Fraser criteria

• In the UK, people 16 years of age and older are presumed to be competent to consent to medical treatment unless otherwise demonstrated. In contrast, competence to consent to medical treatment must be demonstrated in children younger than 16 years of age.
  • In England, Wales and Northern Ireland, it is lawful to provide contraceptive advice and treatment to young people without parental consent, provided that the practitioner is satisfied that the Fraser criteria for competence are met. The criteria are that:
    • The young person understands the practitioner's advice.
    • The young person cannot be persuaded to inform their parents, or will not allow the practitioner to inform the parents, that contraceptive advice has been sought.
    • The young person is likely to begin or to continue having intercourse with or without contraceptive treatment.
    • Unless he or she receives contraceptive advice or treatment, the young person's physical or mental health (or both) are likely to suffer.
    • The young person's best interest requires the practitioner to give contraceptive advice or treatment (or both) without parental consent.
  • In Scotland, the Fraser guidelines do not apply; however, the Age of Legal Capacity Act 1991 applies similar criteria. Competence is demonstrated if the young person is able to:
    • Understand the treatment, its purpose and nature, and why it is being proposed.
    • Understand its benefits, risks, and alternatives.
    • Understand in broader terms what the consequences of the treatment will be.
    • Retain the information for long enough to use it and weigh it up in order to arrive at a decision.

Indications for emergency contraception following potential failure of regular contraception

Examples of indications for emergency contraception following potential failure of hormonal and intrauterine methods of contraception are as follows:

• Hormonal contraception methods 
  • Failure to use additional contraceptive precautions when starting the method:
    • Emergency contraception (EC) is indicated if there has been unprotected sexual intercourse (UPSI) or barrier failure during the time that additional precautions are required for that method of contraception. See the CKS topics on Contraception - combined hormonal methods, Contraception - IUS/IUD, and Contraception - progestogen-only methods for more information.
• Combined hormonal contraception (CHC)
  • Failure to use additional contraceptive precautions whilst using liver enzyme-inducing drugs or in the 28 days after use:
    • EC is indicated if there has been UPSI or barrier failure during, or in the 28 days following, use of liver enzyme-inducing drugs.
    • Offer a copper intrauterine device (Cu-IUD), which is unaffected by liver enzyme-inducing drugs or a double dose (3 mg) of levonorgestrel.
    • Ulipristal acetate is not recommended in this situation.
• Combined hormonal transdermal patch or combined hormonal vaginal ring
  • Patch detachment/ring removal for more than 48 hours, or extension of patch-free or ring-free interval by more than 48 hours:
    • EC is indicated if patch detachment occurs in week 1 and there has been UPSI or barrier failure during the hormone-free interval (HFI) or week 1.
    • If the HFI is extended, a Cu-IUD can be offered up to 13 days after the start of the HFI assuming previous perfect use.
    • If CHC has been used in the 7 days prior to EC, the effectiveness of ulipristal acetate could theoretically be reduced. Consider the use of levonorgestrel.
• Combined oral contraceptive (COC) pill (monophasic pill containing ethinylestradiol)
  • Missed pills (if two or more active pills are missed):
    • EC is indicated if the pills are missed in week 1 and there has been UPSI or barrier failure during the pill-free interval or in week 1.
    • If the pill-free interval is extended (this includes missing pills in week 1), a Cu-IUD can be offered up to 13 days after the start of the HFI assuming previous perfect use.
    • If COC is taken in the 7 days prior to or within 5 days after ulipristal EC, the effectiveness of ulipristal EC could be reduced. But stopping COC for 5 days after ulipristal could further increase the risk of ovulation in a missed COC situation. Consider use of levonorgestrel EC  with immediate continuation or restart of COC (or immediate quick start of a more effective, suitable alternative contraceptive).
• Progestogen-only pill (POP)
  • Failure to use additional contraceptive precautions whilst using liver enzyme-inducing drugs or in the 28 days after use:
    • EC is indicated if there has been UPSI or barrier failure during, or in the 28 days following, use of liver enzyme-inducing drugs.
    • Offer a Cu-IUD, which is unaffected by liver enzyme-inducing drugs or a double dose (3 mg) of levonorgestrel.
    • Ulipristal acetate is not recommended in this situation.
  • Late or missed pill (more than 27 hours since last traditional POP; more than 36 hours since last desogestrel-only pill; more than 48 hours since last active drospirenone pill was taken or more than 24 hours after a new packet of drospirenone should have been started after a hormone-free interval):
    • For traditional and desogestrel POPs, EC is indicated if a pill is late or missed and there has been UPSI or barrier failure before efficacy has been re-established (that is, 48 hours after restarting).
    • For drospirenone consider EC if:
      • Any active pill(s) were missed, and there was unprotected sexual intercourse (UPSI) from the time that the first pill was missed until correct pill-taking had resumed for 7 days.
      • Pill(s) were missed on days 1–7 of the packet, and there was UPSI during the hormone-free interview (HFI).
    • The timing of ovulation after missed pills cannot be accurately predicted. A Cu-IUD is therefore only recommended up to 5 days after the first UPSI following a missed POP.
    • If POP has been taken in the 7 days prior to EC, the effectiveness of ulipristal acetate could theoretically be reduced. Consider using levonorgestrel.
    • For more detailed information, see the section on missed pill rules in the CKS topic on Contraception – progesterone only methods.
• Progestogen-only injectable (depot medroxyprogesterone acetate [DMPA])
  • Late injection (more than 14 weeks since the last injection of DMPA):
    • EC is indicated if there has been UPSI or barrier failure more than 14 weeks after the last injection, and within the first 7 days after late injection.
    • The timing of ovulation after expiry of the progestogen-only injectable is extremely variable.
    • A Cu-IUD is only recommended up to 5 days after the first UPSI that takes place more than 14 weeks after the last DMPA injection.
    • The effectiveness of ulipristal acetate could theoretically be reduced by residual circulating progestogen. Consider using levonorgestrel.
• Progestogen-only implant (Nexplanon®) 
  • Failure to use additional contraceptive precautions whilst using liver enzyme-inducing drugs or in the 28 days after use:
    • EC is indicated if there has been UPSI or barrier failure during, or in the 28 days following, use of liver enzyme-inducing drugs.
    • Offer a copper intrauterine device (Cu-IUD), which is unaffected by liver enzyme-inducing drugs or a double dose (3 mg) of levonorgestrel.
    • Ulipristal acetate is not recommended in this situation.
  • Recently expired implant:
    • The risk of pregnancy in the fourth year of use of the progestogen-only implant is extremely low.
    • EC is unlikely to be required but may be considered.
• Copper intrauterine device (Cu-IUD)
  • Removal without immediate replacement; partial or complete expulsion; threads missing and Cu-IUD location unknown:
    • EC is indicated if UPSI has taken place in the 7 days prior to removal, perforation, or partial or complete expulsion.
    • Oral EC is indicated if there has been UPSI in the last 5 days.
    • Depending on the timing of UPSI and the time since the IUD is known to be correctly placed, it may be appropriate to fit another Cu-IUD for EC.
• Levonorgestrel-releasing intrauterine system (LNG-IUS)
  • Removal without immediate replacement; partial or complete expulsion; threads missing and LNG-IUS location unknown:
    • EC is indicated if UPSI has taken place in the 7 days prior to removal, perforation, or partial or complete expulsion.
    • Oral EC is indicated if there has been UPSI in the last 5 days.
    • Depending on the timing of UPSI and the time since the IUD is known to be correctly placed, it may be appropriate to fit a Cu-IUD for EC.

Liver enzyme-inducing drugs

• Drugs that induce liver enzymes include:
  • Antibiotics:
    • Rifampicin (potent inducer).
    • Rifabutin.
  • Antiepileptics:
    • Carbamazepine.
    • Eslicarbazepine.
    • Oxcarbazepine.
    • Phenytoin.
    • Phenobarbital.
    • Primidone.
    • Rufinamide.
    • Topiramate (weak inducer).
  • Antiretrovirals:
    • Protease inhibitors, for example, ritonavir, atazanavir, darunavir, fosamprenavir, or lopinavir.
    • Non-nucleoside reverse transcriptase inhibitors, for example, efavirenz.
    • Always use the HIV Drug Interaction Checker to identify potential interactions.
  • Others:
    • Bosentan.
    • Modafinil.
    • Aprepitant.
    • St John's Wort.

Contraindications/restrictions to the use of emergency contraception

• The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) offers guidance on the safety of different contraceptives in women with particular medical conditions or personal characteristics. When applied in a clinical setting:
  • UKMEC Category 1 indicates that there is no restriction for use.
  • UKMEC Category 2 indicates that the method can generally be used, but more careful follow up may be required. The advantages of using the method generally outweigh the theoretical or proven risks.
  • UKMEC Category 3 indicates that the method can be used; however, it may require expert clinical judgement and/or referral to a specialist contraception provider since use is not usually recommended unless other methods are not available or acceptable. The theoretical or proven risks usually outweigh the advantages of using the method.
  • UKMEC Category 4 indicates that use in that condition poses an unacceptable health risk, so the method should not be used. 

The copper intrauterine device (Cu-IUD) 

•  The Cu-IUD is a safe option for many women. However:
  • It is contraindicated (UKMEC 4) in the following circumstances: 
    • Post-abortion and postpartum sepsis.
    • Unexplained vaginal bleeding (suspicious for serious condition) before evaluation (initiation only).
    • Gestational trophoblastic disease (GTD): persistently elevated human chorionic gonadotropin (hCG) levels or malignant disease.
    • Cervical cancer: awaiting treatment (initiation only).
    • Endometrial cancer (initiation only).
    • Current symptomatic chlamydial infection (initiation only).
    • Current purulent cervicitis or gonorrhoea (initiation only).
    • Pelvic tuberculosis (initiation only).
    • Current pelvic inflammatory disease (PID) (initiation only).
  •  It should be used with caution and after consultation with an expert (UKMEC 3) in the following circumstances:
    
    • 48 hours to less than 4 weeks postpartum.
    • Organ transplant: complicated: graft failure (acute or chronic), rejection, cardiac allograft vasculopathy (all initiation only).
    • Known long QT syndrome (initiation only).
    • GTD: decreasing hCG levels.
    • Cervical cancer: radical trachelectomy.
    • Uterine fibroid with distortion of the uterine cavity.
    • Distorted uterine cavity.
    • Current asymptomatic chlamydial infection (initiation only).
    • HIV infected: CD4 count less than 200 cells/mm³ (initiation only).
    • Pelvic tuberculosis (continuation only).
• If a woman has known symptomatic Chlamydia trachomatis infection or current Neisseria gonorrhoeae infection, antibiotic treatment should be completed prior to insertion of a Cu-IUD. See the CKS topics on Chlamydia - uncomplicated genital and Gonorrhoea for more information.
• If a woman has asymptomatic C. trachomatis infection, insertion of a Cu-IUD for emergency contraception (EC) may be considered after discussion with the woman regarding risk and benefit. Treatment with appropriate antibiotics should be given at the time of insertion (or sooner if possible).

Ulipristal acetate

• UKMEC includes no contraindications to the use of ulipristal acetate EC — UKMEC 1 in most circumstances, and UKMEC 2 in:
  • Current deep vein thrombosis and pulmonary embolism (on anticoagulants).
  • Current or past breast cancer.
  • Inflammatory bowel disease (including Crohn’s disease and ulcerative colitis).
  • Acute intermittent porphyria.
• However, the manufacturer advises against use in women:
  • With severe asthma controlled with oral steroids because of the antiglucocorticoid effect of ulipristal acetate.
  • With severe hepatic impairment due to an absence of safety data. However, the College of Sexual and Reproductive Healthcare states that pregnancy poses a significant risk in women with severe hepatic impairment and expert opinion suggests that use of a single dose of ulipristal acetate 30 mg is therefore acceptable.

Levonorgestrel 

• UKMEC includes no contraindications to the use of levonorgestrel (LNG) — UKMEC 1 in most circumstances, and UKMEC 2 in:
  
  • Current deep vein thrombosis and pulmonary embolism (on anticoagulants).
  • Current or past breast cancer.
  • Inflammatory bowel disease (including Crohn’s disease and ulcerative colitis).
  • Acute intermittent porphyria.
• The manufacturer of Levonelle One Step^® states that it is not recommended in women with severe hepatic dysfunction.
  • However, the College of Sexual and Reproductive Healthcare (CoSRH) states that 'pregnancy poses a significant risk in women with severe hepatic impairment and expert opinion suggests that use of a single dose of LNG 1.5 mg is therefore acceptable'.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Emergency contraception [CoSRH, 2023a]. Recommendations are also based on the CoSRH UK Medical Eligibility Criteria Contraceptive Use: UKMEC 2016 (Amended September 2019) [CoSRH, 2019a], the CoSRH guidelines Contraceptive choices for young people [CoSRH, 2019b], Progestogen-only pills [CoSRH, 2023b] and Intrauterine Contraception [CoSRH, 2025b] and the Summaries of Product Characteristics (SPCs) for Ulipristal 30mg film-coated tablets [EMC, 2023] and Levonelle One Step® [EMC, 2025a].

• Information on the lactational amenorrhoea method (LAM) criteria is from the CoSRH guideline on Contraception after pregnancy [CoSRH, 2020].

Which emergency contraception should I offer if it is currently within 120 hours since unprotected sexual intercourse?

• If it is currently within 120 hours since the last episode of unprotected sexual intercourse (UPSI), ask whether additional UPSI has occurred in the same cycle (more than 120 hours ago):
  
  • If additional UPSI has not occurred in the same cycle:
    • Offer the copper intrauterine device (Cu-IUD). 
    • If the Cu-IUD is contraindicated or not acceptable to the woman, offer oral emergency contraception (EC) and suitable ongoing contraception.
    • If the woman needs to be referred for the Cu-IUD to be fitted, offer oral EC at the time of referral in case the Cu-IUD cannot be inserted or the woman changes her mind. 
  • If additional UPSI has occurred in the same cycle or the woman is unsure and it is currently 5 days or less after the earliest likely date of ovulation (estimated as the date of the start of the last menstrual period [LMP] plus the number of days in the shortest cycle minus 14):
    • Offer the Cu-IUD. 
    • If the Cu-IUD is contraindicated or not acceptable to the woman, offer oral EC and suitable ongoing contraception.
    • If the woman needs to be referred for the Cu-IUD to be fitted, offer oral EC at the time of referral in case the Cu-IUD cannot be inserted or the woman changes her mind. 
  • If additional UPSI has occurred in the same cycle or the woman is unsure, and it is currently more than 5 days after the earliest likely date of ovulation, or the woman is unsure:
    
    • Offer oral EC and suitable ongoing contraception.
    • Consider pregnancy testing if the earlier UPSI occurred more than 21 days ago and the woman has not had a normal menstrual period since then (that is, UPSI occurred in the same cycle). 

Choice of oral EC 

• If the last UPSI occurred between 96–120 hours ago or the woman is unsure:
  
  • Offer ulipristal acetate plus regular contraception (to be started after 5 days of taking ulipristal acetate).
  • Levonorgestrel is unlikely to be effective.
  • Reconsider the Cu-IUD if all UPSI occurred within 120 hours, or if it is currently within 5 days after the likely date of ovulation.
• If the last episode of UPSI occurred less than 96 hours ago, work out the earliest likely date of ovulation (estimated as the date of the start of the LMP plus the number of days in the shortest cycle minus 14):
  • If UPSI is likely to have taken place during the 5 days before the earliest likely date of ovulation, or the woman is unsure:
    
    • Offer ulipristal acetate plus regular contraception (to be started after 5 days of taking ulipristal acetate).
    • If ulipristal acetate is not suitable, offer levonorgestrel plus immediate quick start of suitable hormonal contraception.
    • Reconsider the Cu-IUD if UPSI is within 120 hours, or if it is currently within 5 days after likely ovulation.
  • If UPSI is unlikely to have taken place during the 5 days before the earliest likely date of ovulation, consider the woman's weight and body mass index (BMI):
    
    • If the woman's BMI is less than 26 kg/m2 or body weight is less than 70 kg, offer levonorgestrel plus immediate quick start of suitable hormonal contraception, or ulipristal acetate plus regular contraception (to be started after 5 days of taking ulipristal acetate).
    • If the woman's BMI is more than 26 kg/m2 or body weight is more than 70 kg, offer ulipristal acetate plus regular contraception (to be started after 5 days of taking ulipristal acetate), or do (3 mg) levonorgestrel plus immediate quick start of suitable hormonal contraception.
• Note that:
  • There is no evidence that oral EC is effective if ovulation has already occurred.
  • Ulipristal acetate is not suitable for use by women who have severe asthma controlled by oral glucocorticoids.

Which emergency contraception should I offer if it has been 120 hours or more since unprotected sexual intercourse (or the time is unknown)?

• If it is currently 120 hours or more since last unprotected sexual intercourse (UPSI), work out the earliest likely date of ovulation (estimated as the date of the start of the last menstrual period [LMP] plus the number of days in the shortest cycle minus 14):
  • If it is currently 5 days or less after the earliest likely date of ovulation:
    
    • Offer the copper intrauterine device (Cu-IUD) and suitable quick start contraception. 
    • Oral emergency contraception (EC) is unlikely to be effective.
  • If it is currently more than 5 days after the earliest likely date of ovulation or the woman is unsure:
    • Offer suitable quick start contraception. 
    • Oral EC is unlikely to be effective.
• If the woman is unsure how long it has been since UPSI, work out the earliest likely date of ovulation (estimated as the date of the start of the LMP plus the number of days in the shortest cycle minus 14):
  • If it is currently 5 days or less after the earliest likely date of ovulation:
    • Offer the Cu-IUD. 
    • If the Cu-IUD is contraindicated or not acceptable to the woman, offer oral EC and suitable ongoing contraception. Note that oral EC is unlikely to be effective if taken after ovulation.
    • If the woman needs to be referred for the Cu-IUD to be fitted, offer oral EC at the time of referral in case the Cu-IUD cannot be inserted or the woman changes her mind. 
  • If it is currently more than 5 days after the earliest likely date of ovulation or the woman is unsure:
    • Offer oral EC and suitable ongoing contraception. Note that oral EC is unlikely to be effective if taken after ovulation.

Choice of oral EC 

• If it is currently 120 hours or more since the last UPSI:
  • Oral EC is unlikely to be effective.
  • Consider immediate quick start of suitable hormonal contraception only.
  • Reconsider the Cu-IUD if it is currently within 5 days after likely ovulation.

Which emergency contraception should I offer to women taking certain medications?

• If the woman is taking live enzyme-inducing drugs or is within 28 days of stopping a liver enzyme-inducing drug (such as rifampicin and carbamazepine):
  
  • The copper intrauterine device (Cu-IUD) is the preferred option —  the effectiveness of oral emergency contraception could be reduced.
  • If the Cu-IUD is contraindicated or not acceptable to the woman, offer double dose (3 mg) levonorgestrel to be taken as a single dose as soon as possible and within 72 hours of unprotected sexual intercourse (UPSI). Explain to the woman that this recommendation is outside the product licence and is based on expert clinical judgement - the effectiveness of this regimen is unknown.
  • Ulipristal acetate is not recommended.
• If the woman has recently taken a product containing progestogen or progesterone (whether for contraceptive purposes, EC, gynaecological indications, or hormone replacement therapy [HRT]):
  
  • Be aware that the effectiveness of ulipristal acetate:
    • Could be reduced if the progestogen was taken in the 5 days after taking ulipristal acetate.
    • Could theoretically be reduced if the progestogen was taken in the 7 days prior to taking ulipristal acetate.
  • It is unknown whether ulipristal acetate taken when there may still be circulating progestogen is more or less effective than levonorgestrel.

Which emergency contraception should I offer to postpartum and breastfeeding women?

• In postpartum and breastfeeding women:
  • The copper intrauterine device (Cu-IUD) is suitable from 4 weeks or more postpartum.
    • Insertion of a Cu-IUD is relatively contraindicated between 48 hours and 28 days after delivery because of the possible increased risk of uterine perforation and expulsion. 
  • If the Cu-IUD is contraindicated or not acceptable to the woman, consider oral emergency contraception (EC). The choice of EC will depend on factors such as:
    • Time since unprotected sexual intercourse (UPSI) — within 120 hours since UPSI or 120 hours or more since UPSI (or time is unknown).
    • Current medications that may interact with oral EC (such as a liver enzyme-inducing drug).
    • The woman's body mass index/weight.
    • Contraindications/restrictions, for example, use of ulipristal acetate should be avoided in women who have severe asthma controlled by oral glucocorticoids.
• In breastfeeding women:
  • If levonorgestrel is prescribed, advise the woman that a small amount is excreted into breast milk. To minimize exposure to the infant, she should take levonorgestrel immediately after breastfeeding and avoid nursing for at least 8 hours following.
  • If ulipristal acetate is prescribed, advise the woman that ulipristal acetate is excreted in breast milk. The College of Sexual and Reproductive Healthcare advise that no interruption of breastfeeding is necessary following a single dose of ulipristal acetate when given for emergency contraception.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Emergency contraception [CoSRH, 2023a].

Risk of pregnancy

• Expert opinion in the CoSRH guideline is that [CoSRH, 2023a]:
  • Pregnancy is extremely unlikely to occur as a result of unprotected sexual intercourse (UPSI) in the first 3 days of a natural menstrual cycle. However, it is theoretically possible after UPSI on most days of the cycle.
  • A woman’s fertile period is considered to be the 6 consecutive days ending with (and including) the day of ovulation. In the days immediately prior to ovulation and on the day of ovulation itself, pregnancy risk following a single episode of UPSI has been estimated to be up to 30%. If a woman has one episode of UPSI in a cycle, there is a 25% chance that the UPSI takes place during her fertile period.
  • Because it can be difficult to predict whether an episode of UPSI has occurred during a woman’s fertile period, emergency contraception (EC) should be offered after UPSI on any day of a woman’s natural menstrual cycle. The choice of EC method may depend on whether it is considered likely that UPSI may have taken place during the woman’s fertile period.

When to insert a copper intrauterine device (Cu-IUD)

• This information is based on the CoSRH guidelines on Intrauterine contraception [CoSRH, 2025b] and Emergency contraception [CoSRH, 2023a].
  • The Cu-IUD can be inserted within 5 days (120 hours) after the first unprotected sexual intercourse (UPSI) in a cycle.
  • The earliest implantation is believed to occur 6 days after ovulation (and over 80% of implantations occur 8–10 days after ovulation). Therefore, a Cu-IUD can also be inserted up to 5 days after ovulation (for example, until day 19 of a regular, 28-day cycle.
    • Ovulation occurs about 14 days before the onset of menstruation.
    • It is established practice that the earliest likely ovulation date is estimated as the date of the start of the last menstrual period (LMP) plus the number of days in the shortest cycle minus 14.
    • The LMP must be accurately known and cycles must be regular in order to make the estimation.

Use of liver enzyme-inducing drugs

• The metabolism of both ulipristal acetate and levonorgestrel is increased during, and for 28 days after, use of drugs that induce liver enzymes  [CoSRH, 2023a].
• The CoSRH advises that although the clinical relevance of this interaction in terms of potential reduction in effectiveness is unknown, a Cu-IUD should be recommended for women using enzyme-inducing drugs if the criteria for use are met, as the Cu-IUD is unaffected by liver enzyme induction. Alternatively, a single dose of 3 mg levonorgestrel (double the licensed dose) can be used off-label.
• The CoSRH and the manufacturer of Levonelle One Step highlight that the effectiveness of 3 mg levonorgestrel for emergency contraception in this situation has not been studied [EMC, 2025a].
• The use of a double dose of ulipristal acetate is not recommended [CoSRH, 2023a].

Use of progestogens

• See the section on Continuing or starting contraception after ulipristal acetate for more information.

Ulipristal acetate not suitable for use by women who have severe asthma controlled by oral glucocorticoids

• The Summary of Product Characteristics (SPC) for Ulipristal 30mg film-coated tablets advises against the use of ulipristal acetate in women with severe asthma controlled with oral steroids because of the antiglucocorticoid effect of ulipristal acetate [EMC, 2023].

Ulipristal acetate and breastfeeding

• The recommendation that no interruption of breastfeeding is necessary following a single dose of Ulipristal Acetate when given for Emergency Contraception (UPA-EC) is based on the CoSRH statement Ulipristal Acetate and Breastfeeding [CoSRH, 2025a].
• Previously the CoSRH had recommended that breast milk should be expressed and discarded for one week after UPA-EC. However, given the lack of evidence relating to the effect of UPA-EC on the infants of breastfeeding women, including no published evidence of any harm and in line with recommendations from the UK Drugs in Lactation Advisory Service (UKDILAS) CoSRH issued a statement in 2025 recommending that no interruption of breastfeeding is necessary following a single dose of UPA-EC.
• At the time of writing, the BNF and the Manufacturers Summary of Product Characteristics (SPC) for Ulipristal 30 mg film-coated tablets recommend avoidance of breastfeeding for one week after intake. In addition, the manufacturer recommends to express and discard the breast milk during this time in order to stimulate lactation [EMC, 2023; BNF, 2025].

What are the possible risks and adverse effects of the copper intrauterine device?

• Possible risks and adverse effects of a copper intrauterine device (Cu-IUD) include:
  • Pain on insertion — most intrauterine contraceptive insertions are associated with mild-to-moderate pain or discomfort, but pain can range from none to severe. Analgesia/anaesthetic options should be discussed. 
  • Pelvic pain — pelvic pain or cramping has been reported by some women.  New-onset pelvic pain in an IUC user should be assessed, and pregnancy should be excluded.
  • Perforation of the wall of the uterus — this is rare (occurs in less than 2 in 1000 women). Lower abdominal pain, non-visible threads, pain during intercourse or changes in bleeding may indicate uterine perforation.
  • Expulsion — the risk of expulsion is around 1 in 20 and is more common in the first year of use, especially within the first 3 months of insertion.
    • Expulsion rates are higher when inserted immediately postpartum compared with interval postpartum insertion or insertion in individuals who have not had a recent pregnancy.
    • Expulsion rates may be higher if intrauterine contraception is inserted after late first-trimester or second-trimester surgical abortions; in people with fibroids and heavy menstrual bleeding; in people with uterine cavity distortion; in people concurrently using a menstrual cup; in those who have had a previous expulsion, in adolescents and in people with a BMI over 25.
  • Pelvic inflammatory disease (PID) — there is a low risk of PID (less than 1% of users). The risk of pelvic infection is greatest in the first 3 weeks following IUC insertion.
  • Ectopic pregnancy — the overall risk of ectopic pregnancy when using intrauterine contraception is very low. If a pregnancy occurs with intrauterine contraception in situ, the likelihood of it being ectopic is greater than if a pregnancy were to occur without intrauterine contraception in situ.
  • Unscheduled bleeding — Cu-IUD use is associated with an increase in menstrual blood loss and intermenstrual bleeding compared with natural menstrual cycles without Cu-IUD. Increased menstrual bleeding associated with Cu-IUD use will often decrease over time; however, intermenstrual bleeding is less likely to do so.
  • Malpositioning — IUC malposition is estimated to affect 7-19% of users. It is unclear if malposition affects the efficacy of the IUC.
  • Thread problems — issues with threads affect 1.4-18% of users. If no threads are visible on speculum examination, pregnancy should be excluded, EC considered, alternative contraception provided, and an ultrasound scan undertaken to locate the device. If perforation is suspected (for example the woman is in pain and this was a recent insertion), an ultrasound scan and/or plain abdominal and pelvic X-ray should be arranged as soon as possible in order to locate the device.

What are the possible risks and adverse effects of ulipristal acetate?

• Vomiting is common with ulipristal acetate.
  • If the woman vomits up to 3 hours after taking ulipristal acetate, she should take a second dose as soon as possible.
• Menstrual irregularities are also common.
  
  • If the woman has early mild bleeding or spotting, this is probably caused by ulipristal acetate and may not be the start of the next menstrual cycle. 
  • Most women will have a normal period at the expected time; some women will have their period later or earlier than normal.
  • She should have a pregnancy test if her next period is more than 7 days late or bleeding is lighter than usual.
• Ectopic pregnancy can occur if the woman becomes pregnant after ulipristal acetate; however, the risk is very small.
  • The woman should seek prompt medical attention if she experiences lower abdominal pain after taking ulipristal acetate.
  • Ectopic pregnancy may continue despite the occurrence of uterine bleeding.
  • See the CKS topic on Ectopic pregnancy for more information.
• Other possible adverse effects of ulipristal acetate include:
  • Common — mood disorders, headache, dizziness, nausea, abdominal pain/discomfort, fatigue, back pain, pelvic pain, dysmenorrhoea, breast tenderness, and myalgia.
  • Uncommon — anxiety, appetite disorder, chills, impaired concentration, diarrhoea, drowsiness, dry mouth, fever, flatulence, hot flush, increased risk of infection, insomnia, libido disorder, malaise, skin reactions, vision disorders, and vulvovaginal disorders.
  • Rare or very rare — abnormal sensation in eye, disorientation, dry throat, eye erythema, genital pruritus, ovarian cyst rupture, painful sexual intercourse, syncope, taste altered, thirst, tremor, and vertigo.

What are the possible risks and adverse effects of levonorgestrel?

• Vomiting is common with levonorgestrel.
  • If the woman vomits up to 3 hours after taking levonorgestrel, she should take a second dose as soon as possible.
• Menstrual irregularities are also common.
  
  • If the woman has early mild bleeding or spotting, this is probably caused by levonorgestrel and may not be the start of the next menstrual cycle.
  • Most women will have a normal period at the expected time; some women will have their period later or earlier than normal.
  • She should have a pregnancy test if her next period is more than 5–7 days late or bleeding is lighter than usual.
• Ectopic pregnancy can occur if the woman becomes pregnant after levonorgestrel; however, the absolute risk is likely to be low.
  • She should seek prompt medical attention if she experiences lower abdominal pain after taking levonorgestrel.
  • Ectopic pregnancy may continue despite the occurrence of uterine bleeding.
  • See the CKS topic on Ectopic pregnancy for more information.
• Other possible adverse effects of levonorgestrel include:
  • Very commonly: headache, nausea, lower abdominal pain and fatigue.
  • Commonly: dizziness, diarrhoea and breast tenderness.
  • Rarely: skin reactions, pelvic pain and facial oedema.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Emergency contraception [CoSRH, 2023a], and Intrauterine contraception [CoSRH, 2025b]; the Summaries of Product Characteristics (SPCs) for Ulipristal 30mg film-coated tablets [EMC, 2023] and Levonelle One Step® [EMC, 2025a] and the British National Formulary [BNF, 2025].

Drug interactions of the copper intrauterine device:

• There are no drug interactions.

Drug interactions of ulipristal acetate emergency contraception include:

• Liver enzyme-inducing drugs — use of ulipristal acetate emergency contraception (EC) in women who have taken enzyme-inducing drugs within the preceding 28 days is not recommended.
  • Women using an enzyme-inducing drug who require EC should be advised that the effectiveness of oral emergency contraception could be reduced.
  • Offer a copper IUD if indicated.
  • If a copper IUD is unacceptable, unsuitable or unavailable, a double dose (3 mg) of levonorgestrel oral EC or a single dose (30mg) of ulipristal acetate oral EC can be offered if indicated, with advice that effectiveness is unknown.
• Drugs that reduce gastric pH
  • Effectiveness may be reduced if taken with drugs that increase gastric pH (such as antacids, H2-receptor antagonists or proton pump inhibitors).
  • Offer a copper IUD or levonorgestrel.
  • If these are unsuitable, ulipristal acetate EC can be offered, but it is possible that effectiveness could be reduced.
• Hormonal contraception
  • Effectiveness of ulipristal acetate EC may be reduced if a progestogen (combined hormonal contraception, progestogen-only pill, progestogen-only implant, progestogen-only injectable, or levonorgestrel-releasing intrauterine system) has been used in the previous 7 days.
  • Effectiveness of ulipristal acetate EC could be reduced if a woman takes progestogen in the 5 days after taking ulipristal acetate EC — do not quick-start hormonal contraception until 5 days after ulipristal acetate EC, as this can reduce the ability to delay ovulation.
  • Advise on consistent use of condoms during the 5 days waiting and until the contraceptive method becomes effective.
  • Ulipristal acetate EC might decrease the efficacy of combined hormonal contraceptives and progesterone-only contraception (theoretical risk).
• Drugs used for the management of HIV/viral hepatitis:
  • For interactions between hormonal contraception and drugs used for the management of HIV/viral hepatitis, see the University of Liverpool HIV Drug Interaction Checker.
• For further information on drug interactions:
  • See the British National Formulary (BNF) drug interactions checker.

Drug interactions of levonorgestrel include:

• Liver enzyme-inducing drugs — use of enzyme-inducing drugs in the 28 days preceding oral emergency contraception may reduce contraceptive effectiveness.
  • Women using an enzyme-inducing drug who require emergency contraception should be advised that the effectiveness of oral emergency contraception could be reduced.
  • Offer a copper IUD if indicated.
  • If a copper IUD is unacceptable, unsuitable or unavailable, a double dose (3 mg) of levonorgestrel oral emergency contraception or a single dose (30mg) of ulipristal acetate oral emergency contraception can be offered if indicated, with advice that effectiveness is unknown.
• Drugs used for the management of HIV/viral hepatitis:
  • For interactions between hormonal contraception and drugs used for the management of HIV/viral hepatitis, see the University of Liverpool HIV Drug Interaction Checker.
• For further information on drug interactions:
  • See the British National Formulary (BNF) drug interactions checker.

Basis for recommendation

Information on drug interactions is based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Emergency contraception [CoSRH, 2023a], Intrauterine contraception [CoSRH, 2025b] and Drug interactions with hormonal contraception [CoSRH, 2022], the Summaries of Product Characteristics (SPCs) for Ulipristal 30mg film-coated tablets [EMC, 2023] and Levonelle One Step® [EMC, 2025a], and the British National Formulary [BNF, 2025].

What information and advice should I give to women using the copper intrauterine device?

• Discuss the mode of action, efficacy, advantages and disadvantages, and possible risks and adverse effects of the copper intrauterine device (Cu-IUD).
• Advise the woman:
  • On how to check for the Cu-IUD threads within the first 4-6 weeks after insertion and the importance of doing this regularly (for example, after every menstrual period). 
  • On how and when to perform a pregnancy test.
    • Pregnancy testing is advised if, after emergency contraception, the next menstrual period is delayed by more than 7 days, is lighter than usual or is associated with abdominal pain that is not typical of the woman’s usual dysmenorrhea.
  • That the device can be removed at any time if she wishes to become pregnant and there is no delay in return to fertility.
  • That the Cu-IUD does not provide protection against sexually transmitted infections (STIs). Only a barrier method of contraception (such as a condom) can reduce the risk of STIs.
• Advise the woman to seek medical advice if:
  
  • She has a positive pregnancy test.
  • Menstrual abnormalities (such as unscheduled bleeding) occur — unscheduled bleeding may be caused by the Cu-IUD itself, however other causes (such as pregnancy, infection, and intrauterine pathology) should be considered and investigated as appropriate.
  • She experiences possible features of pelvic inflammatory disease (pain or tenderness in the lower abdomen, fever, or abnormal or odorous vaginal discharge), especially within the first 3–4 weeks after insertion of the Cu-IUD. See the CKS topic on Pelvic inflammatory disease for management information.
  • She has lower abdominal pain, ‘lost threads’, pain during intercourse or changes in bleeding especially with a history of pain at the time of insertion. These may indicate uterine perforation.
  • Threads are not palpable, thread length becomes shorter or longer, or the stem of the device is felt.
  • She experiences any other adverse effect of the Cu-IUD.
• Provide information on:
  
  • The specific Cu-IUD that has been inserted and when it needs to be removed/replaced. See the CKS topic on Contraception - IUS/IUD for more information.
  • Other sources of useful information and advice regarding the Cu-IUD. For example:
    • The Family Planning Association provides patient information for women using the Cu-IUD.
    • The College of Sexual and Reproductive Healthcare has patient information on Emergency Contraception.

What information and advice should I give to a woman taking ulipristal acetate emergency contraception?

• Discuss (and provide information on) the mode of action, efficacy, advantages and disadvantages, and possible risks and adverse effects of ulipristal acetate.
• Advise the woman that:
  
  • She should take ulipristal acetate as soon as possible after unprotected sexual intercourse (UPSI), but within 120 hours.
  • If she vomits up to 3 hours after taking ulipristal acetate, she should take a second dose as soon as possible.
  • Her next menstrual period might be different:
    • If she has early mild bleeding or spotting, this is probably caused by the ulipristal acetate and may not be the start of the next menstrual cycle.
    • Most women will have a normal period at the expected time; some women will have their period later or earlier than normal.
  • Ulipristal acetate is not 100% effective. She should have a pregnancy test if her next period is more than 7 days late, if abnormal bleeding occurs at the expected date of menstrual periods or if pregnancy is suspected for any other reason.
  • The risk of ectopic pregnancy is very small. However, she should seek prompt medical attention if she experiences lower abdominal pain that is not typical of any usual dysmenorrhoea after taking ulipristal acetate.
  • Ulipristal acetate does not protect against sexually transmitted infections (STIs). Only a barrier method of contraception (such as a condom) can reduce the risk of STIs.
• If the woman is not currently using ongoing contraception:
  
  • Advise that she would need to use ongoing contraception or abstain from sex to avoid further risk of pregnancy. Ulipristal acetate:
    • Is intended for occasional use and should in no instance replace a regular contraceptive method. 
    • Does not provide contraceptive cover for the remainder of the cycle or for subsequent UPSI. There is a significantly increased risk of pregnancy with further UPSI later in the cycle in which oral emergency contraception has been taken.
    • Can be used more than once in the same cycle, but repeated administration is not advisable because of the possibility of disturbance of the cycle. See the section on Additional or advance provision of emergency contraception for more information.
  • Provide verbal and/or written information on all methods of ongoing contraception and information on how to access them.
• If the woman is continuing or starting ongoing contraception:
  • See the section on Continuing or starting contraception after ulipristal acetate for more information.
• If the woman becomes pregnant after taking ulipristal acetate:
  
  • Advise that evidence on the outcome of pregnancies exposed to ulipristal acetate is very limited. However, there have been no associated adverse outcomes with the small number of pregnancies that have been reported to date.
  • If she chooses to continue with her pregnancy, consider informing the manufacturers at the ulipristal pregnancy registry (as they are maintaining an anonymized registry to monitor outcomes of pregnancy in women exposed to ulipristal acetate in utero) and reporting to the Medicines and Healthcare products Regulatory Agency (MHRA) via the Yellow Card Scheme.
• Sources of useful patient information and advice on emergency contraception include:
  • • The Family Planning Association — Contraception Patient Information Guides.
    • The College of Sexual and Reproductive Healthcare — Emergency Contraception.

What information and advice should I give to a woman taking levonorgestrel emergency contraception?

• Discuss (and provide information on) the mode of action, efficacy, advantages and disadvantages, and possible risks and adverse effects of levonorgestrel.
• Advise the woman that:
  
  • She should take levonorgestrel as soon as possible after unprotected sexual intercourse (UPSI), but within 72 hours.
  • If she vomits up to 3 hours after taking levonorgestrel, she should take a second dose as soon as possible.
  • Her next menstrual period might be different:
    • If she has early mild bleeding or spotting, this is probably caused by levonorgestrel and may not be the start of the next menstrual cycle.
    • Most women will have a normal period at the expected time; some women will have their period later or earlier than normal.
  • Levonorgestrel is not 100% effective. She should have a pregnancy test if her next period is more than 5–7 days late or bleeding is lighter than usual.  
  • The risk of ectopic pregnancy is very small. However, she should seek prompt medical attention if she experiences lower abdominal pain that is not typical of any usual dysmenorrhoea after taking levonorgestrel.
  • Levonorgestrel does not protect against sexually transmitted infections (STIs). Only a barrier method of contraception (such as a condom) can reduce the risk of STIs.
• If the woman is not currently using ongoing contraception: 
  
  • Advise that she would need to use ongoing contraception or abstain from sex to avoid further risk of pregnancy. Levonorgestrel:
    • Is intended for occasional use and should in no instance replace a regular contraceptive method. 
    • Does not provide contraceptive cover for the remainder of the cycle or for subsequent UPSI. There is a significantly increased risk of pregnancy with further UPSI later in the cycle in which oral emergency contraception has been taken.
    • Can be used more than once in the same cycle, but repeated administration is not advisable because of the possibility of disturbance of the cycle. See the section on Additional or advance provision of emergency contraception for more information.
  • Provide verbal and/or written information on all methods of ongoing contraception and information on how to access them.
• If the woman is continuing or starting ongoing contraception:
  • See the section on Continuing or starting contraception after levonorgestrel for more information.
• If the woman becomes pregnant after taking levonorgestrel:
  
  • Advise that levonorgestrel will not interrupt an existing pregnancy, and limited epidemiological data indicate no adverse effects on the fetus. However, there are no clinical data on the potential consequences if doses greater than 1.5 mg of levonorgestrel are taken.
• Sources of useful patient information and advice on emergency contraception include:
  • The Family Planning Association — Contraception Patient Information Guides.
  • The College of Sexual and Reproductive Healthcare — Emergency Contraception.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Emergency contraception [CoSRH, 2023a] and Intrauterine contraception [CoSRH, 2025b] and the Summaries of Product Characteristics (SPCs) for Ulipristal 30mg film-coated tablets [EMC, 2023], Emerres 1.5mg tablet, [EMC, 2025b] and Levonelle One Step® [EMC, 2025a].

How should a woman continue or start ongoing contraception after ulipristal acetate emergency contraception?

• If the woman is continuing or starting combined hormonal contraception (CHC [pill, patch, and vaginal ring]) after ulipristal acetate emergency contraception (EC):
  
  • Advise that:
    • She should wait 5 days (at least 120 hours) after taking ulipristal acetate before continuing or starting CHC, with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure.
    • She should use additional contraception (such as a condom) or avoid sexual intercourse until the CHC becomes effective. See the CKS topic on Contraception - combined hormonal methods for more information.
  • There is one specific exception to this:
    • If CHC pills are restarted after a scheduled hormone-free interval and pills are then missed later in the first week of pill taking, ulipristal acetate may be considered, with immediate restart of pill taking. If ulipristal acetate is used in this specific situation, pill-taking can be resumed immediately after taking the ulipristal acetate.
• If the woman is continuing or starting progestogen-only contraception (pill, implant, and injectable) after ulipristal acetate EC:
  
  • Advise that:
    • She should wait 5 days (at least 120 hours) after taking ulipristal acetate before continuing or starting the progestogen-only contraception, with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure.
    • She should use additional contraception (such as a condom) or avoid sexual intercourse until the progestogen-only contraception becomes effective. See the CKS topic on Contraception - progestogen-only methods for more information.
• If the woman is considering starting the copper intrauterine device (Cu-IUD) after ulipristal acetate EC:
  
  • Insert the Cu-IUD within the first 5 days (120 hours) after the first episode of UPSI or within 5 days of the earliest expected time of ovulation (for example, on day 19 of a regular, 28-day cycle), whichever is later. No additional precaution is required.
  • Outside of the above criteria, do not insert the Cu-IUD until pregnancy can be excluded with a pregnancy test performed no sooner than 3 weeks after the last episode of UPSI.
  • See the CKS topic on Contraception - IUS/IUD for more information.
• If the woman is considering starting the levonorgestrel intrauterine system (LNG-IUS) after ulipristal acetate EC: 
  • Do not insert the LNG-IUS until pregnancy has been excluded with a pregnancy test performed no sooner than 3 weeks after the last episode of UPSI.
  • See the CKS topic on Contraception - IUS/IUD for more information.

How should a woman continue or start ongoing contraception after levonorgestrel emergency contraception?

• If the woman is continuing or starting combined hormonal contraception (CHC [pill, patch, and vaginal ring]) after levonorgestrel emergency contraception (EC):
  
  • Advise that:
    • She should quick start the contraception, with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure.
    • She should use additional contraception (such as a condom) or avoid sexual intercourse until the CHC becomes effective. See the CKS topic on Contraception - combined hormonal methods for more information.
• If the woman is continuing or starting progestogen-only contraception (pill, implant, and injectable) after levonorgestrel EC:
  
  • Advise that:
    • She should quick start the contraception, with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure.
    • She should use additional contraception (such as a condom) or avoid sexual intercourse until the progestogen-only contraception becomes effective. See the CKS topic on Contraception - progestogen-only methods for more information.
• If the woman is considering starting the copper intrauterine device (Cu-IUD) after levonorgestrel EC:
  
  • Insert the Cu-IUD within the first 5 days (120 hours) after the first episode of UPSI or within 5 days of the earliest expected time of ovulation (for example, on day 19 of a regular, 28-day cycle), whichever is later. No additional precaution is required.
  • Outside of the above criteria, do not insert the Cu-IUD until pregnancy can be excluded with a pregnancy test performed no sooner than 3 weeks after the last episode of UPSI.
  • See the CKS topic on Contraception - IUS/IUD for more information.
• If the woman is considering starting the levonorgestral intrauterine system (LNG-IUS) after levonorgestrel EC: 
  • Do not insert the LNG-IUS until pregnancy has been excluded with a pregnancy test performed no sooner than 3 weeks after the last episode of UPSI.
  • See the CKS topic on Contraception - IUS/IUD for more information.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guideline Emergency contraception [CoSRH, 2023a] and the Summaries of Product Characteristics (SPCs) for Ulipristal 30mg film-coated tablets [EMC, 2023] and Levonelle One Step® [EMC, 2025a], and the British National Formulary [BNF, 2025].

Continuing or starting hormonal contraceptives after ulipristal acetate emergency contraception (EC)

• Previously, it was recommended that combined hormonal contraception (CHC [pill, patch, and vaginal ring]) and progestogen-only contraception (pill, implant, and injectable) should be quick started immediately after oral EC, with a pregnancy test 21 days later to exclude pregnancy resulting from EC failure. This remains the advice after levonorgestrel EC administration, but not for ulipristal acetate.
• Evidence from a prospective, randomized, pharmacodynamic study (n = 71) identified by the CoSRH showed that starting a desogestrel progestogen-only pill (POP) immediately after ulipristal acetate reduces the ability of ulipristal acetate to delay ovulation [Brache, 2015]. There are currently no studies to investigate whether this affects pregnancy rates or whether quick starting other types of hormonal contraception (CHC and the progestogen-only implant and injectable) after ulipristal acetate has the same effect.
• Extrapolating from this evidence, the CoSRH recommends that women should wait 5 days (at least 120 hours) after taking ulipristal acetate before continuing or starting a CHC (pill, patch, or vaginal ring) or progestogen-only contraception (pill, implant, or injectable). This ensures that the ulipristal acetate is as effective as possible in preventing pregnancy resulting from the episode(s) of UPSI for which it was taken. Importantly, there is a risk of pregnancy if there is further UPSI before ongoing contraception is started and becomes effective.
• The CoSRH points out that there is one specific exception to this: if CHC pills are restarted after a scheduled hormone-free interval and pills are then missed later in the first week of pill taking, ulipristal acetate may be considered, with immediate restart of pill taking. If ulipristal acetate is used in this specific situation, pill-taking can be resumed immediately after taking the ulipristal acetate.

Basis for recommendation

These recommendations are largely based on the College of Sexual and Reproductive Healthcare (CoSRH) guidelines Emergency contraception [CoSRH, 2023a] and the Summaries of Product Characteristics (SPCs) for Ulipristal 30mg film-coated tablets [EMC, 2023] and Levonelle One Step® [EMC, 2025a],

• The CoSRH found evidence (from systematic reviews) that showed that advance provision of oral emergency contraception (EC) did not reduce pregnancy rates when compared with conventional provision, although EC was taken more frequently and sooner after UPSI if supplied in advance. However, many women in the included trials did not use EC after UPSI despite having a supply. Advance provision did not lead to increased frequency of UPSI, change in contraceptive method use, or increased risk of sexually transmitted infections (STIs).
• The CoSRH also identified a randomized trial of advance provision of levonorgestrel EC (plus condoms and an information leaflet) to teenagers in Sweden. The evidence suggested that advance provision shortened the time between UPSI and EC over the following year, without adverse effects on sexual risk-taking or contraceptive use. However, there was a significant loss to follow up in the study.