Emergency Contraception
Emergency Contraception
References
- Canadian Contraception Consensus (Part 3 of 4): Chapter 8 - Emergency Contraception — Journal of Obstetrics and Gynaecology Canada (Black A, Guilbert E, Costescu D, et al.; Society of Obstetricians and Gynaecologists of Canada). J Obstet Gynaecol Can 2015;37(10):S20-S28
- Society of Family Planning Clinical Recommendation: Emergency contraception — Contraception (Salcedo J, Cleland K, Bartz D, Thompson I; Society of Family Planning). Contraception 2023;121:109958
- The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience — Human Reproduction (Cleland K, Zhu H, Goldstuck N, et al.). Hum Reprod 2012;27(7):1994-2000
- Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis — The Lancet (Glasier AF, Cameron ST, Fine PM, et al.). Lancet 2010;375(9714):555-562
- Emergency contraceptive pills to carry warnings for reduced effectiveness in women over a certain body weight — Health Canada. Health Canada Recalls and Safety Alerts, March 26, 2014
- Medical eligibility criteria for contraceptive use, sixth edition — World Health Organization. 6th ed., Geneva: WHO, 2025
- Pharmacist contraceptive prescribing across Canada — Canadian Pharmacists Association. CPhA infographic, July 2023
- FSRH Guideline: Emergency Contraception — Faculty of Sexual & Reproductive Healthcare, now the College of Sexual & Reproductive Healthcare (CoSRH). March 2017, amended July 2023
Clinical Snapshot
Emergency contraception (EC) is used to reduce the risk of pregnancy after a single, isolated episode of unprotected or under-protected vaginal intercourse — it works before a pregnancy is established, by delaying or preventing ovulation (or, for the copper IUD, primarily by impairing sperm function and motility), and none of the available methods disrupt an already-implanted pregnancy.[1][2] Three options are available in Canada: the copper intrauterine device (IUD), oral levonorgestrel, and oral ulipristal acetate, each with a different effective time window, a different degree of effectiveness, and a different accessibility pathway. EC offers no protection against HIV or other sexually transmitted infections, and it is not intended to replace an ongoing, regular contraceptive method — every EC encounter is also an opportunity to address the patient's longer-term contraceptive needs.
Recognize the Condition
Emergency contraception is not a disease to diagnose — a patient requesting EC is not unwell, and there are no examination findings that confirm or exclude the need for it. The clinical task is instead to establish, as quickly as possible, how much time has elapsed since the unprotected intercourse and to match the patient to the most effective option still within its window, without creating unnecessary barriers to access.
The 3 EC options in Canada
Copper IUD
The most effective EC option, and the only one that also provides ongoing contraception once in place. Effective within 5 days of unprotected intercourse, or within 5 days of the estimated day of ovulation if that is later. Requires an in-person insertion visit with a trained provider.[3]
Ulipristal acetate (UPA)
The more effective hormonal option overall, and particularly favoured 72-120 hours after intercourse or in a patient with a higher body weight. Effective up to 120 hours (5 days) after intercourse. Prescription-only in Canada.[4]
Levonorgestrel (LNG)
The most accessible option — available without a prescription from every community pharmacy in Canada. Most effective in the first 24 hours, with declining benefit through 96-120 hours. Effectiveness may be reduced at a higher body weight.[5]
Risk Factors
EC is appropriate after a single episode of unprotected or under-protected intercourse — it is not a substitute for a regular contraceptive method and should not be relied on repeatedly across a cycle when a more effective ongoing method is available. Any of the following situations warrants same-visit consideration of EC:[6]
- No contraceptive method was used.
- Condom breakage, slippage, or known incorrect use.
- Combined hormonal contraceptive pills: 3 or more consecutive pills missed at any point in the cycle, or the pack restarted 3 or more days late after the pill-free interval.
- Progestin-only pills: a dose taken 3 or more hours late, or more than 27 hours since the previous dose.
- Desogestrel-only pills: a dose taken 12 or more hours late, or more than 36 hours since the previous dose.
- Norethisterone enanthate injection: 2 or more weeks late for the next injection.
- Depot medroxyprogesterone acetate (DMPA) injection: 4 or more weeks late for the next injection.
- Combined injectable contraceptive: 7 or more days late for the next injection.
- Diaphragm or cervical cap: dislodgement, breakage, tearing, or early removal.
- Failed withdrawal.
- Spermicide that failed to melt before intercourse.
- A fertility awareness-based method: miscalculation of the abstinence period, or failure to abstain or use a barrier method on a fertile day.
- IUD or contraceptive implant expulsion.
- Sexual assault, when the person was not otherwise protected by an effective contraceptive method.
Red Flags & Refer
EC itself is a low-risk intervention, but the following require urgent assessment rather than reassurance that "EC was already given":
- Severe or worsening lower abdominal or pelvic pain at any point after EC — especially together with a late, unusually light, or otherwise abnormal period — is an ectopic pregnancy until proven otherwise and needs same-day assessment.
- No period within 3 weeks of taking EC, or a period markedly different from usual — a positive pregnancy test at that point needs prompt pregnancy-location assessment, not just confirmation that a pregnancy exists.
- Signs of pelvic infection after copper IUD insertion (fever, purulent discharge, worsening pelvic pain) — refer urgently rather than reassuring as expected post-insertion discomfort.
- Heavy vaginal bleeding, syncope, or any sign of hemodynamic instability.
- Disclosure of sexual assault — refer promptly for forensic, medical, and psychosocial support in addition to EC, using a trauma-informed approach.
- Suspected intimate partner violence or reproductive coercion (for example, a partner interfering with contraception) — screen and refer to local supports.
Assessment & Diagnosis
History
- Exact timing of the unprotected intercourse (or the earliest episode this cycle, if more than one) — this determines which options remain within their effective window.
- Timing and regularity of the last menstrual period, and any earlier unprotected intercourse this cycle, to assess the background risk of an existing, undetected pregnancy.
- Current regular contraceptive method, if any, and why it failed or was missed.
- Body weight, since it affects hormonal EC method selection.
- Current medications, specifically enzyme-inducing drugs (for example, carbamazepine, phenytoin, rifampin, St. John's wort) that can reduce hormonal EC effectiveness.
- Breastfeeding status.
- Contraindications to copper IUD insertion if that option is being considered: current pregnancy, undiagnosed abnormal vaginal bleeding, current pelvic inflammatory disease or untreated active STI, known copper allergy, or a distorted uterine cavity.
- STI risk, and whether this episode involved sexual assault — screen using a trauma-informed, non-judgmental approach.
Pregnancy testing
Do not withhold or delay levonorgestrel, ulipristal acetate, or copper IUD insertion pending pregnancy testing — a urine pregnancy test only detects a pregnancy that is already established, and none of the EC methods harm an established pregnancy.[2]
A urine pregnancy test is reasonable before offering EC when there is a specific reason to suspect an existing pregnancy (for example, an earlier episode of unprotected intercourse this cycle with no period since), and should always be performed before copper IUD insertion given the consequences of placing a device into an unrecognized pregnancy.
Treatment Targets
- Prevent pregnancy from the specific episode of unprotected or under-protected intercourse.
- Offer the most effective option available within the patient's time window, body weight, and access constraints, not simply the most familiar one.
- Avoid any delay in access, since the effectiveness of every EC method declines with time.
- Establish or resume a reliable ongoing contraceptive method so the patient does not need to rely on EC repeatedly.
- Identify and address associated needs: STI risk, sexual assault disclosure, and intimate partner violence.
Choose Initial Treatment
Method selection
1st line, if accessible and acceptable offer the copper IUD to every patient within 5 days of unprotected intercourse (or within 5 days of the estimated day of ovulation if that is later) — it is the most effective EC option and the only one that also gives the patient ongoing contraception going forward.[1][3]
If a copper IUD is not accessible, not desired, or same-day insertion is not available, offer ulipristal acetate 30 mg PO x 1 — it is more effective than levonorgestrel, especially 72-120 hours after intercourse and in a patient with a higher body weight, and remains an option through the full 120-hour (5-day) window.[4]
Use levonorgestrel 1.5 mg PO x 1 when ulipristal acetate is unavailable, contraindicated, or the patient prefers same-day non-prescription access — it is most effective in the first 24 hours, with declining benefit through 96-120 hours, and its effectiveness declines further at a higher body weight.[5]
Do not rely on levonorgestrel alone as the only counselling offered to a patient at or above roughly 75-80 kg body weight if ulipristal acetate or a copper IUD can instead be offered — but never withhold levonorgestrel entirely from a higher-weight patient who has no other accessible option, since it may still provide some benefit.[5][1]
Reserve the estrogen-progestogen (Yuzpe) regimen for the rare situation where none of levonorgestrel, ulipristal acetate, or a copper IUD is available — it is less effective and causes substantially more nausea and vomiting than the alternatives.[1]
The pharmacist's role in Canada
Levonorgestrel EC is available without a prescription from every community pharmacy in Canada; in most provinces it now sits on the shelf for self-selection, though Quebec (not a member of the National Association of Pharmacy Regulatory Authorities) still requires a pharmacist consultation before it is dispensed.[7]
Ulipristal acetate remains prescription-only nationally, but pharmacists with expanded prescribing authority can prescribe it directly at the point of care — a national survey found this authority in place in British Columbia, Alberta, Saskatchewan, Quebec, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador, with provincial scope continuing to expand; confirm current authority with the relevant provincial regulatory college before prescribing.[7]
Copper IUD insertion requires a trained inserter (a physician, nurse practitioner, midwife, or specially trained pharmacist depending on the province) — a pharmacist who cannot insert the device directly should still counsel on it as the most effective option and refer promptly for same-day or next-available insertion, rather than defaulting straight to a hormonal option by omission.
Non-Pharmacologic Treatment
Counselling at the time of EC
- Take the hormonal dose as soon as possible — effectiveness declines the longer it is delayed within the window.
- If vomiting occurs within 2 hours of a levonorgestrel dose, or within 3 hours of a ulipristal acetate dose, repeat the same dose (an antiemetic beforehand can help).
- EC does not protect against STIs, including HIV — discuss barrier methods and STI testing separately.
- Explain that EC works by delaying or preventing ovulation and does not disrupt an already-implanted pregnancy — this reassures patients concerned that EC might act as an abortifacient, and is also relevant if EC is inadvertently taken by someone already pregnant, since no increased risk to that pregnancy has been shown.[2]
- Set expectations: the next period may arrive a few days earlier or later than usual and may differ in flow; if it is more than 3 weeks late, a pregnancy test is needed.
When to start or resume regular hormonal contraception after EC
Starting or resuming a regular hormonal method right away improves uptake and continuation, and the specific timing depends on which EC method was used.[2]
| EC method used | When to start/resume hormonal contraception (HC) | Back-up contraception needed | Why |
|---|---|---|---|
| Copper IUD | Not applicable | None | The IUD itself provides ongoing, highly effective contraception — no separate HC method is needed unless the patient wants to switch later. |
| Levonorgestrel | Immediately, whenever desired | 7 days, or until the next period, whichever comes first | Levonorgestrel does not reduce the effectiveness of a subsequently started hormonal contraceptive. |
| Estrogen-progestogen (Yuzpe) | Immediately, whenever desired | 7 days, or until the next period, whichever comes first | Same rationale as levonorgestrel. |
| Ulipristal acetate | Delay 5 days after the ulipristal acetate dose | An additional 7 days after starting HC (about 12 days total from the ulipristal acetate dose), or until the next period, whichever comes first | Starting a progestogen-containing method too soon can blunt ulipristal acetate's ovulation-delaying effect, since it binds the progesterone receptor with high affinity. |
Pharmacologic Treatment Options
| Drug / intervention | Role | Dose / use | Important adverse effects | Teaching points |
|---|---|---|---|---|
| Copper IUD Preferred | Most effective EC; also gives ongoing contraception | Insertion within 5 days of intercourse (or 5 days of estimated ovulation if later) | Cramping, heavier menses; rare uterine or cervical perforation, rare expulsion | Requires a same-day insertion visit with a trained provider — counsel that this is the most effective option available. |
| Ulipristal acetate Preferred | Preferred hormonal EC, especially 72-120h after intercourse or higher body weight | 30 mg PO x 1, up to 120 hours (5 days) after intercourse | Nausea, headache, dysmenorrhea, abdominal pain, fatigue, dizziness | Prescription only in Canada. Delay starting hormonal contraception for 5 days after this dose. |
| Levonorgestrel Preferred | Most accessible hormonal EC | 1.5 mg PO x 1, most effective within 24h, up to 96-120h | Nausea, vomiting, dizziness, fatigue, headache | Non-prescription in Canada. Effectiveness declines at higher body weight — offer ulipristal acetate or a copper IUD first if accessible. |
| Combined estrogen/progestogen (Yuzpe regimen) Special situation | Last-resort EC when levonorgestrel, ulipristal acetate, and a copper IUD are all unavailable | 2 doses, 12 hours apart; tablet count per dose depends on the specific product (see Drug Tables) | Nausea (common), vomiting | Pretreat with an antiemetic. Less effective and more nauseating than levonorgestrel or ulipristal acetate. |
| Dimenhydrinate Special situation | Antiemetic pretreatment for the Yuzpe regimen | 50-100 mg PO, about 1 hour before each Yuzpe dose | Drowsiness, dry mouth, dizziness | Meaningfully reduces the nausea/vomiting seen with the Yuzpe regimen. |
Special Populations
Breastfeeding
Levonorgestrel and the copper IUD: no restriction — breastfeeding does not need to be interrupted after levonorgestrel EC, and copper IUD insertion does not affect lactation.[2]
Ulipristal acetate: the evidence base is smaller and current guidance differs by source. The WHO Medical Eligibility Criteria (6th edition) advises expressing and discarding breast milk for about 1 week after a ulipristal acetate dose to protect the infant from exposure.[6] More recent specialty-body guidance (FSRH/CoSRH) has moved toward not interrupting breastfeeding after a single dose, given the low absolute infant exposure.[8] Discuss both positions with the patient and individualize through shared decision-making, favouring levonorgestrel or the copper IUD when the patient strongly prefers to avoid any interruption to breastfeeding.
Adolescents
There is no minimum age restriction on non-prescription levonorgestrel access in Canada. Address confidentiality directly, since a young person may be accessing EC through a parent's insurance or may be worried about being asked for identification or personal details at the pharmacy counter.
Sexual assault
Offer EC alongside — not instead of — a full sexual assault response: empiric STI treatment, HIV post-exposure prophylaxis assessment, hepatitis B and HPV vaccination as indicated, forensic evidence collection coordination if the patient wants it, and referral to local sexual assault and psychosocial support services, all delivered with a trauma-informed approach.
Enzyme-inducing medications
In a patient taking (or who has recently taken) an enzyme-inducing medication (for example, carbamazepine, phenytoin, rifampin, St. John's wort), a copper IUD is preferred since its effectiveness does not depend on hepatic metabolism. When a copper IUD is not accessible or acceptable, some guidance supports a single 3 mg dose of levonorgestrel (2 x 1.5 mg tablets) as a fallback, though the added effectiveness of this higher dose in this setting is uncertain and should be presented to the patient as such, not as an equally reliable alternative.[8]
Renal and hepatic impairment
No specific dose adjustment is established for single-dose levonorgestrel or ulipristal acetate in renal impairment, given the brief exposure. Ulipristal acetate is hepatically metabolized and has not been specifically studied in significant hepatic impairment — use with added caution and consider a copper IUD or levonorgestrel instead when hepatic impairment is significant.
Immunosuppression, including solid organ transplant
Immunosuppressed patients, including solid organ transplant recipients, should generally be considered candidates for a copper IUD for EC — current evidence does not show an increased risk of systemic inflammation or infection from IUD placement in this population, and the theoretical concern reflected in some older eligibility guidance is not supported by published outcome data.[2]
Monitoring & Follow-Up
Confirm the patient understands the expected timing and character of the next period, and knows to take a pregnancy test if it is more than 3 weeks late or markedly abnormal — this is the main required follow-up for most patients, and a routine in-person or telephone follow-up visit is not otherwise required.[2] Offer or arrange prompt follow-up for STI screening and for starting an ongoing contraceptive method, since many patients who seek EC are also ready to discuss a regular method at the same visit or shortly after. Review the red-flag symptoms above so the patient knows when to seek urgent assessment rather than waiting. If a copper IUD was placed more than 5 days after the earliest unprotected intercourse episode in that cycle, confirm a negative follow-up pregnancy test given the small chance that a pre-implantation fertilized ovum was already present at the time of insertion.
Treatment Failure / Next Step
- Vomiting within 2 hours of a levonorgestrel dose, or within 3 hours of a ulipristal acetate dose: repeat the same dose, ideally with an antiemetic first; if vomiting recurs, offer a copper IUD instead if still within its window.
- Further unprotected intercourse later in the same cycle after already taking an EC pill: levonorgestrel may be repeated with no specific safety concern; ulipristal acetate repeat dosing in the same cycle is not recommended by the manufacturer and its added effectiveness is unclear — offer a copper IUD instead if accessible, or repeat levonorgestrel if a copper IUD and ulipristal acetate are not options.
- No period within 3 weeks of EC, or a markedly abnormal period: urine pregnancy test; if positive, refer promptly for pregnancy-location assessment (to exclude an ectopic pregnancy) and pregnancy-options counselling.
- Confirmed pregnancy after copper IUD placement for EC: refer urgently — a pregnancy with an IUD in place carries an elevated risk of miscarriage, preterm delivery, and septic abortion; removing the IUD during the pregnancy, if pursued, reduces but does not eliminate this elevated risk.
- Ongoing risk of repeated unprotected intercourse or inconsistent contraceptive use: use the EC encounter to start or resume a regular ongoing method, and consider an advance prescription or advance supply of EC for future need.
Common Errors to Avoid
- Delaying or withholding EC to obtain a pregnancy test first — EC should never be withheld for this reason.
- Offering only levonorgestrel without mentioning ulipristal acetate or a copper IUD as more effective options, especially beyond 72 hours or at a higher body weight.
- Telling a patient that EC disrupts or ends an existing pregnancy — this is not how any EC method works, and repeating this misinformation can needlessly increase a patient's distress or guilt.
- Starting routine hormonal contraception immediately after ulipristal acetate — this can blunt ulipristal acetate's effectiveness; wait 5 days.
- Assuming the discussion is finished once the EC dose is dispensed — always address ongoing contraception, STI risk, and, when relevant, sexual assault or intimate partner violence screening.
- Denying levonorgestrel entirely to a higher-weight patient who has no accessible alternative — some benefit likely remains even though effectiveness is reduced.
- Forgetting that levonorgestrel and ulipristal acetate are both affected by enzyme-inducing medications — a patient on one of these medications needs a copper IUD preferentially, not just a routine hormonal dose.
- Missing the opportunity to counsel on repeat dosing if vomiting occurs, leaving the patient believing the dose simply failed and taking no further action.
Clinical Decision Algorithm
Drug Tables
How to use this table: Doses are adult doses. Confirm patient-specific factors — body weight, current medications, breastfeeding status — before selecting a method. Select any drug name to open its complete Pharmasist Drug Database page.
Intrauterine device
The most effective EC option, and the only one that also provides ongoing contraception once in place.
| Drug / method | Dosage | Adverse effects | Comments |
|---|---|---|---|
| Copper IUD | Adults: Insert within 5 days of unprotected intercourse, or within 5 days of the estimated day of ovulation if that is later | Cramping, heavier or longer menses; rare uterine or cervical perforation at insertion; rare expulsion | Requires insertion by a trained provider. Exclude a pre-existing pregnancy first. Provides years of ongoing contraception if left in place.[3] |
Progestin-only oral EC
| Drug / method | Dosage | Adverse effects | Comments |
|---|---|---|---|
| Levonorgestrel | Single dose (preferred): 1.5 mg PO x 1, as soon as possible, up to 120 hours after unprotected intercourse (most effective within 24 hours; evidence of benefit beyond 96 hours is limited) Split-dose alternative: 0.75 mg PO, then a second 0.75 mg dose 12 hours later (the second dose can be delayed up to 24 hours after the first without a meaningful change in effectiveness) Enzyme-inducer exposure, copper IUD not accessible/acceptable: 3 mg PO x 1 (2 x 1.5 mg tablets) as a single dose — effectiveness at this higher dose is uncertain; a copper IUD remains preferred when accessible | Nausea, vomiting, dizziness, fatigue, headache, lower abdominal pain | Most effective within 24 hours; effectiveness declines with time and at higher body weight. Enzyme-inducing medications (e.g., carbamazepine, phenytoin, rifampin, St. John's wort) may reduce effectiveness — prefer a copper IUD in these patients. Non-prescription in Canada.[5] |
Selective progesterone receptor modulator EC
| Drug / method | Dosage | Adverse effects | Comments |
|---|---|---|---|
| Ulipristal acetate | Adults: 30 mg PO x 1, as soon as possible, up to 120 hours (5 days) after unprotected intercourse | Nausea, headache, dysmenorrhea, abdominal pain, fatigue, dizziness | More effective than levonorgestrel, particularly 72-120 hours after intercourse and at a higher body weight. Avoid in patients who have used an enzyme-inducing medication in the past 4 weeks. Delay starting hormonal contraception for 5 days afterward. Prescription only in Canada.[4] |
Estrogen-progestogen (Yuzpe) regimen — last resort only
Reserve for the rare situation where levonorgestrel, ulipristal acetate, and a copper IUD are all genuinely unavailable — this regimen is less effective and causes substantially more nausea and vomiting than the alternatives.
| Drug / method | Dosage | Adverse effects | Comments |
|---|---|---|---|
| Combined estrogen/progestogen tablets (e.g., a levonorgestrel/ethinyl estradiol product) | First dose: A tablet count providing ethinyl estradiol 100-120 mcg and levonorgestrel 0.5-0.6 mg PO, taken as soon as possible Second dose: The same tablet count PO, 12 hours after the first dose | Nausea (common), vomiting, breast tenderness, headache | The tablet count per dose depends on the specific product's ethinyl estradiol/levonorgestrel content — confirm against the product monograph actually being dispensed. Pretreat with an antiemetic.[1] |
Adjunctive antiemetic
| Drug / method | Dosage | Adverse effects | Comments |
|---|---|---|---|
| Dimenhydrinate | Adults: 50-100 mg PO, about 1 hour before each Yuzpe dose | Drowsiness, dry mouth, dizziness | Give before each dose of the Yuzpe regimen to reduce nausea/vomiting. For any hormonal EC dose, if vomiting occurs within 2 hours (levonorgestrel) or 3 hours (ulipristal acetate), repeat that dose. |
Evidence note: dosing and comments cross-checked against current SOGC, WHO, and Society of Family Planning guidance.[8]
Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.