Can a patient start emergency contraception, such as levonorgestrel (a progestin), when already on oral combined contraceptives (COC) and depot medroxyprogesterone acetate (DMPA)?

Emergency Contraception Use While on Combined Oral Contraceptives and Depot Medroxyprogesterone Acetate

Yes, a patient can and should use emergency contraception even when already on oral combined contraceptives (COC) and depot medroxyprogesterone acetate (DMPA) if there has been unprotected intercourse or contraceptive failure. 1

When Emergency Contraception Is Needed

Emergency contraception is appropriate when:

• Missed or late doses of regular contraception have occurred, particularly if unprotected intercourse happened during the first week of the pill pack or in the previous 5 days 1
• DMPA injection is ≥2 weeks late (≥15 weeks after previous injection) and unprotected intercourse has occurred 1
• Any contraceptive failure has occurred (condom breakage, missed pills, etc.) 2

The fact that a patient is already using hormonal contraception does not preclude the need for emergency contraception if there has been a lapse in coverage or method failure.

Best Emergency Contraception Options

First Choice: Copper IUD

• The copper IUD is the most effective emergency contraceptive and can be inserted up to 5-7 days after unprotected intercourse 3, 4
• Provides ongoing highly effective contraception after insertion 3
• No hormonal interactions with existing COC or DMPA use 1

Second Choice: Ulipristal Acetate (UPA)

• UPA (30 mg single dose) is the most effective oral emergency contraceptive, particularly at 4-5 days after intercourse 3, 5
• Maintains consistent efficacy throughout the full 120-hour (5-day) window 3, 5
• More effective than levonorgestrel in women who are overweight or obese 1, 5

Third Choice: Levonorgestrel

• Levonorgestrel (1.5 mg) is effective but efficacy significantly declines after 72 hours 3, 4
• Less effective in obese women compared to UPA 6
• Should be used as soon as possible, ideally within 72 hours 2

Critical Timing Considerations After Emergency Contraception

After Levonorgestrel Use:

• Resume or start regular contraception immediately 1
• Use barrier method or abstain for 7 consecutive days after restarting hormonal contraception 1

After Ulipristal Acetate Use:

• Any contraceptive method can be started immediately, but this requires special attention 1, 5
• Must use barrier contraception or abstain for 14 consecutive days (or until next menses) after UPA use 1, 3, 5
• This extended backup period is necessary because UPA may reduce the effectiveness of hormonal contraceptives started immediately after its use 5

Restarting Regular Contraception

For a patient already on COC and DMPA:

• Continue the COC as scheduled after emergency contraception use 1
• Ensure DMPA is given on time (within 2 weeks of scheduled injection date) 1
• If DMPA is ≥2 weeks late, treat as a new start with 7 days of backup contraception 1
• The existing hormonal contraception does not interfere with emergency contraception effectiveness 1

Common Pitfalls to Avoid

• Do not delay emergency contraception thinking existing hormonal methods provide adequate protection after missed doses or late injections 1
• Do not forget the 14-day backup period after ulipristal acetate, even though the patient is already on hormonal contraception 3, 5
• Do not assume levonorgestrel is adequate at 4-5 days post-intercourse; UPA or copper IUD are superior choices at this timeframe 3
• Consider BMI when selecting emergency contraception; copper IUD or UPA are preferred for women with BMI >25 kg/m² 6