Emergency Contraception Request

Clinical Scenario

Chloe Williams, 22, a final-year nursing student, calls urgently requesting the morning-after pill. She had unprotected sexual intercourse 52 hours ago after a university party. Her regular combined oral contraceptive pill was missed for 3 consecutive days during exam stress. She is anxious, embarrassed, and wants the consultation to be quick. She has not considered the copper IUD and is unaware it is the most effective option. She is otherwise well with no significant medical history.

What This Case Tests

Accurately assessing the time window for emergency contraception options; explaining the relative efficacy of levonorgestrel, ulipristal, and the copper IUD; conducting a sensitive sexual history without making the patient feel judged; discussing ongoing contraception to prevent recurrence; screening for safeguarding concerns and consent; managing the patient's urgency while being thorough

Common Mistakes Trainees Make

The three most common mistakes are: simply prescribing levonorgestrel because it is the patient's expectation, without explaining that at 52 hours the copper IUD is significantly more effective — this is a failure of informed consent; making the patient feel judged about the missed pills or the unprotected sex, which shuts down honest disclosure; and failing to screen for consent and safeguarding — a routine question in any emergency contraception consultation that should be asked sensitively and non-judgmentally.

The Consultation Challenge

Chloe wants this to be quick and is embarrassed. Honour her feelings while ensuring the consultation is thorough — rushing means missing the most effective option.

Start with warmth and normalisation: 'Hi Chloe, thanks for calling. This is something we deal with regularly, so there's nothing to feel awkward about. I want to make sure you get the best option available, so I'll need to ask a few questions — is that OK?'

Establish the timeline precisely: when was the unprotected sex (52 hours ago), when was her last period, is her cycle regular, and when were the pills missed? This determines which options are available and how urgently.

Present the options with clear comparison. At 52 hours: levonorgestrel (Levonelle) is still within the 72-hour window but efficacy has dropped to approximately 58%; ulipristal acetate (ellaOne) is effective up to 120 hours and is more effective than levonorgestrel at this time point; the copper IUD is the most effective emergency contraception at over 99% efficacy up to 5 days post-intercourse and also provides ongoing contraception.

Explain the IUD option — many patients are unaware of it: 'There's actually a third option that most people don't know about — a small copper coil that can be fitted within 5 days. It's over 99% effective, which is significantly better than either pill at this stage, and it can stay in as your ongoing contraception. Would you like to know more about that?'

If she declines the IUD, prescribe ulipristal (not levonorgestrel) as the more effective oral option at 52 hours. Important: ulipristal interacts with the combined pill — she should wait 5 days before restarting her regular pill, using barrier contraception in the interim.

Screen for consent sensitively: 'I ask everyone this — were you happy and consenting in the situation?' Frame it as routine, not accusatory.

Discuss ongoing contraception: the missed pill episode suggests the combined pill may not suit her lifestyle during exams. Explore long-acting reversible contraception (LARC) — implant or IUD/IUS — as more reliable alternatives.

Time check: Minutes 1-2 on establishing rapport and timeline. Minutes 2-5 on presenting emergency contraception options with efficacy comparison. Minutes 5-8 on IUD discussion and decision-making. Minutes 8-10 on consent screen and ongoing contraception. Final 2 minutes on prescribing, restart advice, and follow-up.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you establish an accurate timeline (hours since intercourse, LMP, pill-taking history), determine which options remain available, and ask about relevant medical history (liver disease, asthma for ulipristal, pelvic infection history for IUD). A sensitive consent screen and STI risk assessment demonstrate thoroughness without being intrusive.

Clinical Management and Medical Complexity: Examiners evaluate whether you present all three emergency contraception options with accurate efficacy data, recommend the most effective option for the time window, and manage the drug interaction between ulipristal and the combined pill correctly. Discussing ongoing LARC options and arranging follow-up shows comprehensive care beyond the immediate request.

Relating to Others: Examiners look for normalisation of the situation, non-judgemental language about the missed pills and unprotected sex, and the ability to slow the consultation down despite the patient's desire for speed. Framing the IUD discussion as 'most people don't know about this option' rather than 'you should have a coil' respects autonomy while ensuring informed choice.

Example Opening

Strong opening: "Hi Chloe, thanks for calling. I want to reassure you — this is something we help with regularly, so there's no need to feel embarrassed. To make sure I recommend the best option for you, I'll need to ask a few questions. Is that OK?"

When presenting the IUD: "I know you came in thinking about the morning-after pill, and that's absolutely an option. But there's actually a more effective choice that most people aren't aware of — a small copper coil. At 52 hours, it's significantly more effective than either pill. I'd be doing you a disservice if I didn't mention it. Would you like to hear more?"

Avoid: "You should have come in sooner" or "How did you manage to miss three pills?" — both are judgemental and shut down the therapeutic relationship.

How This Appears in the SCA

Emergency contraception tests your knowledge of time-sensitive prescribing, your ability to present options objectively including the copper IUD, and your communication skills in a potentially embarrassing consultation. Examiners value candidates who ensure informed consent by presenting all options rather than defaulting to the patient's initial request.

Key Statistic

The copper IUD is over 99% effective as emergency contraception when inserted within 120 hours of unprotected sex, compared with approximately 58% for levonorgestrel and 75% for ulipristal at 49-72 hours post-intercourse.

Relevant Guidelines

• NICE CKS: Emergency contraception
• FSRH guideline on emergency contraception (2023 update)
• FSRH guideline on combined hormonal contraception.

Frequently Asked Questions

What is the most effective emergency contraception and why is it underused?

The copper IUD is the most effective emergency contraception, with over 99% efficacy up to 120 hours post-intercourse. Despite this, it is significantly underused — most patients and many clinicians default to oral options. Barriers include lack of awareness, perceived invasiveness, and access to trained fitters. In the SCA, proactively discussing the IUD demonstrates best-practice knowledge and ensures truly informed consent. FSRH guidelines recommend it as the first-line option when feasible.

When should I prescribe ulipristal vs levonorgestrel?

Ulipristal acetate (ellaOne) is more effective than levonorgestrel (Levonelle) at all time points, but the difference becomes clinically significant beyond 24 hours. At 49-72 hours, ulipristal is approximately 75% effective versus 58% for levonorgestrel. Ulipristal works up to 120 hours; levonorgestrel only to 72 hours. Key consideration: ulipristal interacts with hormonal contraception — the patient must wait 5 days before restarting their regular pill. Levonorgestrel has no such interaction. Choose based on time since intercourse and the patient's ongoing contraception plan.

How do I screen for consent without being intrusive?

Frame it as routine practice: 'I ask everyone who comes in for emergency contraception this question — were you happy and consenting in the situation?' This normalises the question and avoids singling the patient out. If there are concerns, respond with: 'Thank you for telling me. There's support available if you'd like it — I can tell you about your options.' Don't press for details. If she discloses non-consent, this changes the consultation to a safeguarding and support pathway.

What advice do I give about restarting the combined pill after emergency contraception?

This depends on which emergency contraceptive was used. After levonorgestrel: restart the combined pill immediately (the same day or next day) and use condoms for 7 days. After ulipristal: wait 5 days before restarting the pill and use condoms during this interval and for a further 7 days after restarting. This is because the combined pill reduces ulipristal's efficacy if taken too soon. A pregnancy test should be performed 3 weeks after the episode of unprotected sex regardless of which method was used.

Should I offer STI screening in an emergency contraception consultation?

Yes, it is good practice to offer STI screening opportunistically, particularly for chlamydia and gonorrhoea in under-25s. Frame it non-judgementally: 'While you're here, would you like me to arrange an STI screen? We recommend it for anyone who's had unprotected sex, and it's a simple urine test.' Don't insist — offer and respect the response. If she declines, signpost to local sexual health services for future access. This is consistent with NICE and BASHH guidance on opportunistic screening.