11/13/24, 8\:17 PM Guide | Emergency contraception counselling

Emergency contraception counselling

Table of contents

Introduction

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.

About emergency contraception

Emergency contraception should be o
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 1500mg levonorgestrel tablet, also known as "the morning-after pill"
,
Each of these types of emergency contraception will be explained in this article.
"plan B"
, or "one-step"

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explore why the patient wants emergency contraception.

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.
" I n o r d e r t o e s t a b l i s h w h e t h e r y o u m i gh t n e e d e m e r g e n c y c o n t r a c e p t i o n , a n d w h i c h m e t h o d m i gh t w o r k b e s t f o r y o u , I n e e d t o

a b o u t y o u r p e r i o d s , a b o u t a n y r e c e n t s e x u a l p a r t n e r s s o w e c a n t h i n k a b o u t s c r e e n i n g f o r i n f e c t i o n s , a n d a b o u t y o u r h e a l t h i n
g e n e r a l . A f t e r t h i s , w e w i l l s e e w h a t o p t i o n s a r e a v a i l a b l e t o y o u .
"
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
their cycle, and when you might expect them to ovulate (14 days before menstruation).
Details of any current contraception being taken
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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 oscreening 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 speci
should also reiterate that the consultation is con

Ideas, concerns & 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\:
“ H a v e y o u h e a r d o f e m e r g e n c y c o n t r a c e p t i o n ?”
“ W h a t d o y o u a l r e a d y k n o w a b o u t e m e r ge n c y c o n t r a c e p t i o n ?”

Concerns

Ask if the patient has any concerns about emergency contraception\:
“ D o y o u h a v e a n y p a r t i c u l a r w o r r i e s a b o u t e m e r ge n c y c o n t r a c e p t i o n ?”

Expectations

Explore the patient's expectations of the consultation\:
“ W h a t w e r e y o u h o p i n g w e’ d d o t o d a y ?”
" W a s t h e r e a p a r t i c u l a r t y p e o f e m e r ge n c y c o n t r a c e p t i o n t h a t y o u f e l t w o u l d b e s u i t a b l e ?"

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.
" T h a n k y o u f o r d i s c u s s i n g y o u r b a c k gr o u n d w i t h m e . L e t' s t a l k a b o u t e m e r g e n c y c o n t r a c e p t i o n .
"
" E m e r g e n c y c o n t r a c e p t i o n h e l p s t o r e d u c e t h e r i s k o f y o u b e c o m i n g p r e gn a n t a f t e r h a v i n g u n p r o t e c t e d s e x . e x i s t i n g p r e g n a n c y , a n d i t i s n o t t h e s a m e t h i n g a s a t e r m i n a t i o n .
"
I t w i l l n o t s t o p a n
" T h e r e a r e t h r e e t y p e s o f e m e r g e n c y c o n t r a c e p t i o n a v a i l a b l e i n t h e U K . T w o o f t h e s e a r e t y p e s o f ' m o r n i n g-a f t e r p i l l'
, w h i c h
b o t h w o r k i n s i m i l a r w a y s , a l t h o u g h o n e i s a l i t t l e m o r e e
T h e r e i s a l s o t h e o p t i o n o f i n s e r t i n g a c o p p e r I U D , w h i c h i s m o r e e
"
" W e w i l l t a l k t h r o u g h t h e s e o p t i o n s t o g e t h e r a n d s e e w h i c h o n e w o r k s b e s t f o r y o u .
"

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-o
How does Levonelle® work?
Levonelle® works by inhibiting ovulation for around 5 days.
" L e v o n e l l e ® w o r k s b y d e l a y i n g o v u l a t i o n . a l i v e b y t h e t i m e t h a t a n e g g i s r e l e a s e d , I n t h e o r y , t h i s m e a n s t h a t a n y s p e r m p r e s e n t i n t h e ge n i t a l t r a c t s h o u l d n o l o n ge r b e
a n d s o t h e r e i s n o r e s u l t i n g p r e gn a n c y .
"
3
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When can Levonelle® be taken?
Levonelle® should be taken within 72 hours of UPSI. The longer the delay, the less e
a
" L e v o n e l l e ® w o r k s b e s t w h e n t a k e n a s s o o n a s p o s s i b l e a f t e r u n p r o t e c t e d s e x . T h e r e i s a 7 2-h o u r w i n d o w t o t a k e L e v o n e l l e ® . c a n b e t a k e n a l o n g s i d e o t h e r h o r m o n a l c o n t r a c e p t i o n"
I t
How e
Of the forms of available emergency contraception, Levonelle® is on average the least e
studies suggest it is not at all e
contraception is taken, it is di
be informed that Levonelle® is a little less e
most e
taken after ovulation.
3
“ I t i s d i
m o s t e
l a t e r o n i n y o u r c y c l e t h a n L e v o n e l l e ® . H o w e v e r , n e i t h e r o f t h e e m e r g e n c y c o n t r a c e p t i o n t a b l e t s a r e e
a l r e a d y o v u l a t e d i n t h i s m e n s t r u a l c y c l e .
"
What are the risks or side e
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 e
or more, a double dose should be used.
3
" F o r m o s t p a t i e n t s , L e v o n e l l e ® i s a v e r y s a f e m e d i c a t i o n t o t a k e . I t m a y m a k e y o u f e e l a l i t t l e n a u s e o u s , a n d y o u r p e r i o d m i g h t
b e e a r l y o r l a t e . T h e d o s e i s w e i g h t-d e p e n d e n t a n d f o r s o m e p e o p l e , t w o t a b l e t s r a t h e r t h a n o n e a r e r e c o m m e n d e d . I f y o u
v o m i t w i t h i n 3 h o u r s o f t a k i n g t h e t a b l e t y o u w i l l n e e d t o t a k e a s e c o n d d o s e . L e v o n e l l e ® i s n o t k n o w n t o b e h a r m f u l i f y o u d o
b e c o m e p r e g n a n t .
"

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.
“ I f i t i s o k a y w i t h y o u , I’ d n o w l i k e t o t e l l y o u a b o u t t h e b e n e
l e v o n o r g e s t r e l , t h e n h o p e f u l l y y o u w i l l h a v e e n o u gh i n f o r m a t i o n t o m a k e a d e c i s i o n .
”

Advantages of Levonelle®

Well tolerated
" T h e r e a r e v e r y f e w s i d e e
Can be used with ongoing/current contraception
“ T o r e d u c e t h e r i s k o f f u r t h e r p r e g n a n c y w e c a n s t a r t s o m e o n g o i n g c o n t r a c e p t i o n t o d a y t o t a k e a l o n gs i d e L e v o n e l l e ® . e x a m p l e , w e c o u l d t h i n k a b o u t t h e c o n t r a c e p t i v e p i l l , t h e i m p l a n t , t h e d e p o t i n j e c t i o n o r t h e I U S .
"
F o r

Disadvantages of Levonelle®

Less e
" L e v o n e l l e ® i s o f t e n a g o o d o p t i o n , b u t o f t h e f o r m s o f e m e r g e n c y c o n t r a c e p t i o n a v a i l a b l e i t i s o v e r a l l t h e l e a s t e
Shorter window to take the pill than other emergency contraception
“ L e v o n e l l e ® c a n o n l y b e t a k e n w i t h i n 3 d a y s a f t e r u n p r o t e c t e d s e x , w h i l s t t h e o t h e r e m e r ge n c y c o n t r a c e p t i v e m e t h o d s c a n b e
u s e d w i t h i n 5 d a y s , o r s o m e t i m e s e v e n l a t e r o n i n t h e c y c l e”

EllaOne® (ulipristal acetate)

What is ellaOne®?
acetate.
EllaOne® is an emergency contraceptive pill with ulipristal acetate (UPA). It is a one-dose tablet that contains 30mg of ulipristal
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How does ellaOne® work?
EllaOne®, as with Levonelle®, works by delaying ovulation for around 5 days. Unlike Levonelle®, ellaOne® is e
the start of the LH surge.
3
" E l l a O n e ® w o r k s b y d e l a y i n g o v u l a t i o n . I n t h e o r y , t h i s m e a n s t h a t a n y s p e r m p r e s e n t i n t h e ge n i t a l t r a c t s h o u l d n o l o n ge r b e
a l i v e b y t h e t i m e o f t h e ( d e l a y e d ) o v u l a t i o n , a n d s o t h e r e i s n o r e s u l t i n g p r e gn a n c y .
"
When can ellaOne® be taken?
EllaOne® can be taken within 120 hours, or 5 days, of UPSI.
It is rendered less e
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
" E l l a O n e ® c a n b e t a k e n u p t o 1 2 0 h o u r s , o r 5 d a y s , a f t e r u n p r o t e c t e d s e x . I t c a n b e a
i m p o r t a n t t o d i s c u s s w h e t h e r y o u a r e t a k i n g a n y o t h e r f o r m o f c o n t r a c e p t i o n a t t h e m o m e n t a n d w h e t h e r y o u w o u l d l i k e t o s t a r t
o n g o i n g c o n t r a c e p t i o n t o d a y
"
How e
EllaOne® is generally more e
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 di
suggest that EllaOne when taken appropriately can prevent 60-80% of pregnancies. If EllaOne® is taken after ovulation,
evidence suggests that it is not e
the most e
3
“ I t i s d i
e
y o u r c y c l e t h a n L e v o n e l l e ® . H o w e v e r , n e i t h e r o f t h e e m e r g e n c y c o n t r a c e p t i o n t a b l e t s a r e e
o v u l a t e d i n t h i s m e n s t r u a l c y c l e .
"
What are the risks or side e
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 e
asthma.
" F o r m o s t p a t i e n t s , e l l a O n e ® i s a v e r y s a f e m e d i c a t i o n t o t a k e . I t m a y m a k e y o u f e e l a l i t t l e n a u s e o u s , a n d y o u r p e r i o d m i gh t b e
e a r l y o r l a t e . I f y o u v o m i t w i t h i n 3 h o u r s o f t a k i n g t h e t a b l e t y o u w i l l n e e d t o t a k e a s e c o n d d o s e . E l l a O n e ® i s n o t k n o w n t o b e
h a r m f u l i f y o u d o b e c o m e p r e g n a n t .
"

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®.
“ I f i t i s o k a y w i t h y o u , I’ d l i k e t o t e l l y o u a b o u t t h e b e n e
”
t h e n h o p e f u l l y y o u w i l l h a v e e n o u g h

Advantages of ellaOne®

5-day window for use
“ E l l a O n e ® c a n b e t a k e n u p t o 5 d a y s a f t e r u n p r o t e c t e d s e x , h o w e v e r , Well tolerated
“ T h e r e a r e v e r y f e w s i d e e
"
More e
" E l l a O n e ® i s o n a v e r a g e m o r e e
”
e s p e c i a l l y i f y o u a r e n e a r o v u l a t i o n"

Disadvantages of EllaOne®

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Rendered less e
“ E l l a O n e ® d o e s n o t w o r k a s w e l l w h e n y o u h a v e t a k e n o t h e r h o r m o n e s i n t h e 7 d a y s b e f o r e o r t h e 5 d a y s a f t e r t a k i n g
i t . B e c a u s e y o u h a v e t a k e n t h e p r o g e s t o g e n-o n l y p i l l t h i s w e e k , e l l a O n e ® i s n o t r e c o m m e n d e d f o r y o u
"
.
Not e
“ E l l a O n e ® w o r k s b y d e l a y i n g o v u l a t i o n . I f y o u h a v e a l r e a d y r e l e a s e d a n e gg t h i s c y c l e , e l l a O n e ® i s n o t e x p e c t e d t o w o r k a t a l l .
I t i s n o t h a r m f u l t o t a k e a n d i s w o r t h a t r y a s w e a r e u n a b l e t o k n o w e x a c t l y w h e n y o u m i gh t o v u l a t e , b u t i t i s u n l i k e l y t o b e o f
b e n e
"

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 o
3
How does the copper IUD work?
The copper IUD has an inhibitory e
toxicity e
3
" T h e c o p p e r I U D i s a T -s h a p e d p i e c e o f p l a s t i c w h i c h c o n t a i n s a s m a l l a m o u n t o f c o p p e r . T h i s c o p p e r i s t o x i c t o s p e r m a n d
e g g s , a n d t h i s t o x i c e
"
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 e
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
on any day up to day 20 of that cycle, providing that a pregnancy test was negative.
How e
When inserted at the correct time, the copper IUD is the most e
3
“ L e s s t h a n 1 % o f w o m e n w h o u s e t h e c o p p e r I U D a s e m e r ge n c y c o n t r a c e p t i o n b e c o m e p r e gn a n t .
” ²
What are the risks or side e
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 s m a l l p r o c e d u r e i s r e q u i r e d t o i n s e r t t h e I U D . A l t h o u g h t h i s s h o u l d o n l y l a s t a r o u n d 5 m i n u t e s , s o m e p e o p l e c a n
u n c o m f o r t a b l e . T h e r e i s a n a s s o c i a t e d s m a l l r i s k o f i n f e c t i o n , e x p u l s i o n a n d o f p e r f o r a t i o n . S o m e p e o p l e m a y e x p e r i e n c e
i r r e g u l a r b l e e d i n g f o r a f e w d a y s a f t e r t h e

”

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.
“ I f i t i s o k a y w i t h y o u , I’ d l i k e t o t e l l y o u a b o u t t h e b e n e
”
t h e n h o p e f u l l y y o u w i l l h a v e

Advantages of the copper IUD

E
“ T h e c o p p e r I U D i s t h e m o s t e
”
Ongoing contraception
“ W h e n y o u h a v e t h e I U D
I t i s e
Suitable for most patients
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“ T h e c o p p e r I U D w i l l n o t h a v e a n y e
m e d i c a t i o n s s u c h a s t h o s e f o r e p i l e p s y . T h e r e a r e n o h o r m o n e s i n t h e c o p p e r I U D . Y o u r w e i gh t w i l l n o t a
I U D w o r k s”
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.
" T h e c o p p e r I U D c a n o f t e n b e i n s e r t e d e v e n a f t e r 5 d a y s h a v e p a s s e d , d e p e n d i n g o n w h e r e y o u a r e i n y o u r m e n s t r u a l c y c l e .
T h i s m i g h t m e a n t h a t y o u c o u l d t a k e a m o r n i n g-a f t e r p i l l t o d a y , a n d h a v e a f e w d a y s t o t h i n k a b o u t w h e t h e r t h e c o p p e r I U D
m i g h t b e a g o o d o p t i o n f o r y o u
"
Can be taken alongside hormonal emergency contraception
Unless a patient is having a copper IUD inserted immediately, it is good practice to o
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 e
“ S o m e p e o p l e m a y e x p e r i e n c e i r r e g u l a r b l e e d i n g f o r a f e w d a y s a f t e r t h e
”
l o n g e r
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.

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 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 e
contraception would be required.
Both Levonelle® and ellaOne® can be used again in the same menstrual cycle. However, ellaOne® is rendered less
e
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 e
would need to wait 5 days before resuming or starting hormonal contraception. Condoms should be used in these 5 days.
Levonelle® is not a
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Given that emergency contraception is required, it can be assumed that any existing contraception has been missed enough to
be ine
progestogen-only pill is e
are e
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).

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 “C a n
y o u j u s t r e p e a t b a c k t o m e w h a t w e’ v e j u s t d i s c u s s e d r e g a r d i n g …
”
.
It may also be useful to direct the patient to any websites or lea
O
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

Mode of
action
Advantages
Copper IUD EllaOne® Levonelle®
An inhibitory e
fertilisation and implantation due to
copper toxicity
99% e
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
Delays ovulation; e
at the start of the LH surge
5-day window for use
More e
Works at the start of the LH surge
Well-tolerated
Inhibits ovulation if taken
before the LH surge
Can be used alongside other
hormonal contraception
Well-tolerated
https\://app.geekymedics.com/osce-guides/counselling/emergency-contraception-counselling/ 7/811/13/24, 8\:17 PM Guide | Emergency contraception counselling
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 e
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 e
other forms of emergency
contraception
Double dose for BMI
>26/weight >70kg
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/counselling/emergency-contraception-counselling/ 8/8