![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Emergency contraception.

#### BIBLIOGRAPHIC SOURCE(S)

Faculty of Family Planning and Reproductive Health Care Clinical
Effectiveness Unit. FFPRHC Guidance (April 2006). Emergency
contraception. J Fam Plann Reprod Health Care 2006 Apr;32(2):121-8; quiz
128. \[65 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16824309)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Faculty of Family Planning
and Reproductive Health Care Clinical Effectiveness Unit. Emergency
contraception. Aberdeen (Scotland): Faculty of Family Planning and
Reproductive Health Care Clinical Effectiveness Unit; 2003 Jun. 7 p.
\[53 references\]

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Unprotected sexual intercourse

-   Sexual intercourse with potential contraceptive failure

-   Unintended pregnancy

-   Sexually transmitted infection (STI)

#### GUIDELINE CATEGORY

Counseling\
Evaluation\
Management\
Prevention\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Obstetrics and Gynecology\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Patients\
Pharmacists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To provide clinicians information on the safe and effective use of
    emergency contraception

-   To update and replace the previous Faculty recommendations on
    emergency contraception

#### TARGET POPULATION

Women seeking emergency contraception

#### INTERVENTIONS AND PRACTICES CONSIDERED

Medical History (Including Sexual History) and Clinical Examination;
Testing for *Chlamydia trachomatis*; Prophylactic Antibiotics

1.  Counseling patients regarding emergency contraception to help them
    make informed choices

2.  Emergency contraception including:

    -   Oral progestogen-only emergency contraception (POEC)
        (levonorgestrel \[Levonelle-2^®^, Levonelle-1500^®^\])

    -   Copper intrauterine contraceptive devices (IUDs)

> **Note**: Mifepristone has been shown to be an effective emergency
> contraception when taken as a single dose up to 120 hours after
> unprotected sexual intercourse. However, it is not licensed nor
> readily available for this indication in the UK.

3.  Follow-up including pregnancy test if needed and information and
    counseling on use of contraceptive methods

#### MAJOR OUTCOMES CONSIDERED

**Safety, Efficacy, and Cost-effectiveness of Emergency Contraception**

-   Failure rates of emergency contraception (EC) methods, unintended
    pregnancy rate

-   Drug interactions and side effects associated with oral hormonal EC

-   Pelvic infection rate after intrauterine device insertion

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Electronic searches were performed for: MEDLINE (CD Ovid version)
(1996--2006); EMBASE (1996--2006); PubMed (1996--2006); The Cochrane
Library (to December 2005) and the US National Guideline Clearing House.
The searches were performed using relevant medical and subject headings
(MeSH), term and text words. The Cochrane Library was searched for
systematic reviews, meta-analyses and controlled trials relevant to
emergency contraception. Previously existing guidelines from the Faculty
of Family Planning and Reproductive Health Care, the Royal College of
Obstetricians and Gynaecologists (RCOG), the World Health Organization,
and reference lists of identified publications were also searched.
Similar search strategies have been used in the development of other
national guidelines.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Selected key publications were appraised according to standard
methodological checklists before conclusions were considered as
evidence. Evidence was graded using a scheme similar to that adopted by
the Royal College of Obstetricians and Gynaecologists (RCOG) and other
guideline development organizations.

Evidence tables (available on the Faculty Web site
\[[www.ffprhc.org.uk](http://www.ffprhc.org.uk/)\]) summarise relevant
published evidence on emergency contraception (EC), which was identified
and appraised in the development of this Guidance.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Draft One Guidance document is written, providing recommendations
and good practice points based on the literature review. The Clinical
Effectiveness Unit must take overall responsibility for writing the
Guidance document. The Multidisciplinary Group and other peer reviewers
should highlight inconsistencies and errors or where the text is
incomprehensible.

A Multidisciplinary Group Meeting is held, comprising stakeholders and
including service user representation, representation from the Faculty
of Family Planning and Reproductive Health Care (FFPRHC) Education
Committee and, where possible, representation from the FFPRHC Clinical
Effectiveness Committee (CEC) and FFPRHC Council. A one-day meeting is
held in Aberdeen with the Multidisciplinary Group to discuss the Draft
One Guidance document.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendations**

**A**: Evidence based on randomised controlled trials (RCTs)

**B**: Evidence based on other robust experimental or observational
studies

**C**: Evidence is limited but the advice relies on expert opinion and
has the endorsement of respected authorities

**Good Practice Point**: Where no evidence exists but where best
practice is based on the clinical experience of the expert group

#### COST ANALYSIS

Emergency contraception (EC) appears to be cost-effective, whether it is
provided on request or as an advance supply to be used when needed. A
greater use of EC could reduce the medical and social costs of
unintended pregnancy.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The Draft Two Guidance document is peer reviewed by the
Multidisciplinary Group and the Faculty of Family Planning and
Reproductive Health Care Clinical Effectiveness Committee (FFPRHC CEC).
All written feedback on the Draft Two Guidance document is tabulated and
the Clinical Effectiveness Unit (CEU) response to these comments is
outlined. The Draft Three Guidance document is prepared on written
feedback and is sent to the Multidisciplinary Group and the FFPRHC CEC.
Only minor comments can be accepted at this stage. The Final Guidance
document is published by the FFPRHC. Proof reading of the Guidance is
then performed by three members of the CEU team independently and
comments collated and sent back by the Unit Director. A PDF version of
the Guidance is made available on the FFPRHC website.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the grades of recommendation, based on levels of evidence
(A-C, Good Practice Point), are provided at the end of the \"Major
Recommendations\" field.

**[When Is Emergency Contraception Indicated?]{.underline}**

1.  The clinician should summarise evidence of effectiveness and the
    need for emergency contraception (EC) in each woman\'s individual
    circumstance to allow her to make an informed choice regarding its
    use (**Good Practice Point**).

**Table. Recommendations for Emergency Contraception Use in Commonly
Occurring Situations**

  -----------------------------------------------------------------------
  **Situation**            **Indications for Emergency Contraception**
  ------------------------ ----------------------------------------------
  **Potential Failures of  
  Various Contraceptive    
  Methods**                

  Combined pills (21       If *three or more* 30 to 35 microgram EE or
  active tablets)          *two or more* 20 microgram EE pills have been
                           missed in the first week of pill taking (i.e.,
                           Days 1 to 7) and UPSI occurred in Week 1 or
                           the pill-free week

  Progestogen-only pill    If *one or more* POPs have been missed or
  (POP)                    taken \>3 hours late (\>12 hours late for
                           Cerazette®) *and* UPSI has occurred in the 2
                           days following this

  Intrauterine             If complete or partial expulsion is identified
  contraception            or mid-cycle removal of an IUD/IUS is deemed
                           necessary *and* UPSI has occurred in the last
                           7 days

  Progestogen-only         If the contraceptive injection is late (\>14
  injectables              weeks from the previous injection for
                           medroxyprogesterone acetate or \>10 weeks for
                           norethisterone enantate) *and* UPSI has
                           occurred

  Barrier methods          If there has been failure of a barrier method

  **Use of Liver Enzyme    
  Inducers**               

  Liver enzyme inducing    An additional barrier method is recommended if
  drugs (including St.     oral contraceptives, progestogen implants or
  John\'s Wort)            contraceptive patch and liver enzyme-inducers
                           are taken concurrently. EC is indicated if
                           there is UPSI or barrier method failure
                           during, or in the 28 days following, use of
                           liver enzyme-inducers
  -----------------------------------------------------------------------

EC, emergency contraception; EE, ethinylestradiol; IUD, intrauterine
device; IUS, intrauterine system; POP, progestogen-only pill; UPSI,
unprotected sexual intercourse.

**[What Regimens of Oral Hormonal Emergency Contraception Are
Available?]{.underline}**

2.  Levonorgestrel (LNG) should be given as a single 1.5 mg dose as soon
    as possible after unprotected sexual intercourse (UPSI), and within
    72 hours (**Grade A**).

**[How Effective Is Emergency Contraception and How Can Efficacy Be
Optimised?]{.underline}**

3.  Women should be given written and verbal information regarding the
    failure rates of oral and intrauterine EC to allow them to make
    informed choices and to increase compliance and efficacy (**Grade
    A**).

4.  LNG EC may be considered between 73 and 120 hours after UPSI, but
    women should be informed of the limited evidence of efficacy, that
    such use is outside product licence, and the alternative of an IUD
    (**Good Practice Point**).

5.  Women can be advised that LNG EC can be used more than once in a
    cycle if clinically indicated (**Good Practice Point**).

6.  An intrauterine device (IUD) (or advice on how to obtain one) should
    be offered to all women attending for EC even if presenting within
    72 hours of UPSI (**Good Practice Point**).

7.  IUDs with banded copper on the arms and containing at least 380
    mm^2^ of copper have the lowest failure rates and should be the
    first-line choice, particularly if the woman intends to continue the
    IUD as long-term contraception (**Grade A**).

8.  Ideally, an emergency IUD should be fitted at first presentation,
    but insertion can be offered later, at the woman\'s convenience. In
    this case, LNG EC should be given in the interim (**Good Practice
    Point**).

9.  If facilities are unavailable for emergency IUD insertion, local
    referral mechanisms should facilitate timely access to a specialist
    who can provide this service (**Good Practice Point**).

10. A copper IUD can be inserted up to 5 days after the first episode of
    UPSI. If the timing of ovulation can be estimated, insertion can be
    beyond 5 days of UPSI, as long as it does not occur beyond 5 days
    after ovulation (**Grade C**).

**[Are There Any Contraindications to Emergency
Contraception?]{.underline}**

11. The World Health Organization *Medical Eligibility Criteria for
    Contraceptive Use* advises that there are no medical
    contraindications to the use of hormonal EC (**Grade C**).

**[What Drug Interactions Are Relevant to Emergency Contraceptive
Use?]{.underline}**

12. Women using liver enzyme-inducing drugs should be advised that an
    IUD is the preferred option for EC (**Grade A**).

13. Women who are using liver enzyme-inducing drugs who are given 0.75
    mg tablets of LNG (Levonelle-2) should be advised to take a total of
    2.25 mg (three tablets) as a single dose, as soon as possible and
    within 72 hours of UPSI. This use is outside the product licence
    (**Grade C**).

14. Women who are using liver enzyme-inducing drugs who are given 1.5 mg
    tablets of LNG (Levonelle One Step or Levonelle 1500) should be
    advised to take a total of 3 mg (two tablets) as a single dose, as
    soon as possible and within the 72 hours of UPSI. This use is
    outside the product licence (**Good Practice Point**).

15. Women using non-liver enzyme-inducing antibiotics (short- or
    long-term) should follow the normal LNG regimen (1.5 mg within 72
    hours of UPSI) (**Grade C**).

16. There are no drugs that are known to affect emergency IUD use
    (**Grade C**).

**[What Clinical Examinations and Investigations Are Required Before
Providing Emergency Contraception?]{.underline}**

17. A sexual history should be taken from all women attending for EC to
    assess risk of sexually-transmitted infections (STIs) (**Grade C**).

18. Prior to emergency IUD insertion, women at higher risk of STIs (age
    \<25 years, change in sexual partner, or more than one partner in
    the last year) should be offered testing for *Chlamydia trachomatis*
    (as a minimum) (**Grade C**).

19. For women assessed as being at higher risk of STIs, if results of
    testing are not available at the time of emergency IUD insertion,
    the use of prophylactic antibiotics may be considered (**Good
    Practice Point**).

**[What Are the Side Effects of Emergency Contraception?]{.underline}**

20. Women who experience vomiting within 2 hours of administration of
    LNG EC should be advised to return as soon as possible for a repeat
    dose (**Good Practice Point**).

21. Women should be advised that a small increase in pelvic infection
    occurs in the 20 days following IUD insertion, but the risk is the
    same as for the non-IUD-using population thereafter (**Grade A**).

**[What Aftercare and Follow-Up Is Required?]{.underline}**

22. Women should be given information and counselling on use of their
    future contraceptive method of choice (**Good Practice Point**).

23. LNG EC does not provide contraceptive cover for the remainder of the
    cycle and effective contraception or abstinence must be advised
    (**Grade B**).

24. Women should be advised to have a pregnancy test if their expected
    menstruation is more than 7 days late, or lighter than usual
    (**Grade B**).

25. An emergency IUD can be removed at any time after the next
    menstruation if no UPSI has occurred since menses or if hormonal
    contraception was started within the first 5 days of that cycle
    (**Grade C**).

**[Who Can Supply Emergency Contraception?]{.underline}**

26. Patient group directions (PGDs) can be developed to allow nurses and
    other health care professionals to supply and administer
    contraceptives. PGDs may include use outside the terms of the
    product licence provided such use is justified by current best
    practice; the PGD clearly describes the status of use outside the
    licence; and the documentation includes the reason why such use is
    necessary (**Grade C**).

**[Emergency Contraception and Young People]{.underline}**

27. If a young person is assessed for competency, this should be
    documented in case notes as being \'Fraser ruling competent\'
    (advice understood, will have or continue to have sex, advised to
    inform parents, in best interest) (**Grade C**).

**[Should Emergency Contraception Be Supplied in Advance of
Need?]{.underline}**

28. Advance provision of LNG can be offered to women to increase early
    use when required (**Grade A**).

**[Definitions]{.underline}**:

Grades of Recommendation based on levels of evidence as follows:

**A**: Evidence based on randomised controlled trials (RCTs)

**B**: Evidence based on other robust experimental or observational
studies

**C**: Evidence is limited but the advice relies on expert opinion and
has the endorsement of respected authorities

**Good Practice Point**: Where no evidence exists but where best
practice is based on the clinical experience of the Expert Group

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified for each recommendation
(see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate use of emergency contraception

-   Prevention of unintended pregnancy

#### POTENTIAL HARMS

-   Oral and intrauterine emergency contraception (EC) methods can fail
    and result in unintended pregnancy.

-   Women may experience nausea and vomiting after administration of
    levonorgestrel (LNG) EC.

-   Disturbances in the menstrual cycle are common after LNG EC. It may
    be difficult to differentiate between non-menstrual bleeding in the
    early days after EC and actual menstruation. Clinicians and women
    should always err on the side of caution, and undertake pregnancy
    testing if there is any doubt that menstruation has followed EC use.

-   The Summary of Product Characteristics advises caution in use of LNG
    in women with hepatic dysfunction, hereditary problems of galactose
    intolerance, the Lapp lactose deficiency or glucose-galactose
    malabsorption. Women with severe malabsorption syndromes (such as
    Crohn\'s disease) may experience a reduction in efficacy of oral EC.
    Additionally, any women known to have hypersensitivity to LNG or any
    of the other components of the tablet should use oral EC with
    caution.

-   Liver-enzyme inducing drugs (including the herbal remedy, St John\'s
    Wort) may reduce the efficacy of hormonal contraceptives by
    increasing the metabolism of ethinylestradiol and progestogens.

-   A small increase in pelvic infection occurs in the 20 days following
    intrauterine device (IUD) insertion, but the risk is the same as for
    the non-IUD-using population thereafter.

-   Caution is advised when prescribing oral EC for women using the
    anticoagulant drugs, phenindione and warfarin. It has been observed
    that anticoagulant effects may be altered following LNG use. Women
    should be advised about potential drug interactions and attention
    should be paid to their anticoagulation monitoring.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Use of an intrauterine device for emergency contraception (EC) carries
the same contraindications as does routine intrauterine device (IUD)
insertion (refer to the National Guideline Clearinghouse \[NGC\] summary
of the Faculty of Sexual and Reproductive Healthcare \[FFPRHC\]
guideline [The Copper Intrauterine Device as Long-Term
Contraception](http://www.guideline.gov/summary/summary.aspx?doc_id=7102&nbr=4274)).

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Faculty of Family Planning and Reproductive Health Care Clinical
Effectiveness Unit. FFPRHC Guidance (April 2006). Emergency
contraception. J Fam Plann Reprod Health Care 2006 Apr;32(2):121-8; quiz
128. \[65 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16824309)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Jun (revised 2006 Apr)

#### GUIDELINE DEVELOPER(S)

Faculty of Sexual and Reproductive Healthcare - Professional Association

#### SOURCE(S) OF FUNDING

Faculty of Sexual and Reproductive Healthcare

#### GUIDELINE COMMITTEE

Clinical Effectiveness Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Clinical Effectiveness Unit (CEU)*: Ms Lisa Allerton (Research
Assistant), Dr Gillian Penney (Director), Dr Susan Brechin
(Co-ordinator) and Ms Gillian Stephen (Research Assistant) Ms Lisa
Allerton (Research Assistant), Dr Gillian Penney (Director), Dr Susan
Brechin (Co-ordinator) and Ms Gillian Stephen (Research Assistant)

*Clinical Effectiveness Committee*: Dr Kirsten Black (Associate
Specialist, Lambeth Primary Care Trust), Dr Karen Fairhurst (Senior
Lecturer, Divison of Community Health Science -- GP section, University
of Edinburgh), Dr Gillian Flett (Consultant in Sexual and Reproductive
Health, Square 13, Centre for Sexual and Reproductive Health, NHS
Grampian, Aberdeen), Ms Lorraine Forster (Clinical Governance
Coordinator, Sandyford Initiative, Glasgow), Dr Noreen Khan (Consultant
in Community Gynaecology and Sexual Health, Charlestown Sexual Health
Clinics, North Manchester PCT) and Dr Anne Webb (Consultant in Family
Planning and Reproductive Health Care, Abacus Clinics for Contraception
and Sexual Health, Liverpool)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Faculty of Family Planning
and Reproductive Health Care Clinical Effectiveness Unit. Emergency
contraception. Aberdeen (Scotland): Faculty of Family Planning and
Reproductive Health Care Clinical Effectiveness Unit; 2003 Jun. 7 p.
\[53 references\]

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Faculty of Sexual and Reproductive Healthcare Web
site](http://www.ffprhc.org.uk/admin/uploads/449_EmergencyContraceptionCEUguidance.pdf).

Print copies: Available from the Faculty of Sexual and Reproductive
Healthcare, 27 Sussex Place, Regent\'s Park, London NW1 4RG

#### AVAILABILITY OF COMPANION DOCUMENTS

Discussion points and questions for the first prescription of emergency
contraception developed by the Faculty of Sexual and Reproductive
Healthcare are available at the end of the original guideline document.

Electronic copies: Available in Portable Document Format (PDF) from the
[Faculty of Sexual and Reproductive Healthcare Web
site](http://www.ffprhc.org.uk/admin/uploads/449_EmergencyContraceptionCEUguidance.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on July 5, 2005. This summary was
updated by ECRI Institute on May 15, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008