Quick starting contraception

a) Quick starting if pregnancy can be excluded

• Any method of contraception can be quick started at any time in the menstrual cycle if it is reasonably certain that a woman is not pregnant or at risk of pregnancy from recent unprotected sexual intercourse (UPSI). See below.
• HCPs can be ‘reasonably certain’ that a woman is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:
• She has had no intercourse since last normal (natural) menses, since childbirth, abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease.
• She has been correctly and consistently using a reliable method of contraception.
• Is within the first 5 days of the onset of a normal menstrual period.
• Is less than 21 days post-partum (non-breast feeding women).
• Is fully breast feeding, amenorrhoeic and less than 6 months post partum.
• Is within the first 5 days after abortion, miscarriage, ectopic or uterine evacuation for gestational trophoblastic disease.
• Has had no intercourse for more than 21 days and has a negative high sensitivity urine pregnancy test (HSUPT; able to detect hcg levels around 20mIU/ml).

b) Quick Starting if pregnancy cannot be excluded

• Women who have a HSUPT but are at risk of pregnancy from recent UPSI should be advised that:
• Emergency contraception may be indicated.
• Contraceptive hormones are not thought to cause harm to the fetus and they should not be advised to terminate pregnancy on the grounds of exposure.
• Additional contraceptive precautions (barrier or abstinence) are required until the quick started contraceptive method becomes effective. See summary of additional contraceptive requirements table, below.
• A follow up pregnancy test is required no sooner than 21 days after the last UPSI. Provide a pregnancy testing kit or inform of alternative options for pregnancy testing, including local providers of free testing.
• She should return if there are any concerns or problems with contraception.

FSRH Guidance advises that women should be informed that contraceptive hormones are not thought to cause harm to the fetus and they should not be advised to terminate pregnancy on the grounds of exposure.

Wish to continue with the pregnancy (using CHC, POP, IMP, DMPA).

• CHC or POP should be stopped immediately. Implants should be removed promptly if a pregnancy is diagnosed after starting contraception.

Choose not to continue with the pregnancy

• IMP or DMPA:
  Women can continue the method of contraception with no additional contraception precautions after abortion. If DMPA administered at time of mifepristone there may be a slightly higher risk of continuing pregnancy (failed termination).
• CHC or POP:
  Women should stop method and restart contraception immediately after abortion with no additional contraception requirements.
• Using intrauterine contraception (IUC):
  HCPs should advise women whose intrauterine pregnancy is less than 12 weeks gestation that IUC should be removed, as long as the threads are visible or it can be easily removed from the endocervical canal. This is regardless of whether the woman decides to continue with the pregnancy or not. The risk of adverse intrauterine pregnancy events are greater with an IUC insitu compared to those without. IUC removal in first trimester could improve pregnancy outcomes, but it is associated with a small risk of miscarriage.

Quick starting hormonal contraception without being reasonably sure pregnancy is excluded is outside the terms of the product license, however, the FSRH support QS contraception as outlined in their guidance.

The General Medical Council advises that, when prescribing a licensed medication for use outside the terms of the product licence: in emergencies or where there is no realistic alternative treatment and such information is likely to cause distress, it may not be practical or necessary to draw attention to the licence. In other cases, where prescribing unlicensed medicines is supported by authoritative clinical guidance, it may be sufficient to describe in general terms why the medicine is not licensed for the proposed use or patient population.

The Nursing and Midwifery Council advises that nurse or midwife independent prescribers may prescribe outside the product licence if they are satisfied that this better serves the patient/client’s needs, and there is a sufficient evidence base. The patient/client should understand the reasons why such medicines are not licensed for this proposed use, and this should be documented accordingly.

The NMC also states it is acceptable for medicines used outside the terms of the licence to be included in patient group directions (PGDs) when such use is justified by current best clinical practice and the direction clearly describes the status of the product.

NB: After ulipristal acetate emergency contraception wait at least 5 days before starting any hormonal contraception

*Day 1 defined as first day of menstrual bleeding; does not apply to withdrawal or unscheduled bleeding in women already established on hormonal contraception

1. FSRH Clinical Effectiveness Unit. FSRH Clinical Guideline: Quick Starting Contraception [Internet]. The Faculty of Sexual and Reproductive Healthcare; 2017 Apr [cited 2024 May]. https://www.fsrh.org/standards-and-guidance/documents/fsrh-clinical-guidance-quick-starting-contraception-april-2017/
2. General Medical Council. Good practice in prescribing and managing medicines and devices [Internet]. General Medical Council; 2013 Jan [updated 2021 Apr; cited 2024 May]. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-practice-in-prescribing-and-managing-medicines-and-devices
3. NMC Standards for medicines management May 2018 https://www.nmc.org.uk/standards/standards-for-post-registration/standards-for-prescribers/standards-for-prescribing-programmes/[cited 2024 May]