At a glance
This page includes recommendations for health care providers for the use of emergency contraception for persons who have certain characteristics or medical conditions. This information comes from the 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC).
Overview
Classifications are given for the copper intrauterine device (Cu-IUD) as emergency contraception. The Cu-IUD can be placed within 5 days of the first act of unprotected intercourse as emergency contraception. In addition, when the day of ovulation can be estimated, the Cu-IUD can be placed beyond 5 days after sexual intercourse, as long as the placement does not occur >5 days after ovulation. The eligibility criteria for interval Cu-IUD placement also apply for the placement of Cu-IUDs as emergency contraception (Box J1) (Table J1).[1]
Classifications for emergency contraceptive pills (ECPs) are given for ulipristal acetate (UPA), levonorgestrel (LNG), and combined oral contraceptives (COCs). ECPs should be taken as soon as possible within 5 days of unprotected sexual intercourse.[1]
Cu-IUDs, UPA, LNG, and COCs do not protect against sexually transmitted infections (STIs), including HIV infection, and patients using these methods should be counseled that consistent and correct use of external (male) latex condoms reduces the risk for STIs, including HIV infection.[2] Use of internal (female) condoms can provide protection from transmission of STIs, although data are limited.[2] Patients also should be counseled that pre-exposure prophylaxis, when taken as prescribed, is highly effective for preventing HIV infection.[3]
Box J1. Categories for classifying emergency contraception
Abbreviation: U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use.
Table J1. Classifications for emergency contraception, including the copper intrauterine device, ulipristal acetate, levonorgestrel, and combined oral contraceptives
| Condition | Category | Clarification/Evidence/Comment | |||
|---|---|---|---|---|---|
| Cu-IUD | UPA | LNG | COC | ||
| Personal Characteristics and Reproductive History | |||||
| Pregnancy | 4 | NA | NA | NA | Clarification (IUD): The IUD is not indicated during pregnancy and should not be used because of the risk for serious pelvic infection and septic spontaneous abortion. Clarification (ECPs): Although this method is not indicated for a patient with a known or suspected pregnancy, no harm to the patient, the course of pregnancy, or the fetus if ECPs are inadvertently used is known to exist. Evidence: Evidence suggests that poor pregnancy outcomes are rare among pregnant women who used ECPs during conception cycle or early in pregnancy.[4] |
| Breastfeeding | 1 | 1 | 1 | 1 | Evidence: Breastfeeding outcomes do not seem to differ between women exposed to LNG and those who are not exposed.[4] One pharmacokinetic study demonstrated that LNG passes to breast milk but in minimal quantities.[4] UPA and its active metabolite, monodemethyl-ulipristal acetate, are present in human milk in small amounts; no evidence is available on effects of UPA emergency contraception exposure on infants or children who are breastfed.[5] |
| Past ectopic pregnancy | 1 | 1 | 1 | 1 | — |
| Obesity (BMI ≥30 kg/m2) | 1 | 2 | 2 | 2 | Clarification (ECPs): ECPs might be less effective among persons with BMI ≥30 kg/m2 than among persons with BMI <25 kg/m2. Despite this, no safety concerns exist. Evidence: Limited evidence from secondary data analyses suggests that women with BMI ≥30 kg/m2 experience an increased risk for pregnancy after use of LNG compared with women with BMI <25 kg/m2. Two analyses suggest that women with obesity might also experience an increased risk for pregnancy after use of UPA compared with those without obesity, although this increase was not significant in one study.[6] |
| History of bariatric surgery This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
|||||
| a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy) | 1 | 1 | 1 | 1 | — |
| b. Malabsorptive procedures: decrease absorption of nutrients and calories by shortening the functional length of the small intestine (Roux-en-Y gastric bypass or biliopancreatic diversion) | 1 | 1 | 1 | 1 | Comment: Bariatric surgical procedures involving a malabsorptive component have the potential to decrease oral contraceptive effectiveness, perhaps further decreased by postoperative complications such as long-term diarrhea, vomiting, or both. Because of these malabsorptive concerns, an emergency IUD might be more appropriate than ECPs. |
| Condition | Category | Clarification/Evidence/Comment | |||
|---|---|---|---|---|---|
| Cu-IUD | UPA | LNG | COC | ||
| Cardiovascular Disease | |||||
| History of severe cardiovascular disease (ischemic heart disease, cerebrovascular attack, or other thromboembolic conditions) This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 2 | 2 | 2 | Comment: The duration of ECP use is less than that of regular use of COCs or POPs and thus would be expected to have less clinical impact. |
| Condition | Category | Clarification/Evidence/Comment | |||
|---|---|---|---|---|---|
| Cu-IUD | UPA | LNG | COC | ||
| Gastrointestinal Conditions | |||||
| Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) | 1 | 1 | 1 | 1 | — |
| Severe liver disease (including jaundice) This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3). |
1 | 2 | 2 | 2 | Comment: The duration of ECP use is less than that of regular use of COCs or POPs and thus would be expected to have less clinical impact. |
| Condition | Category | Clarification/Evidence/Comment | |||
|---|---|---|---|---|---|
| Cu-IUD | UPA | LNG | COC | ||
Solid Organ Transplantation |
|||||
| Solid organ transplantation
This condition is associated with increased risk for adverse |
|||||
| a. No graft failure | 1 | 1 | 1 | 1 | — |
| b. Graft failure | 2 | 1 | 1 | 1 | — |
| Condition | Category | Clarification/Evidence/Comment | |||
|---|---|---|---|---|---|
| Cu-IUD | UPA | LNG | COC | ||
| Other | |||||
| Repeated ECP use | — | 1 | 1 | 1 | Clarification (ECPs): Frequently repeated ECP use might be harmful for persons with conditions classified as category 2, 3, or 4 for CHC or POC use. Evidence: In one case-control study, risk for ectopic pregnancy compared with intrauterine pregnancy did not increase after repeated use of LNG ECPs compared with nonuse.[4] |
| Sexual assault | 2 | 1 | 1 | 1 | Clarification (IUD): Persons who have experienced sexual assault are at increased risk for STIs, including HIV infection. According to CDC STI treatment guidelines, routine presumptive treatment of chlamydia, gonorrhea, and trichomonas is recommended after sexual assault.[2] Persons with current purulent cervicitis, chlamydial infection, or gonococcal infection should not undergo IUD placement (category 4). |
| CYP3A4 inducers (e.g., bosentan, carbamazepine, felbamate, griseofulvin, oxcarbazepine, phenytoin, rifampin, St. John’s wort, topiramate, efavirenz, and lumacaftor) | 1 | 2 | 2 | 2 | Clarification (ECPs): Strong CYP3A4 inducers might reduce the effectiveness of ECPs. Evidence: According to labelling information, rifampin markedly decreases UPA levels by ≥90%, which might decrease its efficacy.[5] Therefore, theoretical concerns extend to use of other CYP3A4 inducers as well as to COC and LNG ECPs, which have metabolic pathways similar to those of UPA. A small pharmacokinetic study found that concomitant efavirenz use decreased LNG levels in women taking LNG ECPs (1.5 mg) by 56% compared with LNG ECPs alone.[7] |
Abbreviations: BMI = body mass index; CHC = combined hormonal contraceptive; COC = combined hormonal contraceptive; Cu-IUD = copper intrauterine device; CYP = cytochrome P450; ECP = emergency contraceptive pill; IUD = intrauterine device; LNG = levonorgestrel; NA = not applicable; POC = progestin-only contraceptive; POP = progestin-only pill; STI = sexually transmitted infection; UPA = ulipristal acetate.
References
- Curtis KM, Nguyen AT, Tepper NK, et al. U.S. selected practice recommendations for contraceptive use, 2024. MMWR Recomm Rep 2024;73(No. RR-3):1–77.
- Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. PMID:34292926 https://doi.org/10.15585/mmwr.rr7004a1
- CDC. US Public Health Service preexposure prophylaxis for the prevention of HIV infection in the United States—2021 update: a clinical practice guideline. Atlanta, GA: US Department of Health and Human Services, CDC; 2021. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf
- Jatlaoui TC, Riley H, Curtis KM. Safety data for levonorgestrel, ulipristal acetate and Yuzpe regimens for emergency contraception. Contraception 2016;93:93–112. PMID:26546020 https://doi.org/10.1016/j.contraception.2015.11.001
- HRA Pharma America. Ella [Package insert]. Morristown, NJ: HRA Pharma America; 2021.
- Jatlaoui TC, Curtis KM. Safety and effectiveness data for emergency contraceptive pills among women with obesity: a systematic review. Contraception 2016;94:605–11. PMID:27234874 https://doi.org/10.1016/j.contraception.2016.05.002
- Carten ML, Kiser JJ, Kwara A, Mawhinney S, Cu-Uvin S. Pharmacokinetic interactions between the hormonal emergency contraception, levonorgestrel (Plan B), and efavirenz. Infect Dis Obstet Gynecol 2012;2012:137192. PMID:22536010 https://doi.org/10.1155/2012/137192