What is the approach for a patient seeking emergency contraception in an outpatient clinic office?

Emergency Contraception in Outpatient Clinic

Classification of Concern

• Acute, time-sensitive, non-traumatic reproductive health concern requiring intervention within 120 hours (5 days) of unprotected intercourse 1
• Not a medical emergency but effectiveness decreases with time, particularly after 72 hours 1

Concise History (Top Questions)

1. When did unprotected intercourse occur? (Exact date/time - critical for method selection and efficacy) 1
2. Are you currently using any contraception? (Assess for contraceptive failure vs. non-use) 2, 3
3. When was your last menstrual period? (Rule out existing pregnancy, estimate ovulation timing) 1
4. What is your weight/BMI? (Levonorgestrel less effective if BMI >30 kg/m²) 1, 4
5. Do you have any chronic health conditions? (Diabetes, cardiovascular disease, thromboembolism history - affects method eligibility) 5
6. Are you taking any medications? (Anticonvulsants, rifampin reduce oral EC effectiveness) 5
7. Have you had unprotected intercourse at other times this cycle? (May affect copper IUD timing) 1
8. Do you desire ongoing contraception after this episode? (Copper IUD provides both EC and long-term contraception) 1, 6

Differential Diagnosis

Top 3 Dangerous (If Pregnancy Occurs)

• Ectopic pregnancy (risk with any pregnancy, not increased by EC failure) 6
• Pregnancy complications in patients with contraindications to pregnancy (cardiovascular disease, uncontrolled diabetes, thrombophilia) 5
• Pregnancy in context of sexual assault (requires additional trauma-informed care, STI prophylaxis, forensic evaluation) 2

Top 3 Common Presentations

• Contraceptive failure (condom breakage, missed oral contraceptive pills) 2, 3
• Unprotected intercourse without contraception use 2, 3
• Missed or delayed hormonal contraception (>48 hours late on pills, patch, or ring) 1

Top 3 Rare Scenarios

• Drug interaction reducing regular contraceptive efficacy (enzyme-inducing anticonvulsants, rifampin) 5
• Vomiting/diarrhea ≥48 hours affecting oral contraceptive absorption 1
• IUD expulsion discovered after unprotected intercourse 6

Diagnostic Workup

No routine laboratory tests or examinations are required before providing emergency contraception 5

Essential Assessment

• Urine pregnancy test (to rule out pre-existing pregnancy - EC will not terminate established pregnancy) 4, 6
• Calculate BMI (document weight and height for method selection) 1, 4
• Brief medical history review (cardiovascular risk factors, medication list) 5

Additional Testing (Only if Clinically Indicated)

• STI screening if sexual assault or high-risk exposure 6
• Pelvic examination only if considering copper IUD insertion 6
• No imaging, blood work, or hormonal testing required 5

Empiric Treatment Options (Pharmacotherapeutic)

First-Line: Copper IUD (Most Effective)

• Copper IUD insertion within 5 days of unprotected intercourse is the most effective emergency contraception (<1% failure rate) 1, 5, 6
• Can be inserted up to 5 days after estimated ovulation if ovulation timing can be determined 1
• Provides ongoing highly effective contraception for up to 10-12 years 6
• No weight/BMI limitations on efficacy 6

Second-Line: Ulipristal Acetate (Ella) 30 mg

• Single oral dose within 120 hours (5 days) of unprotected intercourse 1, 4
• More effective than levonorgestrel after 72 hours and in women with BMI >25 kg/m² 1, 4
• Observed pregnancy rate 1.9% when taken 0-72 hours, 2.2% when taken 48-120 hours 4
• Requires prescription 4
• Avoid if patient plans to start/continue progestin-containing contraception immediately (may reduce UPA efficacy; wait 5 days before starting hormonal contraception) 6

Third-Line: Levonorgestrel 1.5 mg (Plan B One-Step)

• Single oral dose within 72 hours of unprotected intercourse (can be used up to 120 hours but less effective) 1, 5
• Available over-the-counter without age restrictions 6
• Less effective if BMI >30 kg/m² (observed pregnancy rate 7.4% vs. expected 4.4% in comparative trial) 4
• Can start regular hormonal contraception immediately after levonorgestrel 6

Fourth-Line: Combined Estrogen-Progestin (Yuzpe Method)

• 100 μg ethinyl estradiol + 0.50 mg levonorgestrel, two doses 12 hours apart 1
• Less effective than ulipristal or levonorgestrel and more side effects (nausea, vomiting) 1
• Only use if other methods unavailable 1

Emerging Option: Levonorgestrel 52 mg IUD

• Limited evidence but may be effective for emergency contraception 6
• Requires further research 6

Important Red Flag Symptoms to Discuss

Seek Immediate Care If:

• Severe lower abdominal pain 3-5 weeks after EC use (possible ectopic pregnancy) 6
• Heavy vaginal bleeding with dizziness/syncope (possible ruptured ectopic, hemorrhage) 6
• No menstrual period within 3 weeks of expected date (pregnancy test required) 6
• Severe persistent vomiting within 2 hours of oral EC (may need to repeat dose or use alternative method) 6

Expected Side Effects (Reassure Patient)

• Menstrual cycle changes (next period may be early, late, heavier, or lighter) 4, 6
• Spotting or irregular bleeding in the weeks following EC use 4
• Nausea (10-20% with levonorgestrel, less with ulipristal) 4
• Breast tenderness, headache, fatigue (transient, resolve within days) 4

Critical Counseling Points

• EC does not protect against STIs - discuss condom use 1, 6
• EC is not an abortifacient - will not terminate established pregnancy 6
• Advance provision of EC is recommended for future use 1
• Regular contraception should be initiated/resumed after EC use 6

Natural History/Untreated Prognosis

• Without emergency contraception, pregnancy risk after single unprotected intercourse is 5-6% depending on cycle timing 4
• Risk highest during fertile window (5 days before ovulation through day of ovulation) 1
• Copper IUD reduces pregnancy risk by >99% 1, 6
• Ulipristal reduces pregnancy risk by approximately 65% (from 5.5% expected to 2.2% observed) 4
• Levonorgestrel reduces pregnancy risk by approximately 60-75% when taken within 72 hours 1
• Effectiveness of all oral methods decreases with time from unprotected intercourse 1, 4

Suggested Follow-Up

Immediate (Same Visit)

• Provide or prescribe emergency contraception without delay 1, 6
• Counsel on ongoing contraception options and provide method if desired 6
• Provide advance EC supply for future use 1

Short-Term (3 Weeks)

• Pregnancy test if no menses within 3 weeks of expected date 6
• Return visit not routinely required unless patient desires ongoing contraception counseling 7

Medium-Term (3 Months)

• Follow-up for ongoing contraception if method initiated (assess satisfaction, side effects, adherence) 7
• Blood pressure check if combined hormonal contraception started 7

Long-Term

• Annual well-woman visit for contraceptive counseling, STI screening, and preventive care 6
• No specific long-term monitoring required for EC use itself 6

Common Pitfalls to Avoid

• Do not delay EC provision waiting for laboratory results - pregnancy test and provision can occur simultaneously 5
• Do not withhold EC from adolescents - no age restrictions for any EC method 6
• Do not prescribe combined hormonal contraceptives to patients with cardiovascular risk factors (diabetes, hyperlipidemia, smoking >35 years) - use progestin-only methods 5
• Do not assume levonorgestrel is adequate for all patients - consider BMI and timing when selecting method 1, 4
• Do not forget to discuss that 7 consecutive days of hormonal contraception are needed before relying on regular method after EC use 1