 days of IUD insertion

— Appendicitis, ovarian torsion — standard workup

— Expected after Yuzpe; less common with LNG/UPA — antiemetic and reassurance

— Hyperemesis suggests pregnancy — check hCG

— Single-dose EC does not carry the stroke/migraine risk of chronic combined OCPs; new focal neurologic symptoms require standard evaluation, not attribution to EC

— Common, self-limited; persistent breast changes → pregnancy test

— Endometritis/PID — pelvic exam, GC/CT, treat empirically; leave IUD in place unless no improvement after 48–72 h of antibiotics

Key distinction: PID with IUD in situ → treat antibiotics first, do NOT immediately remove the IUD (CDC guidance). Remove only if no clinical improvement.

Step 3 management: Any post-EC pelvic pain + positive hCG = ectopic until proven intrauterine by ultrasound.

When a patient returns after EC use with symptoms, consider:

Irregular bleeding (most common):

Amenorrhea / missed period after EC:

Pelvic pain after EC:

Severe nausea/vomiting:

Headache/visual symptoms:

Breast tenderness, mood changes:

Fever, vaginal discharge after IUD insertion:

Transition to Ongoing Contraception and Long-Term Plan

— Resume or start hormonal contraception (pill, patch, ring, DMPA, implant) immediately

— Use backup barrier method for 7 days (or until next menses for OCPs)

— IUD can be placed same day (and itself serves as EC if within 120 h)

— Wait 5 days before starting/restarting any progestin-containing contraception — progestins displace UPA from the receptor and blunt its effect

— Use backup barrier for 7 days after starting the new method (so 12 days total from UPA dose)

— Exception: Copper IUD can be placed immediately (no hormonal interaction)

— Offer same-day or next-visit IUD/implant placement — most effective ongoing prevention

— Copper IUD: 10–12 years; LNG IUD: 8 years; etonogestrel implant: 3 years (FDA), evidence supports up to 5 years

— Any contraceptive method can be started on the day of EC counseling regardless of cycle day — with appropriate backup and a follow-up pregnancy test in 3–4 weeks

— Prescribe a supply of LNG or UPA to keep at home for future need — proven to increase appropriate use without increasing risky behavior

— Correct condom use, dual method (condom + hormonal) for STI protection

— Recognition of contraceptive failure (missed pill, late shot)

— When to use EC vs. when not needed

— Cost and access — Title X, Medicaid, OTC availability

Board pearl: 5 days is the magic interval between UPA and starting a progestin — the most-tested transition detail.

Step 3 management: Document the ongoing contraceptive plan in the EC visit note — leaving a patient with EC alone is a quality-of-care failure.

EC is a one-time bridge — every encounter must include a contraception plan.

After LNG (Plan B):

After UPA (ella):

LARC transition:

Quick Start protocol:

Advance provision:

Education topics:

Follow-Up, Monitoring, and Counseling

— Pregnancy test at 3–4 weeks, or sooner if menses delayed >7 days from expected

— Reassess contraception adherence and satisfaction

— STI testing per CDC if any unprotected exposure; repeat at 2 weeks if initial negative and clinical suspicion remains

— HIV: 4–6 weeks and 3 months if at risk

— String check at 4–6 weeks

— No routine TVUS unless symptoms

— Counsel on expulsion warning signs (cramping, lengthening strings, partner feels device)

— Mechanism: Prevents/delays ovulation; not an abortifacient (important for patient autonomy and informed consent)

— Efficacy: Honest disclosure of failure rates — most effective ≠ 100%

— Side effects and what is expected vs. concerning

— When to return: Severe pain, heavy bleeding, missed period, signs of pregnancy

— Repeat use: EC can be used more than once in a cycle and across cycles — not harmful, but signals need for a better ongoing method

— STI risk: EC does not prevent STIs — pair with testing and prevention

— Track time-from-presentation-to-EC as a quality metric in urgent care/ED

— Stocking UPA and copper IUDs is a measure of EC access

— Provide written summary; reproductivehealthaccess.org and Bedsider are validated resources

CCS pearl: "Schedule follow-up in 3–4 weeks" + "urine hCG at that visit" + "start ongoing contraception" — three orders that close the loop on every EC case.

Key distinction: A patient using EC repeatedly is using a method that works but is not optimal — counsel toward LARC without judgment.

Standard follow-up after oral EC:

Follow-up after IUD as EC:

Counseling content at every EC visit:

Health-system level monitoring:

Patient education materials:

Ethical, Legal, and Patient Safety Considerations

— Some patients (and some providers) believe EC is abortifacient — it is not. ACOG, FDA, and NIH consensus: EC prevents or delays ovulation; it does not disrupt an established pregnancy.

— Accurate mechanism disclosure is required for true informed consent; misrepresenting EC as abortion is a documented patient-safety failure.

— Clinicians and pharmacists may decline to dispense EC in some states, but the standard of care requires timely referral to another provider/pharmacy. Refusal without referral is a breach of duty and may violate state pharmacy regulations.

— Document referral path; ensure no delay beyond the efficacy window.

— All US states permit minors to consent to contraception including EC; explicit parental consent is not required for LNG (OTC) or, in most states, for prescribed EC.

— Use confidential communication channels (EHR portal settings, billing privacy) to avoid disclosure.

— Minors and vulnerable adults: Mandated reporting in all states

— Competent adults: Patient's choice in most jurisdictions; document patient preference and offer law-enforcement and victim-advocacy resources

— Screen routinely; offer covert contraception options (DMPA, implant, IUD with trimmed strings)

— Safety plan and refer to National DV Hotline (1-800-799-7233)

— EC visits often occur in urgent care, ED, or pharmacy without continuity — explicitly close the loop by sending records to primary care and scheduling follow-up

— A missed pregnancy test at 3–4 weeks is the most common safety failure — system-level reminders matter

— ACA mandates contraception coverage including EC; UPA must be covered without cost-sharing in compliant plans

Step 3 management: A pharmacist refusing to dispense EC must transfer the prescription to another pharmacy same-day — counsel patient to call ahead and provide alternate locations.

Board pearl: Conscientious refusal without timely referral = ethics violation and a frequent test item.

Mechanism counseling and informed consent:

Provider conscientious objection:

Confidentiality for minors:

Sexual assault — mandatory reporting:

Reproductive coercion / IPV:

Transition-of-care safety:

Insurance and access equity:

High-Yield Associations and Rapid-Fire Facts

Board pearl: If the stem mentions BMI 34 and intercourse 90 hours ago → answer is UPA (or copper IUD); LNG is wrong on both counts.

Step 3 management: Memorize the three discriminators — time, BMI, drug interactions — and the answer choice usually falls out.

Most effective EC: Copper IUD (>99%)

Most accessible EC: LNG 1.5 mg (OTC, no age limit)

Best oral EC at 72–120 h or higher BMI: UPA

EC mechanism: Delays/inhibits ovulation; not abortifacient

EC and existing pregnancy: No teratogenic effect, no benefit, do not give

Maximum window: 120 h for UPA, LNG (less effective), copper IUD, LNG IUD

BMI cutoffs: LNG declines at BMI >26 or weight >70 kg; UPA declines at BMI >35

Drug interactions: CYP3A4 inducers (rifampin, anticonvulsants, St. John's wort) reduce oral EC → use IUD

UPA + progestin: Wait 5 days before restarting progestin contraception

LNG + ongoing contraception: Start/resume immediately, backup 7 days

Vomiting within 3 h: Repeat dose

Breastfeeding: LNG safe; UPA discard milk 1 week

Sexual assault bundle: EC + STI prophylaxis (ceftriaxone/doxy/metronidazole) + HIV PEP + hep B + forensic exam + mental health

Most common antibiotic that reduces OCP efficacy: Rifampin (not amoxicillin)

IUD with pregnancy: Higher proportion ectopic; obtain TVUS; remove if strings visible and intrauterine

Repeat EC use: Safe; not harmful; signals need for LARC

EC and VTE: Not contraindicated — single dose is not chronic OCP

Adolescents: LNG OTC, no age restriction, confidential

Follow-up: Pregnancy test at 3–4 weeks; sooner if menses delayed >7 d

State law variation: Pharmacist refusal allowed in some states with mandatory referral

Cost: UPA $35–60; LNG $10–50 OTC; copper IUD covered by ACA without cost-share

PID after IUD: Treat antibiotics, leave IUD unless no improvement

EC in perimenopause: Indicated until 12 months amenorrhea or age 55

Board Question Stem Patterns

— 24-year-old, BMI 32, condom broke 80 hours ago. Best EC?

— Answer: Copper IUD (most effective regardless of BMI/time); if IUD declined → UPA

— Distractor: LNG (less effective beyond 72 h and at higher BMI)

— Patient with epilepsy on carbamazepine, unprotected sex 24 h ago. Best EC?

— Answer: Copper IUD (CYP3A4 inducer reduces oral EC efficacy)

— Patient asks if EC is an abortion. Best response?

— Answer: Explain EC prevents/delays ovulation; does not affect established pregnancy. This is informed consent.

— Patient took UPA yesterday, wants to start OCPs. When?

— Answer: Wait 5 days, then start, use backup for 7 more days (or until next menses)

— Pharmacist refuses to dispense UPA. Next step?

— Answer: Transfer prescription to another pharmacy; ensure same-day access

— Adult presents 12 h after assault. Management?

— Answer: EC (UPA or LNG or copper IUD) + STI prophylaxis + HIV PEP + hep B + forensic exam + mental health referral; reporting per patient choice

— 16-year-old requests Plan B. Parental consent needed?

— Answer: No — LNG is OTC at any age

— Positive hCG 3 weeks after IUD-EC. Next step?

— Answer: TVUS to localize; if intrauterine and strings visible, remove IUD

— Patient on amoxicillin took her pill regularly, had sex. Need EC?

— Answer: No — amoxicillin does not reduce OCP efficacy

— Patient on third EC use this year. Best next step?

— Answer: Counsel and offer LARC (IUD or implant), nonjudgmentally

Board pearl: When two answer choices both seem reasonable, pick the one with higher efficacy that the patient will accept — usually IUD > UPA > LNG.

Step 3 management: The "correct" answer almost always integrates method choice + transition plan + follow-up, not just the pill.

Pattern 1 — Time and BMI vignette:

Pattern 2 — Drug interaction:

Pattern 3 — Mechanism counseling / religious objection:

Pattern 4 — Transition to ongoing method:

Pattern 5 — Pharmacist refusal:

Pattern 6 — Sexual assault:

Pattern 7 — Adolescent confidentiality:

Pattern 8 — IUD pregnancy:

Pattern 9 — Antibiotic myth:

Pattern 10 — Repeat EC:

One-Line Recap

Emergency contraception prevents pregnancy by delaying or inhibiting ovulation (or, for the copper/LNG IUD, by creating a hostile intrauterine environment) when administered within 120 hours of unprotected intercourse, and the choice among copper IUD, LNG 52 mg IUD, ulipristal acetate, and levonorgestrel is driven by time elapsed, BMI, drug interactions, and the patient's desire for ongoing contraception — with the IUD always being the most effective option.

Board pearl: Memorize 120 h, BMI 26 and 35, 5-day UPA-progestin gap, 3–4 week follow-up hCG — these four numbers answer most Step 3 EC questions.

Step 3 management: Close every EC encounter with a documented ongoing contraception plan, follow-up appointment, and STI/safety screen — the visit is preventive medicine, not just a pill.

Hierarchy of efficacy: Copper IUD ≈ LNG 52 mg IUD > UPA > LNG > Yuzpe — offer the most effective method the patient will accept.

Three discriminators: Time since intercourse (LNG ≤72 h best; UPA and IUD to 120 h), BMI (LNG drops >26; UPA drops >35; IUD unaffected), and CYP3A4 inducers (use IUD).

Always pair EC with: A transition to ongoing contraception (immediate after LNG; wait 5 days after UPA before progestins), STI testing if indicated, and a 3–4 week follow-up pregnancy test.

Counseling non-negotiables: EC is not abortifacient, is not teratogenic if pregnancy already exists, is safe in adolescents (LNG OTC at any age), is appropriate after sexual assault as part of a full bundle, and pharmacist refusal requires same-day referral to maintain the efficacy window.