How should I incorporate emergency contraception counseling into my practice?

EMERGENCY CONTRACEPTION OVERVIEW

Counseling on emergency contraception is essential in reproductive healthcare. Emergency contraception works by various mechanisms to prevent pregnancy after inadequately protected intercourse (Table 1).^1–3 It is not an abortifacient and will not work if implantation has already occurred.¹

Options for emergency contraception approved by the US Food and Drug Administration include ulipristal acetate and oral levonorgestrel. Off-label options include the copper 380-mm² intrauterine device (IUD), the levonorgestrel 52-mg IUD, and the Yuzpe regimen (2 high doses of ethinyl estradiol plus levonorgestrel taken 12 hours apart). However, the Yuzpe regimen is less effective and less well tolerated than the other oral options.⁴

The copper IUD is the most effective form of emergency contraception, and the levonorgestrel IUD appears to be noninferior.³ Both IUDs also provide long-term contraception. Ulipristal acetate is the most effective oral emergency contraception method, particularly for patients with larger body mass indices.¹ All methods of emergency contraception can be used within 5 days of intercourse,⁴ although oral emergency contraception is more effective the sooner it is taken.

APPROPRIATE USE MAY BE LIMITED

Misconceptions and barriers limit the appropriate use of emergency contraception. Common misconceptions include its conflation with medication-induced abortion and concerns that access to emergency contraception increases risky sexual behavior or decreases use of other contraceptive methods—concerns that the literature does not support.⁵ Confusion about the legality of emergency contraception also creates misunderstandings, although no state explicitly bans its use. Barriers that limit access to emergency contraception include the following:

• State policies that allow clinicians, institutions, or insurers to refuse to dispense or cover emergency contraceptives (present in 14 states as of September 2025)⁶

• Cost due to lack of insurance or coverage specifically for emergency contraception

• Clinician time constraints and a tendency to avoid routine discussion of emergency contraception, waiting instead for patients to request it or report unprotected intercourse

• Limited availability of clinicians trained to place IUDs

• Lack of ulipristal acetate availability at pharmacies—a study of 344 pharmacies in major US cities found that less than 10% stocked ulipristal acetate.⁷

Access to emergency contraception is particularly difficult for certain populations, including adolescents, non–English-speaking women, victims of sexual assault, those who are incarcerated, and women with low income.⁵ Of note, there is no age restriction for emergency contraception.

ADVANCE PROVISION IMPROVES ACCESS

Long-standing evidence shows that prescribing oral emergency contraception before it is needed (advance provision) helps ensure timely access to emergency contraception. Multiple meta-analyses have shown that women prescribed emergency contraception in advance of need are more likely to use it and to use it sooner.^8–10 Advance provision of emergency contraception is endorsed by the American College of Obstetricians and Gynecologists⁵ to increase awareness and reduce barriers to immediate access. This is particularly important for ulipristal acetate given its greater efficacy and its added barrier of being prescription only.

CANDIDATES FOR EMERGENCY CONTRACEPTION

All patients at risk of unintended pregnancy should be counseled on emergency contraception and offered a prescription in advance of need. This includes patients at risk of contraceptive failure due to incorrect or inconsistent use (eg, missed doses of oral contraceptives); those using less effective methods such as condoms, spermicide, withdrawal, diaphragms, or fertility-based awareness; those electing no method; those experiencing sexual assault, reproductive coercion, or relationship violence; and those facing barriers to healthcare.

There are no medical contraindications to oral emergency contraception, and no examination or testing is needed before it is used. Its use is not recommended with known or suspected pregnancy as it will be ineffective if implantation has already occurred; however, there is no known harm to the fetus or pregnancy if oral emergency contraception is used in this setting.¹¹

PRACTICAL COUNSELING STRATEGIES

Reproductive goals

Counseling can be initiated by asking women with reproductive capability about their desire to become pregnant. One Key Question (“Would you like to become pregnant in the next year?”) is a commonly used tool for pregnancy intention screening.¹² Patients who do not desire immediate pregnancy present an opportunity to discuss contraception, including emergency contraception and advance provision, particularly for patients who choose a less effective method or no method. This discussion is not limited to clinic visits and can also be initiated on hospital discharge. Figure 1 reviews how to incorporate advance provision of emergency contraception into contraception counseling.

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Figure 1

Contraception counseling that incorporates advance provision of emergency contraception.

THE BOTTOM LINE

Routine counseling on reproductive goals is essential. Patients who do not currently desire pregnancy but decline contraception or choose a less effective method should be counseled on emergency contraception and offered a prescription for ulipristal acetate in advance of need. Advance provision ensures patients can quickly take emergency contraception if needed to reduce risk of unintended pregnancy.

DISCLOSURES

The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.