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Experts estimate that, in the United States, up to 95 percent of teenage pregnancies are unintended.1 At the same time, at least 40 percent of all pregnancies in the United States are unintended.1
Unintended pregnancy can occur when a woman’s regular method of contraception fails or she uses it incorrectly. For example, she might forget to take her birth control pills for two or three days in a row. She might be unable to get her contraceptive injection on time. Her diaphragm might slip. Or she and her partner might accidentally tear a condom. Unintended pregnancy can also occur after a couple has had unprotected sex.
Finally, unintended pregnancy can occur as a result of rape or sexual assault. In fact, experts estimate that at least 25,000 pregnancies occur each year in the United States as a result of forced sex.2
Yet, many Americans –females and males, health professionals and consumers – do not know that there is a contraceptive method that works after unprotected sexual intercourse to prevent pregnancy.3,4,5 This method is known as emergency contraception. Emergency contraception (EC) is also known as the ‘morning after pill’ and Plan B®.
EC is up to 89 percent effective in preventing pregnancy, depending on how quickly a woman begins the pills, the type of pills taken, and when the sex occurred during the woman’s menstrual cycle.6 In August 2006, the Food and Drug Administration (FDA) ruled that women (and men) ages 18 and older can obtain Plan B® without a prescription.7 Plan B® is the only prepackaged, dedicated emergency contraceptive pill product currently available in the United States. On March 23, 2009, the U.S. District Court for the Eastern District of New York ruled that the Food and Drug Administration (FDA) must extend over-the-counter access to Plan B to 17 year olds by the end of April 2009 and must reconsider making it available without a prescription for those younger.24 Young women under age 18 still need a prescription to receive Plan B®.
Please note (July 2009): The newly approved Plan B One-Step is now available without a prescription for women and men 17 and older.
As a health care provider, you can take a number of steps to ensure that patients know about this important pregnancy prevention method. Prescribe or recommend emergency contraceptive pills for patients who are at risk of unintended or unwanted pregnancy – regardless of whether the risk is due to coercion, improper use of a regular contraceptive method, method failure, or nonuse of any regular contraception. The American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Adolescent Medicine, and other reputable medical organizations recommend: 1) giving young women emergency contraception (or a prescription) in advance of need so that they will have EC on hand in an emergency; 2) prescribing/recommending EC without concern regarding repeated use; and 3) responding immediately – without exams or tests of any kind – to a young woman’s need for emergency contraceptive pills.6,8,9 Finally, ensuring that services are welcoming, affordable, and confidential can encourage young women to seek the reproductive health care they need to prevent unintended or unwanted pregnancy as well as sexually transmitted infections (STIs), including HIV.6,8,9,10,11
Emergency contraceptive pills are hormonal contraception. Specifically, they are the same type of hormonal contraception that comprises regular contraceptive pills. Emergency contraceptive regimens include levonorgestrel-only (progestin-only) and the Yuzpe regimen of combined estrogen and progestin.
The latest research shows that levonorgestrel, taken in a 1.50 mg single dose, is the most effective regimen and has the fewest side effects.6,12
- The levonorgestrel-only regimen consists of either: a) 1.50 mg of levonorgestrel in a single dose; or b) two doses of 0.75 mg each, taken up to 12 hours apart.
- The combined estrogen-progestin regimen consists of two doses, taken 12 hours apart, of 100 mcg ethinyl estradiol plus 0.50 mg of levonorgestrel.
Emergency contraceptive pills are currently available in the United States either in a specifically packaged levonorgestrel product (Plan B®) or in the use of various brands of combined pills (see chart below, current as of April 2009. See a list of contraceptive brands that can be used as emergency contraception and the number of pills to prescribe, current as of April 2009. For a list that is updated whenever there is new information, please visit http://ec.princeton.edu.
In 1997, the U.S. Food and Drug Administration (FDA) recognized the use of oral contraceptives as being safe and effective as emergency contraception.15 Emergency contraceptive pills are effective in preventing pregnancy after unprotected sex. They are especially effective when begun within 12 to 24 hours after sex. The pills remain effective when begun up to 72 hours after sex. Some studies indicate that they continue to be effective, although somewhat less so, when begun up to 120 hours after sex.6,12 Studies indicate that efficacy declines substantially over time.6,12,14
The levonorgestrel-only regimen is more effective than the combined estrogen-progestin regimen.
- Four studies of the levonorgestrel regimen in almost 5,000 women showed that it reduced a woman’s chance of pregnancy by up to 93 percent (range 60 to 93 percent).12,16,17,18,19
- A meta-analysis of eight studies of the combined estrogen-progestin regimen in over 3,800 women concluded that this regimen prevented about 74 percent of pregnancies (range 56 to 89 percent).20
- Finally, a randomized trial compared the two regimens and found that the chance of pregnancy among women who received the levonorgestrel-only regimen was about one-third (0.36) the chance among those who received the combined regimen.12,17
Emergency contraceptive pills work in two established ways to prevent pregnancy. Emergency contraceptive pills have been proven to delay ovulation. It is probable that they inhibit fertilization. It is also possible, though unproven, that emergency contraceptive pills may prevent implantation. The medical community widely agrees that pregnancy begins when implantation is complete.6,12
Emergency contraceptive pills are sometimes confused with medical abortion. Whereas mifepristone (RU-486) terminates an existing pregnancy, emergency contraception is effective only before the pregnancy is established (that is, before implantation). If a woman is already pregnant, emergency contraception will not cause an abortion.6 By contrast, mifepristone is an entirely different medication, unrelated to hormonal contraception.
Emergency contraceptive pills are entirely safe. In fact, the American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Adolescent Medicine, World Health Organization, and many other reputable medical organizations assert that emergency contraceptive pills are entirely safe even for women for whom regular contraceptive pills are unsafe as well as those for whom pregnancy is a serious risk.6,8,9,21 (See World Health Organization findings under Statements of Prominent Medical Organizations, below.)
Emergency contraceptive pills do not cause birth defects. Over 40 years experience with oral contraceptives has shown no risk of birth defects if a woman is already pregnant when she takes them. Emergency contraceptive pills are contraindicated for pregnant women only because the medication will not end a pregnancy.6,8,9,12,21 Studies of older, higher-dose oral contraceptives have shown that emergency contraception confers no increased risk to an established pregnancy or harm to a developing embryo.6
Because emergency contraceptive pills are not dangerous under any known circumstances, routine screening – such as pelvic exam or pregnancy and/or blood test – is entirely unnecessary. If a woman has missed her period, she might also request a pregnancy test. However, administration of emergency contraceptive pills should not be delayed in order to perform any test.6,8,9,12
Short-term side effects can include nausea, vomiting, abdominal pain, fatigue, headache, dizziness, breast tenderness, and irregular vaginal spotting or bleeding. The levonorgestrel-only regimen carries significantly lower chance than the combined regimen of causing nausea and vomiting.6,12
To minimize nausea and vomiting, American College of Obstetricians and Gynecologists, Society for Adolescent Medicine, and International Consortium for Emergency Contraception recommend the levonorgestrel-only regimen in preference to the combined estrogen-progestin regimen.6,8,12 In addition, medical experts also recommend that:
- Women using the combined regimen receive pretreatment with antiemetic drugs (meclizine or metoclopramide).
- If vomiting occurs within two hours after either dose, repeat the dose.
- In cases of severe vomiting, consider vaginal administration of the dose.6,12
Women should be advised that their menses will probably occur within a week before or after the time they would have expected it. If menses is delayed more than two weeks beyond the time expected, the woman should seek a pregnancy test and, if she is pregnant, appropriate care.6,12
Making Emergency Contraceptive Pills Readily Available to Young Women
Young women face barriers to reproductive health care. These barriers constitute an additional obstacle to their seeking, receiving, and using emergency contraceptive pills during the relatively short time frame of the pills’ effectiveness. In order to help young women avoid unintended and unwanted pregnancy, you can work to dismantle these barriers in a number of ways.
- Train all staff, from nurse practitioners to receptionists, to respond promptly and positively to phone requests for emergency contraception. Train staff to inquire about the interval since the incident of unprotected sex.
- Make sure that staff understands that the longer the time lapse, the more urgent the need for emergency contraception. The pills remain effective when begun up to 72 hours after unprotected sex. Some studies indicate that they continue to be effective, although somewhat less so, when begun up to 120 hours after sex.6,12Studies indicate that efficacy declines substantially over time.6,12,14
- At the same time, be sure that staff understands that emergency contraceptive pills are most effective when begun within 12 hours after unprotected sex. So, if the incident just occurred, staff should still ensure that the patient’s need is met promptly.
- Encourage women ages 18 and older to go immediately to a nearby pharmacy, and bring proof of age, so that they can purchase and take Plan B®. Although the package instructs young women to take the pills 12 hours apart, the Society for Adolescent Medicine recommends that young women be advised to take both pills together, at one time – this is an easier regimen to follow and just as effective.8
- If your practice’s protocol requires seeing the patient in order to prescribe medication, then be sure that she receives an immediate appointment (the same day). If she is a regular patient under age 18, and you can phone in a prescription without a prior office visit, please do so.
- Determine which pharmacies in your community carry emergency contraceptive pills, especially Plan B®. Identify the pharmacies that will provide the medication promptly and courteously. Refer your patients to these pharmacies. If no such pharmacy exists in your community, consider repackaging levonorgestrel-only oral contraceptives to give patients in an emergency.
- Offer a sliding fee scale so that young women (who are more likely than older women to lack health insurance) can afford the emergency contraceptive pills they need.
- For young women under age 18 who are seeking a prescription for emergency contraceptive pills, offer free or very low cost services so that they do not have to use their parents’ insurance. Doing this for your younger patients will help ensure their confidentiality and increase the likelihood of their seeking the care they need.
- Ensure that the practice’s protocols do not require pregnancy test, pelvic exam, or other laboratory tests as prerequisites for obtaining emergency contraceptive pills.
- Be sure that the waiting room and examining rooms provide pamphlets, posters, and wallet cards educating women about emergency contraceptive pills and about the importance of using regular contraception.
- During office visits, counsel young people about contraception. Offer advance prescriptions for emergency contraceptive pills to all women under age 18 who may be at risk of pregnancy.
- Use the opportunity provided by a young woman’s seeking emergency contraceptive pills to schedule a follow-up appointment so that she can then receive other needed health care, such as contraception, STI testing, and/or pregnancy testing (if indicated).
- Regardless of the reason why a young woman needs emergency contraceptive pills, treat her respectfully and non-judgmentally.
Statements of Prominent Medical Organizations regarding Emergency Contraceptive Pills**
- American College of Obstetricians and Gynecologists: Emergency contraception should be offered to women who have had unprotected or inadequately protected sexual intercourse and who do not desire pregnancy… The levonorgestrel-only regimen is more effective and is associated with less nausea and vomiting and should, if available, be used in preference to the combined estrogen-progestin regimen…. Prescription or provision of emergency contraception in advance of need can increase availability and use… No clinical examination or pregnancy testing is necessary before provision or prescription of emergency contraception… Emergency contraception may be made available to women [who have] contraindications to the regular use of conventional oral contraceptive preparations.6
- Society for Adolescent Medicine: Adolescent health care providers are encouraged to counsel all adolescents about emergency contraceptive pills during visits for acute as well as routine health care... All female adolescents being treated for sexual assault should be counseled about emergency contraception and offered a complete course of emergency contraceptive treatment at that time… Provision of emergency contraception should not be contingent on an adolescent’s receiving pregnancy testing, pelvic examination, Pap smear, or STI testing… Health care providers should provide progestin-only emergency contraceptive pills as the regimen of choice because of higher efficacy and lower side effects. Adolescents should be counseled to take both pills at once [emphasis added] (rather than the current FDA-approved regimen of the first tablet immediately and the second 12 hours later).8
- American Academy of Pediatrics: Emergency contraception has the potential to further decrease the rate of unintended teen pregnancies in the United States… Education and counseling about emergency contraception should be part of the annual preventive health care visit for all teen and young adult patients when sexuality issues are addressed… Advance prescription should be considered for teens and young adults… An increase in awareness and availability of emergency contraception does not change reported rates of sexual activity or increase the frequency of unprotected intercourse among adolescents… The AAP continues to support improved availability of emergency contraception to teens and young adults, including over-the-counter access and limiting the barriers to access placed by some health care providers and venues.9
- American Medical Association: It is the policy of the AMA to enhance efforts to expand access to emergency contraception, including making emergency contraceptive pills more readily available through hospitals, clinics, emergency rooms, acute care centers, and physicians’ offices… Emergency contraception is considered safe and effective by the medical community as a whole… Given that emergency contraceptive pills are more effective the sooner they are used, the Council believes establishing prescription and dispensing mechanisms that are convenient for women is crucial to their ability to use the therapy effectively… Physicians could also work to ensure that office staff answering the telephone and scheduling appointments is aware of [emergency contraceptive pills] and able to arrange immediate care for women who call seeking emergency contraceptive treatment.10
- American Medical Women’s Association: AMWA agrees with respected organizations such as the National Institutes of Health and the American College of Obstetricians and Gynecologists (ACOG) in defining pregnancy as beginning with implantation…6,22 Emergency contraceptive pills work prior to implantation and therefore are considered by these respected organizations and AMWA as a contraceptive, not as an abortifacient. Emergency contraceptive pills do not affect an established pregnancy and numerous studies of the teratologic risk of conception during regular use of oral contraceptives (including the use of older, higher-dose preparations) found no increase in risk.6 AMWA affirms its commitment to supporting reproductive choice for women and believes that emergency contraception is an important option. AMWA is committed to promoting awareness of and improving access to emergency contraception for women of diverse ethnic and socioeconomic backgrounds.11
- American Nurses Association: There are safe and effective measures available for emergency contraception… As nurses, [we] individually and collectively, can educate school administrators, parents and other policy makers about the severity of the public health issues of teen pregnancy, STDs, and sexual abuse in the community and in this country… [We] can advocate on behalf of more comprehensive approaches for educating teens in practice settings, community, and schools… [We] can be sure that there are available and affordable and non-punitive resources for teens to obtain contraceptive information and protection in [the] community.23
The position of these respected medical organizations is supported by findings of the World Health Organization and the U.S. Food and Drug Administration:
- World Health Organization: Medical eligibility criteria include no conditions in which the risks of emergency contraceptive pills outweigh the benefits. Evidence supports emergency contraceptive use in women who: are breastfeeding; have a history of ectopic pregnancy; have been raped; and/or have a history of repeated use of emergency contraceptive pills. In addition, because the use of emergency contraceptive pills is less than the regular use of oral contraceptive pills (and emergency contraceptive pills, thus, have less clinical impact), the World Health Organization’s review of the medical literature found that emergency contraceptive pills are appropriate for use in women with a history of cardiovascular complications, angina pectoris, migraine, and/or severe liver disease.21
As for the U.S. Food and Drug Administration, emergency contraceptive pills meet all the FDA’s requirements for over-the-counter (non-prescription) status: 1) a woman can, and indeed always does, self-diagnose her need for emergency contraception; 2) swallowing pills does not require medical supervision; and 3) emergency contraceptive pills are safe and effective.
In 2004, the FDA’s joint advisory committee on women’s reproductive health voted 23 to four in favor of non-prescription status for Plan B®, the only pre-packaged, dedicated emergency contraceptive pill product currently available in the United States.8 In 2006, the FDA approved nonprescription status for Plan B® for women age 18 and older.7 Pharmacies began making emergency contraception available without a prescription in early 2006. On March 23, 2009, the U.S. District Court for the Eastern District of New York ruled that the Food and Drug Administration (FDA) must extend over-the-counter access to Plan B to 17 year olds by the end of April 2009 and must reconsider making it available without a prescription for those younger.24 Young women under age 18 still need a prescription to receive Plan B®.
* This document reports the assessments by major medical organizations that conducted reviews of the extensive medical literature on emergency contraception.
** Except where noted by brackets [ ], these are exact quotations from the cited documents.
Written by Sue Alford, MLS
Advocates for Youth © 2008
An earlier version of this publication was funded by New Morning Foundation
- Abma JC et al. Fertility, Family Planning and Women’s Health: New Data from the 1995 National Survey of Family Growth. [Vital and Health Statistics, Series 23, no. 19] Hyattsville, MD: NCHS, 1997.
- Stewart FH, Trussell J. Prevention of pregnancy resulting from rape: a neglected preventive health measure. American Journal of Preventive Medicine 2000; 19:228-229.
- Harper CC, Cheong M, Rocca CH, Darney PD, Raine TR. The effect of increased access to emergency contraception among young adolescents. Obstetrics & Gynecology 2005; 106:483-491.
- Petitti DB, Harvey SM, Preskill D, Beckman LJ, Postlethwaite D et al. Emergency contraception: preliminary report of a demonstration and evaluation project. Journal of the American Medical Women’s Association 1998; 53(Supplement 2): 251-254.
- Philliber Research Associates. Knowledge of Emergency Contraception, September 2006. Research on behalf of New Morning Foundation. Columbia SC: South Carolina Emergency Contraception Initiative, 2006.
- American College of Obstetricians and Gynecologists. Emergency contraception. ACOG Practice Bulletin: Clinical Management Guidelines, December 2005 (#69).
- Food and Drug Administration. “Plan B®: Questions and Answers.” http://www.fda.gov/cder/drug/infopage/planB/planBQandA20060824.htm ; accessed 02/01/2008.
- Society for Adolescent Medicine. Provision of emergency contraception to adolescents: position paper of the Society for Adolescent Medicine. Journal of Adolescent Health 2004; 35:66-70.
- American Academy of Pediatrics, Committee on Adolescence. Emergency contraception: policy statement. Pediatrics 2005; 116:1038-1047.
- American Medical Association, Council on Medical Service. Access to Emergency Contraception [CMS Report 1 – I-00] Chicago, IL: AMA, 2000.
- American Medical Women’s Association. Emergency Contraception; http://www.jamwa.org/index.cfm?objectid=0EF88909-D567-0B25-531927EE4CC23EFB ; last accessed 02/01/2008.
- International Consortium for Emergency Contraception. Emergency contraceptive pills: Medical and Service Delivery Guidelines, 2nd edition. New York: Author, 2004; http://www.cecinfo.org/publications/PDFs/resources/MedicalServiceDeliveryGuidelines_Eng.pdf ; last accessed 2/10/2008.
- Emergency Contraception Website (not-2-late.com). Answers to Frequently Asked Questions about … Types of Emergency Contraception. Princeton NJ: Princeton; http://ec.princeton.edu/questions/dose.html; last accessed 02/01/2008.
- Conard LAE, Fortenberry JD, Blythe MJ, Orr DP. Emergency contraceptive pills: a review of the recent literature. Current Opinion in Obstetrics and Gynecology 2004; 16:389-395.
- Food and Drug Administration. Prescription drug products: certain combined oral contraceptives for use as postcoital emergency contraception. Federal Register 1997; 62:8610-8612.
- Von Hertzen H, Piaggio G, Ding J, Chen J, Song S et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet 2002; 360:1803-1810.
- Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998; 352:428-433.
- Arowojolu AO, Okewole IA, Adekunle AO. Comparative evaluation of the effectiveness and safety of two regimens of levonorgestrel for emergency contraception in Nigerians. Contraception 2002; 66:269-273.
- Ho PC, Kwan MS. A prospective randomized comparison of levonorgestrel with the Yuzpe regimen in post-coital contraception. Human Reproduction 1993; 8:339-92.
- Trussell J, Rodriguez G, Ellertson C. Updated estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception 1999; 59:147-151.
- World Health Organization. Medical Eligibility Criteria for Contraceptive Use. Geneva, Switzerland, Author, 2004; http://www.who.int/reproductive-health/publications/mec/index.htm ; last accessed 02/01/2008.
- U.S. Government Printing Office. OPRR reports: protection of human subjects. Code of Federal Regulations 46, 1983.
- Schumann MJ. Prevention of adolescent pregnancy and sexually transmitted disease: a moral imperative, a public health imperative or both? Nursing World: Ethics and Human Rights Issues Updates 2002; 1(3).
- Stein, Rob. “FDA Ordered to Rethink Age Restriction for Plan B.” Washington Post, Tuesday, March 24, 2009. Accessed from http://www.washingtonpost.com/wp-dyn/content/article/2009/03/23/AR2009032301275.html on April 15, 2009.
This publication is a part of the From Research to Practice series.