Emergency Contraception Use with Combined Oral Contraceptives and Depot Medroxyprogesterone Acetate

Indications for Emergency Contraception

A patient can and should use emergency contraception even when already on oral combined contraceptives (COC) and depot medroxyprogesterone acetate (DMPA) if there has been unprotected intercourse or contraceptive failure, as recommended by the American Academy of Family Physicians and the Centers for Disease Control and Prevention 1, 2
Emergency contraception is appropriate when missed or late doses of regular contraception have occurred, particularly if unprotected intercourse happened during the first week of the pill pack or in the previous 5 days, according to the American Academy of Family Physicians 1
Emergency contraception is also appropriate when DMPA injection is ≥2 weeks late (≥15 weeks after previous injection) and unprotected intercourse has occurred, as stated by the American Academy of Family Physicians 1

The existing hormonal contraception does not interfere with emergency contraception effectiveness, as reported by the Centers for Disease Control and Prevention 2, 3
No hormonal interactions with existing COC or DMPA use occur with the copper IUD, according to the Centers for Disease Control and Prevention 2
Ulipristal Acetate (UPA) is more effective than levonorgestrel in women who are overweight or obese, as noted by the American Academy of Family Physicians 1

Resume or start regular contraception immediately after levonorgestrel use, and use barrier method or abstain for 7 consecutive days after restarting hormonal contraception, as recommended by the American Academy of Family Physicians 1
After ulipristal acetate use, any contraceptive method can be started immediately, but this requires special attention, and barrier contraception or abstinence is necessary for 14 consecutive days (or until next menses) after UPA use, as advised by the American Academy of Family Physicians 1

Continue the COC as scheduled after emergency contraception use, as recommended by the American Academy of Family Physicians 1
Ensure DMPA is given on time (within 2 weeks of scheduled injection date), and if DMPA is ≥2 weeks late, treat as a new start with 7 days of backup contraception, as stated by the American Academy of Family Physicians 1

The Centers for Disease Control and Prevention recommends a copper intrauterine device (Cu-IUD) as the most effective option for emergency contraception 5 days after unprotected sex 4
The Cu-IUD can be inserted within 5 days of unprotected intercourse as an emergency contraceptive, and it provides ongoing contraception after insertion 4
Ulipristal acetate (UPA) is the only effective oral option at 5 days after unprotected sex, with a single 30 mg dose effective up to 5 days (120 hours) after unprotected sex 4
The American College of Obstetricians and Gynecologists recommends UPA as a highly effective emergency contraceptive option, particularly for women with higher BMI compared to levonorgestrel 4

The Cu-IUD is highly effective as emergency contraception at 5 days, with the highest efficacy 4
UPA maintains effectiveness throughout the full 120-hour window, with observed pregnancy rates as low as 1.3% when taken between 96-120 hours after unprotected sex is not cited, however UPA is more effective than levonorgestrel when taken 3-5 days after unprotected sex 4
Levonorgestrel has significantly reduced effectiveness after 72 hours, with pregnancy rates increasing at 4-5 days 4

The first choice for emergency contraception at 5 days is the Cu-IUD if appropriate for the patient and provider available, as it provides the highest efficacy 4, 5
The second choice is ulipristal acetate (30 mg), as it is the only oral option that maintains consistent efficacy at 5 days 4
Levonorgestrel or combined regimen are not recommended at 5 days due to significantly reduced effectiveness at this timepoint 4, 5

After UPA use, any regular contraceptive method can be started immediately, but barrier contraception or abstinence is needed for 14 days or until next menses, as recommended by the Centers for Disease Control and Prevention 6
Advance provision of emergency contraception may increase likelihood of timely use, as recommended by the American College of Obstetricians and Gynecologists 4