Management of Patient Not Interested in Emergency Contraception
When a patient declines emergency contraception after unprotected intercourse, focus immediately on establishing effective ongoing contraception to prevent future unintended pregnancies and counsel on barrier methods for STI prevention. 1
Immediate Steps
Respect Patient Autonomy
- Document the patient's informed refusal of emergency contraception 1
- Ensure the patient understands that emergency contraception remains an option if reconsidered within the appropriate timeframe (up to 5 days for ECPs, up to 5 days for Cu-IUD insertion) 1
Initiate Contraceptive Counseling
Immediately transition to discussing and implementing highly effective ongoing contraceptive methods to prevent future pregnancy risk. 1
Contraceptive Method Selection Algorithm
First-Tier: Long-Acting Reversible Contraception (LARC)
Prioritize IUDs (copper or progestin) or progestin implants as they are the most effective methods with lowest user-dependency. 1
- IUDs are appropriate even for women on immunosuppressive therapy 1
- Copper IUD provides immediate contraception and can serve dual purpose if patient changes mind about emergency contraception within 5 days 1
- Progestin implant offers 3-year protection with failure rate <1% 1
Second-Tier: Hormonal Methods
If LARC methods are declined or contraindicated:
- Combined oral contraceptives (20-30 μg ethinyl estradiol with levonorgestrel) for patients without contraindications 2
- Progestin-only pills for patients with estrogen contraindications 1
- Injectable depot medroxyprogesterone acetate (DMPA) - avoid in patients at risk for osteoporosis 1
- Transdermal patch or vaginal ring 1
Third-Tier: Barrier Methods
Recommend barrier methods (condoms) if more effective methods are contraindicated or declined, emphasizing dual protection against pregnancy and STIs. 1
Special Considerations
Assess for Contraindications
- For patients with positive antiphospholipid antibodies: avoid combined estrogen-progestin contraceptives; use IUDs (preferred) or progestin-only pills 1
- For patients on mycophenolate: require IUD or combination of two other contraceptive forms 1
Provide Advance Emergency Contraception Supply
Offer an advance supply of emergency contraceptive pills so they are available for future use if needed, as this increases likelihood of timely use. 1
- Studies show 2-7 times greater ECP use when provided in advance 1
- Does not decrease use of regular contraception 1
Ongoing Contraceptive Education
Missed Pill Protocol (if oral contraceptives chosen)
- One pill late (<24 hours): Take immediately, continue regular schedule 2
- One pill missed (24-48 hours): Take most recent missed pill immediately, use backup contraception for 7 days 2
- Two or more pills missed (≥48 hours): Take most recent missed pill, discard others, use backup contraception for 7 consecutive days 2
Backup Contraception Guidance
Counsel that backup contraception (condoms) or abstinence is required for 7 consecutive days after missed pills or gastrointestinal illness affecting pill absorption. 1
Common Pitfalls to Avoid
- Do not simply accept refusal without establishing ongoing contraception - this leaves the patient at continued risk for unintended pregnancy 1
- Do not fail to document the discussion and patient's informed decision 1
- Do not neglect STI risk assessment and barrier method counseling - contraception alone does not prevent infections 1
- Do not recommend fertility awareness methods (Standard Days Method) for patients with irregular cycles (<26 or >32 days) as pregnancy risk is significantly higher 1
Follow-Up Planning
- Schedule follow-up visit for LARC insertion if not performed same-day 1
- Provide written instructions for chosen contraceptive method 1
- Ensure patient has access to emergency contraception information for future reference 1
- Discuss contraception and pregnancy planning at every visit with women of reproductive age 1