Emergency Contraception Counselling – OSCE Guide

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Contraceptive counselling often features in OSCEs, and it’s therefore important to be familiar with the various methods of contraception available. This article focuses on counselling patients about emergency contraception, including the common questions patients ask, the answers you’ll be expected to articulate and how best to structure the consultation. This guide should not be used to inform clinical decision-making. It is for educational purposes only.


About emergency contraception

Emergency contraception (EC) should be offered if someone has had unprotected sexual intercourse (UPSI) or if they think their contraception may have failed. It is used soon after UPSI to try and prevent a pregnancy from occurring. Emergency contraception is not an abortive device.

There are three main types of emergency contraception in the UK:

  • The copper intrauterine device, also known as the “copper coil” or “Cu-IUD”
  • Ulipristal acetate (UPA) 30mg tablet, brand names include EllaOne®, also known as “the morning-after pill”
  • Levonorgestrel (LNG) 1.5mg tablet, brand names include Levonelle®, also known as “the morning after pill”, “plan B”, or “one-step”

Each of these types of emergency contraception will be explained in this article.

Emergency contraception is free from the following places:

  • Any GP clinic that provides contraceptive services
  • Any sexual health or most genitourinary medicine clinics
  • Any young person’s service
  • NHS walk-in centres
  • Many pharmacies
  • Some emergency departments
When should emergency contraception be considered?

Emergency contraception should be considered where UPSI has occurred in a patient not using contraception, who does not wish to become pregnant. EC should be offered irrespective of where a patient is in their cycle, although the chances of pregnancy will vary depending on where the patient was in their cycle at the time of sex. 

This also includes following pregnancy:

  • From day 21 postnatally (unless meets criteria for lactational amenorrhoea)
  • From day 5 after miscarriage, termination of pregnancy or ectopic pregnancy

It should also be considered when contraception has been used incorrectly (e.g. missed pills, expired implant etc.)

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Types of emergency contraception

Copper intrauterine device (IUD)

The copper IUD, also called the copper coil (Cu-IUD), can be used for emergency and non-emergency contraception. For more information, see our guide to copper coil counselling.

What is the copper IUD?

A Cu-IUD is a small T-shaped plastic and copper device inserted into the womb during a small procedure. 

All eligible patients should be offered the copper IUD as a form of emergency contraception.

How does the copper IUD work?

The Cu-IUD has an inhibitory effect on both fertilisation and implantation. Fertilisation inhibition occurs through the direct toxicity effects of copper on both the ovum and sperm. This toxic effect prevents pregnancy. If fertilisation does occur, the inflammatory reaction within the endometrium prevents implantation.

As the Cu-IUD may prevent pregnancy by preventing implantation, it is important to explain the mechanism as some patients may have personal, cultural, or religious beliefs and want to avoid this method. However, under UK law, pregnancy begins at implantation, not before and therefore this is not considered a termination of pregnancy.

When can the copper IUD be used?

The Cu-IUD can be inserted for emergency contraception within 5 days of the earliest expected date of ovulation regardless of the number of episodes of UPSI leading to that point. 

Alternatively, up to 5 days (120 hours) after unprotected sex within that menstrual cycle, providing there is no other UPSI earlier in the cycle.

How do I work out someone’s earliest likely ovulation date?

Ovulation occurs 14 days before menses. The earliest likely ovulation date is calculated by taking the patient’s shortest cycle length and subtracting 14. For example, a patient with a 30-day cycle will have an earliest likely ovulation date of day 16 (30 – 14).

How effective is the copper IUD?

When inserted at the correct time, the Cu-IUD is the most effective form of emergency contraception.

What are the risks or side effects of the copper IUD?

The risks associated with IUD insertion are the same whether the Cu-IUD is used for emergency or non-emergency contraception. For more information, see our guide to copper coil counselling.

Advantages and disadvantages

Advantages include:

  • Safe and well tolerated
  • More effective than oral methods
  • Effective even if fertilisation has occurred as it prevents implantation, therefore has a longer window of use
  • Immediately effective as ongoing contraception
  • It can be left in place for between 5 to 10 years, depending on the coil inserted, to provide ongoing contraception
  • Not affected by enzyme-inducing medication or weight/BMI

Disadvantages include:

  • It is not as easily accessible as oral methods as a procedure is required to insert it, which needs to be arranged through sexual health services or the GP
  • Cu-IUD can make periods heavier and longer and may not be an acceptable method for patients with pre-existing heavy menstrual bleeding or painful periods (dysmenorrhoea)

Levonorgestrel (Levonelle®)

What is Levonorgestrel Emergency Contraception (LNG-EC)?

Levonorgestrel (LNG) is a tablet containing 1.5mg of levonorgestrel, a synthetic progestogen. It is taken as a one-off dose.

How does Levonorgestrel work?

LNG-EC works by inhibiting ovulation for the next 5 days. By the time ovulation happens, any sperm in the reproductive tract will no longer be viable. 

When can LNG-EC be taken?

LNG should be taken within 72 hours of UPSI. The longer the delay, the less effective LNG is. LNG is licensed for up to 72 hours but can be used until 96 hours, although this is unlicensed.

How effective is LNG-EC?

Oral EC is not effective after ovulation due to the mechanism of action. It is difficult to quantify how effective oral methods of EC are as many other factors are at play, for example, where the patient is in their cycle, the number of episodes of UPSI, whether the patient has already ovulated etc.

What are the risks or side effects of LNG-EC?

LNG-EC is a very safe medication. It can commonly cause nausea, vomiting, and delayed or early menses. If the patient vomits within 3 hours of taking LNG-EC, they must repeat the dose.

There are no known risks to an early pregnancy with LNG-EC.

Advantages of LNG-EC

  • Safe and well tolerated medication with generally few side effects
  • It is safe for breastfeeding patients, and patients can continue breastfeeding after using LNG-EC
  • Other methods of contraception, for example, the POP, can be started immediately after taking LNG-EC, and this is called quick-starting
  • LNG is not affected by other progestogen use i.e. it can be used alongside other hormonal contraception, for example if pills were missed

Disadvantages of LNG-EC

  • LNG-EC is less effective if the patient is taking enzyme-inducing medication, or has a BMI of >26 or a weight of >70kg
  • If the above applies, a double dose of 3mg LNG-EC should be used, but the effectiveness is unknown
  • LNG-EC is ineffective if the LH surge has begun

Ulipristal acetate Emergency Contraception (EllaOne®)

What is Ulipristal acetate Emergency Contraception (UPA-EC)?

Ulipristal acetate (UPA) is a tablet containing 30mg of ulipristal acetate, a selective progesterone receptor modulator. It is taken as a one-off dose.

How does UPA-EC work?

UPA, like LNG, works by delaying ovulation for up to 5 days.

Unlike LNG, UPA will delay ovulation even at the start of the LH surge. By the time ovulation happens, any sperm in the reproductive tract will no longer be viable. 

When can UPA-EC be taken?

UPA-EC can be taken within 120 hours, or 5 days, of UPSI.

How effective is UPA-EC?

Oral EC is not effective after ovulation due to the mechanism of action. It is difficult to quantify how effective oral methods of EC are as many other factors are at play, for example, where the patient is in their cycle, the number of episodes of UPSI, whether the patient has already ovulated etc.

The added benefit of UPA-EC is that it is still effective even if the LH surge has begun.

What are the risks or side effects of UPA-EC?

UPA-EC is a very safe medication. It can commonly cause nausea, vomiting, and delayed or early menses. This should be explained to the patient. You should communicate that if a patient vomits within 3 hours of taking UPA-EC, they must repeat the dose.

There are no known risks to an early pregnancy with UPA-EC.

Advantages and disadvantages

Advantages include:

  • Safe and well tolerated medication with generally few side effects.
  • Has a longer window of use as can be used up to 5 days or 120 hours after UPSI
  • Can still delay ovulation even if the LH surge has begun

Disadvantages include:

  • UPA-EC is less effective if the patient has been exposed to any progestogens in the preceding 7 days or following 5 days
  • This means if the patient has been using their pill and missed pills in the prior 7 days you should not use UPA
  • This could include patients using contraception incorrectly (e.g. missed pills), or those using HRT, or those who have used LNG-EC in the previous 7 days
  • If wishing to quick-start contraception or resume their regular contraception, the patient must not take this until 5 days after taking the UPA-EC, so provide condoms or abstain in the interim
  • UPA-EC may be less effective if the patient is taking enzyme-inducing medication, but it can still be used (a double dose is not recommended)
  • UPA-EC is not recommended in patients with severe asthma taking oral glucocorticoids due to the anti-glucocorticoid effect of UPA
  • Breastfeeding must be avoided for 7 days after using. If UPA-EC is the only suitable method of EC for a patient who is breastfeeding, they should continue to express milk for one week and discard the breast milk
How do I decide between LNG and UPA?

It is important to remember that both work by inhibiting ovulation, so if ovulation has already occurred, they are unlikely to be effective. However, both can be offered irrespective of where a patient is in their cycle.

Only UPA can be used if UPSI occurred between 96 and 120 hours ago (4 to 5 days). 

If UPSI occurred between 0-96 hours ago, the choice depends on the risk of pregnancy. If the pregnancy risk is from UPSI within 5 days of the patient’s earliest estimated date of ovulation, UPA should be offered instead of LNG. However, as UPA is affected by other progestogens (e.g. patient requires EC due to missed pills), LNG should be used preferentially.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explore why the patient wants emergency contraception.


History

To establish whether emergency contraception is required and which method might be appropriate for the patient, it is important to take a history. This information may already be given to you in an OSCE setting. However, if you need to gather information, signpost this to the patient.

“In order to establish whether you might need emergency contraception and which method might work best for you, I need to first ask you a few questions. We will talk about the details of the sex and any contraception you may be using, about your periods, about any recent sexual partners so we can think about screening for infections, and about your health in general. After this, we will see what options are available to you.”

In particular, the history should include:

  • Details of the unprotected sexual intercourse (UPSI), including dates and times
  • Whether there has been other UPSI this menstrual cycle
  • Details of the patient’s menstrual cycle, including the first day of their last period. You will need to calculate where they are in their cycle, and when you might expect them to ovulate (14 days before menstruation).
  • Details of any current contraception being taken

A complete history should also include a sexual history to assess the risk for sexually transmitted infections, a past medical history, and a drug history.

Patients should be offered screening for sexually transmitted infections when they are seen in a sexual health clinic.

Safeguarding

As part of this consultation, it is important to think about safeguarding. You should screen for potential sexual and domestic abuse, as patients may not volunteer this information. During your history-taking you should clarify, in a sensitive manner, if the unprotected sexual intercourse that has resulted in this consultation was consensual.

You should also ask if the patient currently feels safe and supported in their current relationship (if relevant), asking specifically about domestic violence. You should also reiterate that the consultation is confidential.


Ideas, concerns and expectations

It is important to explore the patient’s ideas, concerns and expectations early in the consultation, as you may need to correct any misconceptions about emergency contraception and address the patient’s concerns. When exploring concerns, it is important to do so in a sensitive and honest manner.

Ideas

Explore what the patient currently understands about emergency contraception:

  • “Have you heard of emergency contraception?”
  • “What do you already know about emergency contraception?”

Concerns

Ask if the patient has any concerns about emergency contraception:

  • “Do you have any particular worries about emergency contraception?”

Expectations

Explore the patient’s expectations of the consultation:

  • “What were you hoping we’d do today?”
  • “Was there a particular type of emergency contraception that you felt would be suitable?”

Signposting and summary of options

You should summarise emergency contraception options, including their suitability for the patient. In doing so, you can help the patient make an informed decision about their options.

“Thank you for discussing your background with me. Let’s talk about emergency contraception.”

“Emergency contraception helps to reduce the chance of you becoming pregnant after having unprotected sex. It will not stop an existing pregnancy, and it is not the same thing as a termination.”

From your history, you should be able to consider which methods would be most appropriate. The Cu-IUD is the most effective method and provides ongoing contraception, so it should always be considered if acceptable to the patient. Whilst it is important for the patient to understand what the options are, be clear when discussing methods that they may not all be an option today. The patient should not feel pressured or coerced into deciding. The example below assumes the patient could have either an oral method or a Cu-IUD.

“There are two types of emergency contraception available in the UK. One is a tablet method that you could take today, and the other is the copper coil, which is a T-shaped device that sits inside the womb. The copper coil is more effective and would provide you with ongoing contraception, but the decision is yours.”

Choosing the Cu-IUD

Remember the Cu-IUD can only be inserted for emergency contraception within 5 days of the earliest expected date of ovulation, regardless of the number of episodes of UPSI leading to that point, or up to 5 days (120 hours) after UPSI within that menstrual cycle, provided there has been no other UPSI earlier in the same cycle. 

“The copper coil is a small plastic shaped device that sits inside the womb after a small procedure. It is the most effective method of emergency contraception and has the added benefit of providing you with ongoing contraception lasting for 5 or 10 years. It does not contain any hormones. There is a small procedure involved which has some risks, and we can talk through these if you decided to go ahead with this method. Your bleeding pattern can change over the first 3 to 6 months of having the coil fitted and long term, your periods might become heavier and longer but not everyone experiences this. You should also take a pregnancy test 3 weeks from when you last had unprotected sex.”

Choosing an oral method

Remember the choice of the oral method depends on the timing of the UPSI (<96hrs versus >96 to 120 hours), where the patient is in their cycle/ovulation, any history of progestogen use in the prior 7 days, past medical history, such as asthma on glucocorticoids etc. Generally, the consultation for both LNG and UPA is very similar.

“Levonorgestrel/Ulipristal is a tablet that is taken as a one-off dose and works by delaying ovulation. It is more effective the sooner it is taken after unprotected sex. It is difficult to say how effective the tablet would be. It is a very safe tablet with few side effects. Commonly, it can cause nausea and you may find that your next period is later than you would usually expect it. If you were to become pregnant and decided to continue with the pregnancy, this medication would not harm the ongoing pregnancy. You should take a pregnancy test 3 weeks from when you last had unprotected sex.”


Follow up

All patients should be advised to take a pregnancy test 3 weeks after UPSI, to ensure that they have not become pregnant. This should be done even if they have bleeding as this may not represent a normal period. 


Frequently asked questions

How will I know if the emergency contraception has worked?

The only way to be sure if emergency contraception has worked is by taking a pregnancy test. This should be taken 3 weeks after UPSI. This should be done even if they have bleeding as this may not represent a normal period. Ideally, patients should be given a pregnancy test at the time of being provided with emergency contraception.

“To rule out a pregnancy, it is important that you take a pregnancy test 3 weeks from the last unprotected sex. This is the only reliable way to know if pregnancy has occurred.” 

Can I take an emergency contraceptive method more than once?

A Cu-IUD is effective as contraception immediately upon insertion, and therefore, no further emergency contraception would be required.

There are no limits to how many times oral EC can be used.

Both LNG-EC and UPA-EC can be used again in the same menstrual cycle. However, UPA-EC is less effective when progestogens are used in the 7 days preceding and 5 days following use. As such, LNG-EC is not recommended for use in those days around UPA-EC use. There are no limits to how many times LNG can be used if LNG was previously used as EC. The choice of a repeat EC should be guided by previous use, and ongoing contraception should be recommended.

“Although you are taking emergency contraception today, you are still at risk of pregnancy if any further unprotected sex occurs without contraception. You should contact us again if there any other episodes of unprotected sex after today and we can give you advice about whether further emergency contraception is needed.” 

What should I do about taking other contraception?

This is dependent on what the contraception is, when it was last taken, and which emergency contraceptive was used.

Remember, UPA-EC is less effective when progestogens are taken 5 days following administration. As such, patients need to wait 5 days before resuming or starting hormonal contraception. Condoms should be used in these 5 days. LNG-EC is not affected in the same way, and contraceptives should be continued or resumed at the time of administration. 

If you are quick-starting contraception or restarting contraception after giving LNG-EC.

“After you have taken the tablet with levonorgestrel, you can resume/start your contraception immediately afterwards.”

If you are quick-starting contraception or restarting contraception after giving UPA-EC.

“After you have taken the tablet with ulipristal, you must not use any hormonal contraception for the next five days as this can prevent the emergency contraception from working. For the next five days, either use condoms or abstain from sex. Remember, when you start taking contraception again you will need to wait for it to become effective before you can rely on it as a contraceptive method.”

Given that emergency contraception is required, it can be assumed that any existing contraception has been missed enough to be ineffective. As such, the usual lead-in times are needed when resuming existing contraception. As a reminder, the progestogen-only pill is effective after 48 hours; and combined hormonal contraceptives, the implant, and the contraceptive injection are effective after 7 days of use. The copper IUD is effective immediately.


Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any further questions or concerns that haven’t been addressed.

Throughout the consultation you should check the patient’s understanding at regular intervals, using phrases such as “Can you just repeat back to me what we’ve just discussed regarding…”.

It may also be useful to direct the patient to any websites or leaflets with further information.

Offer the patient time to consider their decision (if possible).

Encourage the patient to use condoms if they are not currently using contraception.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Summary of emergency contraceptive methods

  Copper IUD UPA-EC LNG-EC
Mode of action Prevents implantation of fertilised ovum, toxic to sperm and eggs Delays ovulation – effective up to and including the LH surge Delays ovulation – effective up to the LH surge
Advantages
  • The most effective form of emergency contraception
  • Ongoing contraception for 5-10 years
  • 5-day window for use; and can be inserted up to 5 days after the earliest expected date of ovulation
  • 5-day window for use
  • Works at the start of the LH surge
  • Well-tolerated
  • Can be used alongside other hormonal contraception
  • Well-tolerated
  • Safe in breastfeeding
Disadvantages
  • Requires a procedure for insertion
  • May be inconvenient to access for the patient
  • Not as easily accessible
  • May result in heavier or more painful periods during use
  • Less effective when progestogens have been taken in the 7 days preceding or 5 days following use
  • Not suitable for patients with severe asthma
  • Breastfeeding patients must not breastfeed for 1 week after taking
  • Shorter window of use than UPA
  • Double dose for BMI >26/weight>70kg and patients using enzyme inducers
Risks As with any intrauterine contraception: Infection, expulsion, perforation, ectopic pregnancy Vomiting, change to menses Vomiting, change to menses

Reviewer

Dr Najia Aziz

Consultant in Sexual and Reproductive Health


References

  • Faculty of Sexual and Reproductive Healthcare (FSRH). FSRH Clinical Guideline: Emergency Contraception (March 2017, amended July 2023). Available from: [LINK]
  • NHS. Emergency contraception. Available from: [LINK]

 

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