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 types 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.

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About emergency contraception

Emergency contraception 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 “IUD”
• EllaOne^® which is a 30mg ulipristal acetate tablet, also known as “the morning-after pill”
• Levonelle^®  which is a 1.5mg levonorgestrel tablet, 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.

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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.

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History

In order to establish whether emergency contraception is required, and which form 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 ensure to 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 need to ask a few questions. We will talk about the details of the unprotected 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, a 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 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. 

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 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.

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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?”

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Signposting: summary of options

You should summarise emergency contraception options, including their suitability for the patient. In doing so, you will be able to help the patient to 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 risk 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.”

“There are three types of emergency contraception available in the UK. Two of these are types of ‘morning-after pill’, which both work in similar ways, although one is a little more effective than the other. These pills are called Levonelle® and ellaOne®. There is also the option of inserting a copper IUD, which is more effective than the morning after pill but involves a procedure.”

“We will talk through these options together and see which one works best for you.”

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Levonelle® (levonorgestrel)

What is Levonelle®?

Levonelle® is a tablet containing 1.5mg of levonorgestrel, which is a synthetic progestogen. It is taken as a one-off dose.

How does Levonelle® work?

Levonelle® works by inhibiting ovulation for around 5 days. 

“Levonelle® works by delaying ovulation. In theory, this means that any sperm present in the genital tract should no longer be alive by the time that an egg is released, and so there is no resulting pregnancy.”³

When can Levonelle® be taken?

Levonelle® should be taken within 72 hours of UPSI. The longer the delay, the less effective Levonelle® is. Levonelle® is not affected by other progestogen use i.e. it can be used alongside other hormonal contraception.

“Levonelle® works best when taken as soon as possible after unprotected sex. There is a 72-hour window to take Levonelle®. It can be taken alongside other hormonal contraception”

How effective is Levonelle®?

Of the forms of available emergency contraception, Levonelle® is on average the least effective. If taken after ovulation, studies suggest it is not at all effective. Due to the importance of the timing in the menstrual cycle when emergency contraception is taken, it is difficult to accurately assess how effective oral emergency contraception is. As such, patients should be informed that Levonelle® is a little less effective than ellaOne® at preventing pregnancy and that the copper IUD is the most effective form of emergency contraception. Patients should also be made aware that Levonelle® is not effective when taken after ovulation. ³

“It is difficult to give an accurate statistic about how effective Levonelle® is. What we do know, is that the copper IUD is the most effective form of emergency contraception. EllaOne®  is a little more effective than Levonelle® and has an effect slightly later on in your cycle than Levonelle®. However, neither of the emergency contraception tablets are effective if you have already ovulated in this menstrual cycle.” 

What are the risks or side effects of Levonelle®?

Levonelle® 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 Levonelle®, they will need to repeat the dose. There are no known risks to an early pregnancy with Levonelle®. 

Levonelle® is rendered less effective by enzyme-inducing medication. For patients with a BMI of 26 or over, or who weigh 70kg or more, a double dose should be used.³ 

“For most patients, Levonelle® is a very safe medication to take. It may make you feel a little nauseous, and your period might be early or late. The dose is weight-dependent and for some people, two tablets rather than one are recommended. If you vomit within 3 hours of taking the tablet you will need to take a second dose. Levonelle® is not known to be harmful if you do become pregnant.”

Pros and cons of Levonelle®

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of using the emergency contraceptive pill with levonorgestrel.

 “If it is okay with you, I’d now like to tell you about the benefits and disadvantages of the emergency contraceptive pill with levonorgestrel, then hopefully you will have enough information to make a decision.”

Advantages of Levonelle®

Well tolerated

“There are very few side effects from Levonelle® and it is a safe medication to take”

Can be used with ongoing/current contraception

“To reduce the risk of further pregnancy we can start some ongoing contraception today to take alongside Levonelle®. For example, we could think about the contraceptive pill, the implant, the depot injection or the IUS.” 

Disadvantages of Levonelle®

Less effective than other methods

“Levonelle® is often a good option, but of the forms of emergency contraception available it is overall the least effective”

Shorter window to take the pill than other emergency contraception

“Levonelle® can only be taken within 3 days after unprotected sex, whilst the other emergency contraceptive methods can be used within 5 days, or sometimes even later on in the cycle”

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EllaOne® (ulipristal acetate)

What is ellaOne®?

EllaOne® is an emergency contraceptive pill with ulipristal acetate (UPA). It is a one-dose tablet that contains 30mg of ulipristal acetate. 

How does ellaOne® work?

EllaOne®, as with Levonelle®, works by delaying ovulation for around 5 days. Unlike Levonelle®, ellaOne® is effective even at the start of the LH surge.³

“EllaOne® works by delaying ovulation. In theory, this means that any sperm present in the genital tract should no longer be alive by the time of the (delayed) ovulation, and so there is no resulting pregnancy.”

When can ellaOne® be taken?

EllaOne® can be taken within 120 hours, or 5 days, of UPSI.

It is rendered less effective by progestogen hormones, and as such should not be taken in a 7 day period following progestogen use. Similarly, progestogens should not be taken in the 5 days following ellaOne® use. In practical terms this may mean that patients who have missed contraceptive pills may not be advised to take ellaOne® for UPSI; and that starting ongoing contraception at the same time as giving ellaOne® as emergency contraception is less simple. Bear in mind that Levonelle® is a progestogen too.³

“EllaOne® can be taken up to 120 hours, or 5 days, after unprotected sex. It can be affected by other hormones so it is important to discuss whether you are taking any other form of contraception at the moment and whether you would like to start ongoing contraception today”

How effective is ellaOne®?

EllaOne® is generally more effective than Levonelle® at preventing pregnancy. Unlike Levonelle®, ellaOne® can work to delay ovulation even after the start of the LH surge. Due to the importance of the timing in the menstrual cycle when emergency contraception is taken, it is difficult to accurately assess how effective oral emergency contraception is. Studies suggest that EllaOne when taken appropriately can prevent 60-80% of pregnancies. If EllaOne® is taken after ovulation, evidence suggests that it is not effective. This should be emphasised to patients, along with the fact that the copper IUD is the most effective form of emergency contraception.³

“It is difficult to give an accurate statistic about how effective EllaOne® is. What we do know, is that the copper IUD is the most effective form of emergency contraception. EllaOne®  is more effective than Levonelle® and has an effect slightly later on in your cycle than Levonelle®. However, neither of the emergency contraception tablets are effective if you have already ovulated in this menstrual cycle.” 

What are the risks or side effects of ellaOne®?

EllaOne® 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 ellaOne®, they will need to repeat the dose. There are no known risks to an early pregnancy with ellaOne®. 

EllaOne® is rendered less effective by enzyme-inducing medication and is not suitable for use in patients with severe asthma.

“For most patients, ellaOne® is a very safe medication to take. It may make you feel a little nauseous, and your period might be early or late. If you vomit within 3 hours of taking the tablet you will need to take a second dose. EllaOne® is not known to be harmful if you do become pregnant.”

Pros and cons of ellaOne®

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of choosing ellaOne®.

 “If it is okay with you, I’d like to tell you about the benefits and disadvantages of ellaOne®, then hopefully you will have enough information to make a decision.”

Advantages of ellaOne®

5-day window for use

“EllaOne® can be taken up to 5 days after unprotected sex, however, we advise that you try to take the pill as soon as possible.”

Well tolerated

“There are very few side effects from EllaOne® and it is a safe medication to take.”

More effective than Levonelle®

“EllaOne® is on average more effective than Levonelle® for emergency contraception, especially if you are near ovulation”

Disadvantages of EllaOne®

Rendered less effective by progestogen use

“EllaOne® does not work as well when you have taken other hormones in the 7 days before or the 5 days after taking it. Because you have taken the progestogen-only pill this week, ellaOne® is not recommended for you”. 

Not effective after ovulation

“EllaOne® works by delaying ovulation. If you have already released an egg this cycle, ellaOne® is not expected to work at all. It is not harmful to take and is worth a try as we are unable to know exactly when you might ovulate, but it is unlikely to be of benefit. The copper IUD may be an alternative option for you.”

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Copper intrauterine device (IUD)

What is the copper IUD?

Explain to the patient that a copper IUD is a small T-shaped plastic and copper device which is inserted into the womb during a small procedure. It is also known as a coil. 

All eligible patients should be offered the copper IUD as a form of emergency contraception.³

How does the copper IUD work?

The copper IUD has an inhibitory effect on both fertilisation and implantation. Fertilisation inhibition occurs through direct toxicity effects of the copper on both ovum and sperm. This toxic effect prevents pregnancy.³ 

“The copper IUD is a T-shaped piece of plastic which contains a small amount of copper. This copper is toxic to sperm and eggs, and this toxic effect prevents pregnancy”

When can the copper IUD be used?

The copper IUD can be inserted for emergency contraception up to 5 days, (120 hours) after unprotected sex; or within 5 days of the earliest expected date of ovulation. ¹ In order to be effective, the copper IUD should remain in situ ideally for 21 days. It can be left in place for up to 10 years to provide ongoing contraceptive protection.

For example, Patient A has a regular 29-day cycle. Her earliest expected date of ovulation would be day 15 of her cycle i.e. 14 days before menstruation. If patient A has UPSI on day 4 of her cycle, a copper IUD could be fitted for emergency contraception on any day up to day 20 of that cycle, providing that a pregnancy test was negative. 

How effective is the copper IUD?

When inserted at the correct time, the copper IUD is the most effective form of emergency contraception.³

“Less than 1% of women who use the copper IUD as emergency contraception become pregnant.” ²

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

The risks associated with IUD insertion are the same whether the copper IUD is used for contraception, or for emergency contraception. See our guide about the copper IUD for more information. 

“A small procedure is required to insert the IUD. Although this should only last around 5 minutes, some people can find it uncomfortable. There is an associated small risk of infection, expulsion and of perforation. Some people may experience irregular bleeding for a few days after the fitting of the IUD. Periods may be heavier, longer and more painful, especially in the first few months.”

Pros and cons of the copper IUD

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing the pros and cons of choosing a particular type of emergency contraception.

“If it is okay with you, I’d like to tell you about the benefits and disadvantages of the copper IUD, then hopefully you will have enough information to make a decision.”

Advantages of the copper IUD

Effective emergency contraception

“The copper IUD is the most effective method of emergency contraception.”

Ongoing contraception

“When you have the IUD fitted, you can keep it as your regular contraception for up to 10 years. It is effective immediately after insertion”

Suitable for most patients 

“The copper IUD will not have any effect on your other medications, which makes it a good option if you are taking certain medications such as those for epilepsy. There are no hormones in the copper IUD. Your weight will not affect how the copper IUD works”

Longer window for use

The copper IUD can be inserted up to 5 days after UPSI, or up to 5 days after the earliest expected date of ovulation, whichever is later in the cycle. For some patients, the copper IUD may be an option for emergency contraception even after they are out of the window for oral emergency contraception. 

“The copper IUD can often be inserted even after 5 days have passed, depending on where you are in your menstrual cycle. This might mean that you could take a morning-after pill today, and have a few days to think about whether the copper IUD might be a good option for you”

Can be taken alongside hormonal emergency contraception

Unless a patient is having a copper IUD inserted immediately, it is good practice to offer a hormonal emergency contraceptive to take straight away even if there is a plan for copper IUD insertion later on. There may be a failed insertion, or the patient might change their mind, and at this point, they may be out of the window for a tablet- in these cases, it is worthwhile to already have emergency contraception on board.

Disadvantages of the copper IUD

Procedure required

See our guide about the copper IUD for more information. 

Side effects of ongoing copper IUD use

“Some people may experience irregular bleeding for a few days after the fitting of the IUD. Your periods may be heavier, longer and more painful, especially in the first few months.”

Availability and convenience

Unlike oral emergency contraception, the copper IUD is not readily available at pharmacies. Patients may need to attend a sexual health clinic or a GP surgery in order to arrange for an IUD insertion. 

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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. 

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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 unprotected intercourse. This should be done even if they have bleeding as this may not represent a normal period. Ideally, patients should be issued with a pregnancy test at the time of being provided with emergency contraception. 

Can I take an emergency contraceptive method more than once?

In the case of a copper IUD, this is effective as contraception immediately upon insertion and therefore no further emergency contraception would be required.

Both Levonelle® and ellaOne® can be used again in the same menstrual cycle. However, ellaOne® is rendered less effective by progestogen use in the 7 days preceding and 5 days following use. As such, Levonelle® is not recommended to be used in those days around ellaOne® use. There is no such interaction when using Levonelle®. The choice of a repeat emergency contraception agent should be guided by previous use, and ongoing contraception should be recommended.³

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.

Of note, ellaOne® is rendered less effective when progestogens are taken in the 5 days following administration. As such, one would need to wait 5 days before resuming or starting hormonal contraception. Condoms should be used in these 5 days. Levonelle® is not affected in the same way and contraceptives should be continued or resumed at the time of administration.  

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 depo injection are effective after 7 days of use. The copper IUD is effective immediately. 

Where can I access emergency contraception?

Emergency contraception is free from the following places: ¹

• 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 A&E departments

Emergency contraceptive pills can be purchased from most pharmacies (however the patient will need to be over the age of 16).

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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.

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Summary of emergency contraceptive methods

	Copper IUD	EllaOne®	Levonelle®
Mode of action	An inhibitory effect on both fertilisation and implantation due to copper toxicity	Delays ovulation; effective before or at the start of the LH surge	Inhibits ovulation if taken before the LH surge
Advantages	99% effective: 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 More effective than Levonelle® Works at the start of the LH surge Well-tolerated	Can be used alongside other hormonal contraception Well-tolerated
Disadvantages	Requires a procedure for insertion May be inconvenient to access for the patient May result in heavier or more painful periods during use	Not effective when progestogens have been taken in the 7 days preceding or 5 days following use Not suitable for patients with severe asthma	72-hour window for use Overall less effective than other forms of emergency contraception Double dose for BMI >26/weight >70kg
Risks	As with IUD generally: Infection, expulsion, perforation, ectopic pregnancy	Vomiting, change to menses	Vomiting, change to menses

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Reviewer

Dr Grace Farrington

GP Trainee

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References

1. FPA.org.uk. (2018). Your guide to emergency contraception [online] Available at: LINK [Accessed 20 Jan. 2019].
2. NHS UK. (2018). Your contraception guide [online] Available at: LINK [Accessed 20 Jan. 2019].
3. FSRH (2020). FSRH CEU Clinical Guidance: Emergency Contraception [online] Available at: LINK [Accessed 28 Feb. 2022].

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