Emergency Contraception for Low-Risk Intercourse
Yes, you should offer emergency contraception despite the low pregnancy risk from condom-protected intercourse without ejaculation, as this provides reassurance and follows standard practice guidelines for any patient requesting emergency contraception after intercourse. 1, 2
Recommended Emergency Contraception Options
First-Line: Levonorgestrel 1.5 mg (Plan B)
For this patient presenting within hours of intercourse, levonorgestrel 1.5 mg as a single dose is the most appropriate option. 1, 2
- Take as a single 1.5 mg dose (or two 0.75 mg tablets together) as soon as possible 1, 2
- Maximum effectiveness occurs within 72 hours, with efficacy decreasing significantly after this window 1, 2, 3
- Prevents approximately 7 out of 8 expected pregnancies when taken as directed 3
- Can be taken up to 120 hours (5 days) after intercourse, though less effective at 4-5 days 1, 2
Weight Considerations
- If the patient weighs >165 lbs (75 kg), ulipristal acetate (UPA) 30 mg is more effective than levonorgestrel 2
- Levonorgestrel may be less effective in obese women regardless of dose 2
Alternative: Ulipristal Acetate (ella) 30 mg
- More effective than levonorgestrel between 72-120 hours post-intercourse 1, 2, 4
- Maintains 65% lower pregnancy risk compared to levonorgestrel throughout the full 120-hour window 2, 5
- Single 30 mg dose 1, 4
- Requires prescription in most settings 4
Most Effective Option: Copper IUD
- The copper IUD is the most effective emergency contraception method with <1% failure rate 1, 2, 5
- Can be inserted within 5 days of intercourse (or up to 5 days after ovulation if timing is known) 1, 5
- Provides ongoing contraception after insertion 1
Post-Emergency Contraception Management
After Levonorgestrel Use
- Patient can resume or start regular contraception immediately 2
- Use barrier method or abstain for 7 days after starting regular contraception 2
- Perform pregnancy test if menses delayed by >1 week 1
After UPA Use
- Start regular contraception immediately 1, 2
- Must use barrier method or abstain for 14 days (or until next menses, whichever comes first) 1, 2
- Pregnancy test if no withdrawal bleed within 3 weeks 1
Special Considerations for PCOS Patients
Previous Diane 35 Use
- The patient's history of Diane 35 (cyproterone acetate/ethinyl estradiol) for PCOS does not contraindicate emergency contraception 6, 7
- Emergency contraception can be given regardless of previous hormonal contraceptive use 1
Resuming Regular Contraception
- If she wishes to restart Diane 35 or another contraceptive, she can begin immediately after levonorgestrel 2
- PCOS patients benefit from combined oral contraceptives for menstrual regulation and hyperandrogenism management 6, 7
Clinical Reassurance Points
Actual Pregnancy Risk Assessment
- Condom use with no ejaculation represents very low pregnancy risk 1
- However, emergency contraception should not be withheld based on perceived low risk when patient requests it 1, 5
- Pre-ejaculate can theoretically contain sperm, though risk is minimal 1
Common Pitfalls to Avoid
- Do not delay administration while debating necessity—efficacy decreases with time for all oral methods 2, 3
- Do not assume emergency contraception is unnecessary based on condom use alone—patient autonomy and anxiety warrant offering it 1
- Do not forget to counsel about the 14-day barrier method requirement if UPA is chosen 1, 2
Practical Algorithm
Within 72 hours + normal weight (<165 lbs): Levonorgestrel 1.5 mg single dose 2
Within 72 hours + weight >165 lbs: Consider UPA 30 mg instead 2
72-120 hours post-intercourse: UPA 30 mg preferred 2, 5
Seeking highest efficacy regardless of timing: Copper IUD insertion 2, 5
For this specific patient (few hours post-intercourse, likely normal weight): Levonorgestrel 1.5 mg is appropriate and immediately available 2