Contraceptive Pearl: Starting Hormonal Contraception After Emergency Contraception
There are more and more options for emergency contraception (EC) available for patients. Not only do we have levonorgestrel (LNG) 1.5mg pills, ulipristal acetate 30mg pills, and the copper IUD (Cu-IUD), recent studies have shown that the 52mg progestin IUD can be used for EC up to 5 days after unprotected intercourse. While it’s great that there are more and more options available, this also makes starting hormonal contraception after EC a bit more complicated.
Levonorgestrel Pills (LNG):
This form of EC contains a progestin that can be found in different types of hormonal contraception. People wishing to start contraception after taking LNG 1.5mg can start any hormonal method of contraception immediately. This includes the pill, patch, ring, progestin injection (Depo), and implant. Although some prefer to wait for a negative pregnancy test post-EC, there is no need to delay starting any of the hormonal methods mentioned above as they do not contain any hormones that will harm a pregnancy, and they don’t change the effectiveness of the LNG EC. It is important to counsel patients that they should still take a pregnancy test in 2-3 weeks. Prompt diagnosis of a pregnancy allows a person to consider their options and form a plan that’s best for them.
Ulipristal Acetate Pills:
This form of EC is a selective progesterone receptor modulator with antagonistic and partial agonistic effects. Because of its antagonistic effects on progesterone, it is possible for ulipristal acetate to decrease the effectiveness of hormonal contraceptives and vice versa. It’s recommended to delay the start of hormonal contraception for at least 5 days after taking this form of EC.
For clinician-dependent methods, such as an implant or IUD, where delaying initiation would require a person to return to the clinic after 5 days, it’s important to weigh the possibility of decreased effectiveness against the burden of an additional clinic visit. In cases where returning to the clinic in 5 days time is too burdensome, the desired method of contraception can be placed the same day EC is taken. Patients who choose this option should be counseled to use a backup method for 7 days and about the increased risk of pregnancy due to this possible interaction.
For a method like progestin injection/Depo, clinicians should consider dispensing or providing a prescription for the subcutaneous version and educating the patient on self-injection. This allows a patient to wait the recommended 5 days and administer their own injection rather than returning to the clinic. For patients who prefer the intramuscular version of Depo, the same consideration should be made as with other clinician-dependent methods.
Since this form of EC also functions as a non-hormonal birth control method, there is no need to consider the timing of initiation for hormonal contraception. Once this form of EC is placed, it is effective in preventing pregnancy immediately.
This form of EC also serves as a hormonal method of birth control. Similarly to the copper IUD, there is no need to consider when to initiate other forms of hormonal contraception. This IUD is also immediately effective in preventing pregnancy once it is placed.
A note on irregular bleeding
All forms of EC including the IUDs can cause a change in a person’s bleeding pattern. The same is true when hormonal contraception is initiated after taking EC. It’s important to advise patients of this ahead of time. Some patients may falsely assume that any bleeding after taking EC is a menses which can lead to false reassurance that they are not pregnant. This may be especially true for adolescents and people who are taking EC for the first time. The irregular bleeding caused by EC can also trigger gender dysphoria for transgender and gender-diverse people. This can be particularly troublesome for someone who has been amenorrheic while on testosterone. Anticipatory guidance and use of a nonsteroidal anti-inflammatory, when needed, can help to reduce distress and confusion for all patients.
Emergency Contraception Pill User Guide
Emergency Contraception: Which EC is Right for Me?
Your Birth Control Choices Fact Sheet
Emergency Contraception. Cdc.gov. Published October 6, 2019. Accessed July 19, 2021. https://www.cdc.gov/
Hatcher RA, Trussell J, Stewart FH, et al. Contraceptive Technology. 21st ed. Managing Contraception; 2018.
Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception. N Engl J Med. 2021;384(4):335-344. doi:10.1056/NEJMoa2022141
The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or contraception. The information in the Contraceptive Pearls is unbiased, based on science alone.