Client assessment and management protocol

• If a woman opts for forensic examination and chooses Cu-IUD as EC, clinical examination and insertion should be deferred until after this examination. Antibiotic cover needs to be considered.
• If a woman elects to have a Cu-IUD as EC, prescribe oral EC in case Cu-IUD fitting is delayed or she changes her mind.
• Please ensure that the client is offered EC/STI testing if her care is transferred to Forensic Medical Examiners.

• Please follow local guidance for this form. Some units inform the Young People (YP) Team of all attendances aged below 16 years.
• Complete a Young Peoples Risk Assessment on NaSH.
• All methods of EC, including Cu-IUD, should be offered to adolescent women.

• STI risk assessment should be made and testing offered as appropriate, taking window periods into consideration.
• Antibiotic cover may be considered for Cu-IUD insertion if there is a significant risk of STI that could be associated with ascending pelvic infection.

Enzyme inducers

• The effectiveness of oral EC may be reduced in those taking drugs which are enzyme inducers and Cu-IUD should be recommended to these women.
• If oral EC is chosen, 3mg LNG should be considered, but the woman should be informed that the effectiveness of this regimen is unknown. There is no evidence to support an increased dose of UPA-EC.

Progestogen-containing drugs

• Effectiveness of UPA-EC could theoretically be reduced if any progestogen-containing drug has been taken in the 7 days prior to EC use.
• The increased efficacy of UPA over LNG must be balanced against the theoretical reduced efficacy of prior progestogen, taking into consideration any quick starting plans. Please see the quick starting protocol.
• An exception to this is in established CHC users who have missed pills, patch removal, or ring removal in days 2 to 7 of week 1 after hormone-free week. They can restart the method immediately after UPA-EC and use additional precautions for next 7 days (9 if Qlaira) All products containing a progestogen or progesterone should be avoided in the 5 days after taking UPA-EC.

Severe asthma

• UPA-EC is not suitable for any woman with asthma controlled by oral glucocorticoids.

Breast feeding

• There is a higher rate of uterine perforation during Cu-IUD insertion in breastfeeding women.
• Breastfeeding women should be advised not to breastfeed and to express and discard
  milk for a week after they have taken UPA-EC.
• LNG-EC has not been shown to affect breast milk.

Previous EC use in cycle

• If already taken UPA-EC once or more in a cycle, can offer UPA-EC again after further UPSI in the same cycle.
• If already taken LNG-EC once or more in a cycle, can offer LNG-EC again after further UPSI in the same cycle.
• If a woman has already taken UPA-EC, LNG-EC should not be taken in the following 5 days.
• If a woman has already taken LNG-EC, UPA-EC could theoretically be less effective if taken in the following 7 days.

If weight is greater than 70kg or BMI greater than 26 kg/m², Cu-IUD remains the 1st choice. If not acceptable, offer UPA-EC. If not appropriate offer double dose LNG-EC.

These aid the decision to which method of EC is the most appropriate. However, the final choice must take into consideration client choice and whether there is also quick-starting of an ongoing contraceptive method. See this table for more information.

a. Cu-IUD EC

• The most effective method, and the only method effective after ovulation.
• Contraindications are the same as for any routine Cu-IUD insertion.
• Also provides ongoing contraception.

b. UPA-EC

• Has been shown to be effective up to 120 hours after UPSI. Always more effective than LNG-EC.
• Can be given more than once in a cycle. However, if UPA-EC has already been given in the cycle LNG-EC should not be given in the following 5 days.
• If UPSI has occurred in the 5 days prior to ovulation, this should be the first line oral EC if a Cu-IUD has been declined.
• Women must wait 5 days after UPA-EC before starting ongoing hormonal contraception.
  • The exception to this is established CHC users who:
    • commenced method correctly on day 1 after hormone free week, and
    • had pill failure (or similar patch or ring failure) on days 2-7 of week 1 only.     

The method can be restarted immediately, then use condoms for 7 days (9 days for Qlaira).

• During this period condoms or abstinence must be used reliably. See quick start protocol for more information.

c. LNG-EC

• This is licensed for up to 72 hours following UPSI. Evidence suggests it is ineffective after 96 hours.
• It can be given more than once in a cycle, but if further EC is required there is a theoretical reduced effectiveness of UPA-EC if given in the following 7 days.
• Hormonal contraception can be started immediately after LNG-EC. This makes LNG-EC the more suitable oral EC if there is likely to be further UPSI in the cycle due to a delay in commencing an ongoing method. See quick start protocol for more information.

Discuss future contraception, quick starting contraception, and safer sex/infection risks.

Arrange future appointments for STI testing, pregnancy testing, and ongoing contraception as appropriate following the consultation.

• Advise women that if they vomit within 3 hours of taking oral EC, they should return for a repeat prescription.
• Advise women to take a pregnancy test 21 days following last UPSI to assess their pregnancy status.

Record consultation notes and any prescriptions on NaSH, including whether EC was off license.