Emergency Contraception - American Academy of Pediatrics
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POLICY STATEMENT Organizational Principles to Guide and Define the Child Health
Care System and/or Improve the Health of all Children
Emergency Contraception
Krishna K. Upadhya, MD, MPH, FAAP, COMMITTEE ON ADOLESCENCE
Despite significant declines over the past 2 decades, the United States abstract
continues to experience birth rates among teenagers that are significantly
higher than other high-income nations. Use of emergency contraception (EC)
within 120 hours after unprotected or underprotected intercourse can reduce
the risk of pregnancy. Emergency contraceptive methods include oral Children’s National Health System, Washington, District of Columbia
medications labeled and dedicated for use as EC by the US Food and Drug Policy statements from the American Academy of Pediatrics benefit
Administration (ulipristal and levonorgestrel), the “off-label” use of combined from expertise and resources of liaisons and internal (AAP) and
external reviewers. However, policy statements from the American
oral contraceptives, and insertion of a copper intrauterine device. Indications Academy of Pediatrics may not reflect the views of the liaisons or the
for the use of EC include intercourse without use of contraception; condom organizations or government agencies that they represent.
breakage or slippage; missed or late doses of contraceptives, including the Dr Upadhya was responsible for all aspects of revising and writing the
policy statement with input from reviewers and the Board of Directors;
oral contraceptive pill, contraceptive patch, contraceptive ring, and injectable she approves the final manuscript as submitted.
contraception; vomiting after use of oral contraceptives; and sexual assault. The guidance in this statement does not indicate an exclusive course
Our aim in this updated policy statement is to (1) educate pediatricians and of treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
other physicians on available emergency contraceptive methods; (2) provide
All policy statements from the American Academy of Pediatrics
current data on the safety, efficacy, and use of EC in teenagers; and (3) automatically expire 5 years after publication unless reaffirmed,
encourage routine counseling and advance EC prescription as 1 public health revised, or retired at or before that time.
strategy to reduce teenaged pregnancy. This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have filed
conflict of interest statements with the American Academy of
Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
BACKGROUND INFORMATION
DOI: https://doi.org/10.1542/peds.2019-3149
Emergency contraception (EC) refers to methods of contraception that are
Address correspondence to Krishna K. Upadhya, MD, MPH, FAAP. E-mail:
used after sexual intercourse to reduce the risk of pregnancy. Methods kupadhya@childrensnational.org
currently available in the United States are (1) ulipristal acetate (UPA), an
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
oral progesterone receptor agonist-antagonist; (2) levonorgestrel (LNG),
an oral progestin; (3) the copper intrauterine device (Cu-IUD); and (4) off- Copyright © 2019 by the American Academy of Pediatrics
label use of combined oral contraceptives (Yuzpe method). EC can reduce FINANCIAL DISCLOSURE: The author has indicated she has no financial
the risk of pregnancy if used up to 120 hours after unprotected relationships relevant to this article to disclose.
intercourse, and hormonal emergency contraceptive pills (ECPs) are more FUNDING: No external funding.
likely to be effective the sooner they are used.1 Use of EC after unprotected POTENTIAL CONFLICT OF INTEREST: The author has indicated she has
or underprotected intercourse remains an important strategy to reduce no potential conflicts of interest to disclose.
unintended pregnancies among adolescents and women.
By the age of 19 years, approximately two-thirds of youth will have To cite: Upadhya KK, AAP COMMITTEE ON ADOLESCENCE.
Emergency Contraception. Pediatrics. 2019;144(6):
initiated sexual intercourse.2 Most teenagers report first intercourse with
e20193149
a steady partner and consensual sex.3 Approximately 11% of US high
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PEDIATRICS Volume 144, number 6, December 2019:e20193149 FROM THE AMERICAN ACADEMY OF PEDIATRICSschool students report experiencing EC is the only contraceptive method thereby preventing the binding of
a forced sexual experience ranging designed to prevent pregnancy after progesterone, and inhibits ovulation.
from kissing to forced intercourse.4 intercourse. Indications for the use of Ulipristal, sold under the brand name
Sexual assault is 1 factor associated EC include intercourse without use of ella (Watson, Morristown, NJ), is
with risk for unintended pregnancy contraception; condom breakage or a single pill containing 30 mg of UPA
among adolescents.5 Youth with slippage; missed or late doses of and is indicated for use up to
developmental and other disabilities contraceptives, including the oral 120 hours after unprotected
may be at even higher risk of contraceptive pill, contraceptive intercourse. It is important for
experiencing sexual abuse or assault patch, contraceptive ring, and patients to be counseled that onset of
than their peers are.6,7 Improved use injectable contraception; vomiting menses after UPA use may be later
of contraception, not declines in after use of oral contraceptive pills, than expected and a pregnancy test is
sexual activity, has been the most and sexual assault. ECPs include indicated if the patient does not have
significant contributor to the decline products labeled and approved by the a period within 3 weeks. UPA is
in pregnancy risk among US US Food and Drug Administration currently available by prescription
teenagers over the past decade.8 (FDA) for use as EC (levonorgestrel only, regardless of age, and many
Pediatricians have an important role and UPA) and the off-label use of pharmacies do not have it in stock.
to play in enabling adolescent access combination oral contraceptives (the
to all available contraceptive methods Yuzpe method) that have been Progestin-Only Pills
to address the Healthy People 2020 described in the literature since Levonorgestrel EC was approved by
objective of continuing to reduce 1974.13 Insertion of a Cu-IUD within the FDA in 1999 under the brand
adolescent pregnancy in the United 5 days of unprotected intercourse is name Plan B and is currently
States.9 an additional method of EC available marketed under several names,
in the United States. Insertion of a Cu- including Plan B One Step (Teva
The most commonly used methods of IUD is the most effective method of Women’s Health, Woodcliff Lake, NJ),
contraception reported by teenagers EC and has the extra benefit of Take Action (Teva Women’s Health),
who have had intercourse in the providing ongoing contraception Next Choice One Dose (Actavis
United States are the condom, when left in place.1 Pharma, Inc, Parsippany, NJ), and My
followed by withdrawal, the oral Way (Gavis Pharmaceuticals,
Studies have shown that adolescents
contraceptive pill, and ECPs.2 Somerset, NJ). Although
are more likely to use ECPs when
Condoms are important for levonorgestrel EC originally consisted
they have been supplied or
protection against sexually of 2 pills, current regimens are
prescribed in advance of need.14 As of
transmitted infections (STIs) as well packaged as a single pill with 1.5 mg
August 2013, levonorgestrel EC is
as pregnancy, and the oral of levonorgestrel. Package labeling
approved for over-the-counter sale
contraceptive pill can be an effective indicates that levonorgestrel EC
throughout the United States to
method for pregnancy prevention; should be taken within 72 hours of
people of all ages15; however, barriers
however, both methods require strict unprotected intercourse; however,
to access include cost and availability
adherence by the user to be data support that use up to 120 hours
in pharmacies.16 Surveys suggest that
maximally effective. Withdrawal is after intercourse may prevent
most practicing pediatricians and
not recommended because of its pregnancy.23,24 Adolescents should be
pediatric residents do not routinely
relatively low effectiveness for instructed to take 1.5 mg of
counsel patients about EC and do not
pregnancy prevention and because it levonorgestrel as soon as possible
prescribe it.17–21 This policy
provides no protection against STIs. and up to 120 hours after
statement provides updated guidance
Although the American Academy of unprotected intercourse. Adolescents
on all methods of EC available to US
Pediatrics (AAP) and other medical should be aware that the medicine is
adolescents (Table 1) and ongoing
organizations recommend the use of less likely to be effective when taken
policy and access issues.
intrauterine devices (IUDs) and at 120 hours when compared with
implants as the most effective immediate use. No physical
methods for adolescents,10,11 rates of EC METHODS examination or pregnancy testing is
use of these methods remain low. The required before use. Adolescents are
EC Pills
most recent analysis from the Centers advised to test for pregnancy (at
for Disease Control and Prevention UPA Progesterone Agonist-Antagonist home or in a clinic) if they do not
(CDC) indicates that only 3% of 15- to In August 2010, the FDA approved have a period within 3 weeks of EC
19-year-olds who have ever had sex a progesterone agonist-antagonist, use. It is important for patients to
have used an IUD, and 3% report ever UPA, for use as an EC.22 UPA binds to know that levonorgestrel use may
having used an implant.12 the human progesterone receptor, cause the next period to come sooner
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2 FROM THE AMERICAN ACADEMY OF PEDIATRICSTABLE 1 Selected Regimens for EC Available in the United States
Brand First Dose Second Dose, 12 h Later Ethinyl Estradiol Levonorgestrel
per per
Dose, mg Dose, mg
Progestin-only pills
Next Choice or Plan B 2 pills None 0 1.5
Plan B One Step 1 pill None 0 1.5
Ovrette 20 pills 20 pills 0 0.75
Other ECP: ella 30 mg of UPA — — —
IUD: Paragard Insert within 120 h of unprotected Insert within 120 h of unprotected NA NA
intercourse intercourse
Combined estrogen and progestin
pills
Ovral 2 white pills 2 white pills 100 0.5
Levora 4 white pills 4 white pills 120 0.6
Nordette 4 light-orange pills 4 light-orange pills 120 0.6
Seasonale 4 pink pills 4 pink pills 120 0.6
Triphasil 4 yellow pills 4 yellow pills 120 0.5
Alesse 5 pink pills 5 pink pills 120 0.5
Additional combinations are available at https://ec.princeton.edu/questions/dose.html#dose. NA, not applicable.
than expected.1 Because use of ECPs Practice Recommendations for by the timing of use within the
may result in a delay in ovulation, it is Contraceptive Use” and professional menstrual cycle. A recently published
imperative to counsel patients to organizations such as the American meta-analysis of ECP trial data
abstain from intercourse or use College of Obstetricians and compared the effectiveness of EC
condoms for pregnancy prevention Gynecologists acknowledge the use of methods. Pooled data from trials
until the next menses. combination oral contraceptives as suggest that UPA resulted in fewer
safe and effective for EC.25,26 pregnancies than levonorgestrel did
Combined Hormonal Regimens (Yuzpe (relative risk, 0.59; 95% confidence
Method) IUD interval, 0.35–0.99; 2 randomized
The use of combination oral Studies have established that the controlled trials, n = 3448; I2 = 0%;
contraceptives for EC is commonly insertion of a Cu-IUD within 5 days of high-quality evidence).1
referred to as the Yuzpe method.13 unprotected or underprotected Levonorgestrel also resulted in fewer
Used since 1974, its acceptability and intercourse is the most effective pregnancies than the Yuzpe method
efficacy were limited by adverse method of EC.27–29 It must be did (relative risk, 0.57; 95%
effects of nausea and vomiting. The inserted by a trained provider. In confidence interval, 0.39–0.84; 6
Yuzpe method involves taking 2 doses comparison with ECPs, the randomized controlled trials, n =
of pills 12 hours apart, each effectiveness of the Cu-IUD for EC 4750; I2 = 23%; high-quality
containing a minimum of 100 µg of results from the copper component evidence).1 It should be noted,
ethinyl estradiol and a minimum of and is not believed to vary by time of however, that current CDC guidance
500 µg of levonorgestrel. Other pill insertion within 120 hours of does not indicate a preference for
formulations used for EC are included unprotected or underprotected sex. UPA over levonorgestrel regimens.
in Table 1. Similar information is The mechanisms of action of Two secondary analyses of ECP trial
available from the Office of hormonal IUDs differ from those of data identified that repeat
Population Research at Princeton the Cu-IUD, and hormonal IUDs have unprotected intercourse in the same
University, which maintains not been approved for use as EC. One cycle was associated with EC
a comprehensive source of published study found that women failure.31,32 The delay of ovulation
information on EC (http://ec. presenting for EC who desired an IUD from ECPs highlights the need for
princeton.edu/). The availability of for contraception could be offered abstinence or contraception after
many combination oral levonorgestrel ECPs and also have ECP use.
contraceptives with norgestrel or a hormonal IUD placed at the same
levonorgestrel makes this alternative visit for ongoing contraception.30
particularly helpful when there is no EFFECT OF BMI ON EFFECTIVENESS OF
or limited access to an EC product. ALL METHODS
Although combination oral COMPARATIVE EFFECTIVENESS OF ECPS Efficacy of the Cu-IUD is not affected
contraceptives have not been labeled The effectiveness of oral EC depends by body weight. CDC
specifically for EC, the CDC “Selected on inhibiting ovulation and is affected recommendations indicate that young
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PEDIATRICS Volume 144, number 6, December 2019 3women in need of EC who do not the use of UPA. Finally, repeat use of vomiting can be decreased
wish to use a Cu-IUD or who do not ECPs should prompt discussion of significantly by using an antiemetic
have access to IUD insertion should more effective, ongoing 1 hour before an estrogen-containing
be offered ECPs regardless of their contraception, but there is no specific regimen. Antiemetics are ineffective if
weight. limit on repeated use, including taken after nausea is already
Although no clinical trials have within the same cycle. As noted present.41 If vomiting occurs within
specifically evaluated the impact of below, however, the use of hormonal 3 hours of a dose, the dose should be
BMI on the effectiveness of oral EC, contraceptives within 5 days of UPA repeated. As with daily use of oral
meta-analyses have suggested that may reduce the effectiveness of UPA. contraceptives, other adverse effects
both levonorgestrel and UPA may be might include fatigue, breast
Ulipristal tenderness, headache, abdominal
less effective in adolescents and
women who are overweight.31–33 In The most common adverse effects pain, and dizziness. It should be noted
response to these data and labeling reported by users of UPA include that CDC Medical Eligibility Criteria
changes to EC products in Europe, the headache (18%), nausea (12%), and indicate that benefits of estrogen-
FDA conducted its own review of the abdominal pain (12%).36 It is containing pills for EC generally
evidence and issued a statement in recommended to redose UPA if outweigh the risks of use even in
2016 indicating that the data vomiting occurs within 3 hours of the adolescents or women with health
regarding BMI and the effectiveness initial dose. For clinicians who are conditions, such as thromboembolic
of levonorgestrel EC are conflicting providing this medication in a setting disease (ie, category 2).35
and made no labeling changes. The where the patient is discharged
before 3 hours after the dose and Cu-IUD
FDA stated that there are no safety
concerns with the use of without an ongoing relationship with The Cu-IUD can be inserted within
levonorgestrel EC in women with BMI the patient (ie, emergency 5 days of the first act of unprotected
greater than 25 or with body weight departments or urgent care), it may sexual intercourse as EC. Otherwise,
greater than 165 pounds and that the be important to discuss provisions for eligibility criteria and initiation
most important factor affecting the repeat dosing with patients if procedures for the Cu-IUD are the
medication’s effectiveness is how indicated. same for emergency or
quickly it is taken after unprotected nonemergency Cu-IUD insertion. Pain
Levonorgestrel-Only Methods with insertion is possible with use of
or underprotected intercourse.34
The most common adverse effect the Cu-IUD for EC, and some patients
reported after use of levonorgestrel may be fearful of pain and/or the
ADVERSE EFFECTS AND EC is heavier menstrual bleeding; required pelvic examination. Events
CONTRAINDICATIONS spotting may also be reported.37 The associated with ongoing use of the
The only contraindication for use of rate of nausea and vomiting with Cu-IUD include expulsion (∼6% in
EC is known pregnancy. According to levonorgestrel EC is approximately first year) and heavy menstrual
the CDC Medical Eligibility Criteria for half that with the Yuzpe method, and bleeding and/or painful periods
Contraceptive Use, pregnancy is an the routine use of antiemetics is not (∼12%). Contraindications for Cu-
absolute contraindication for indicated. If vomiting does occur IUD use include anatomic features
insertion of a Cu-IUD (category 4).35 within 3 hours of use, the dose should that prevent insertion, Wilson
ECPs are not indicated for use in be taken again. Repeated use of disease, and signs of active cervical
patients with documented or levonorgestrel EC is associated with and/or pelvic infection.35 Of note,
suspected pregnancy; however, the same adverse effects as 1-time negative STI test results are not
according to CDC Medical Eligibility use. A Cochrane Review of the subject required before the insertion of an
Criteria, no harms to the woman, found no serious adverse effects in IUD. However, if an adolescent has
pregnancy, or fetus of inadvertent trials of repeated use.38 not been screened for gonorrhea and
ECP use during pregnancy are known Chlamydia according to screening
to exist.35 Use of ECPs will not disrupt Yuzpe and Estrogen-Containing guidelines,42 screening can be
a pregnancy that is implanted in the Methods performed at the time of IUD
uterus, and ECPs are not The most common adverse effects insertion, and IUD insertion should
abortifacients. Years of use of that occur during the first 24 to not be delayed. The American College
hormonal contraceptives indicate that 48 hours of using estrogen-containing of Obstetricians and Gynecologists
there is no risk of teratogenicity from EC methods are nausea (∼50%) and Long-Acting Reversible Contraception
use of levonorgestrel EC or the Yuzpe vomiting (∼20%), which seem to be Program provides links to resources
method. There have also been no unaffected by food intake.39–41 The for clinicians who are interested in
reports of fetal malformations after severity and incidence of nausea and obtaining training on IUD insertion
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4 FROM THE AMERICAN ACADEMY OF PEDIATRICS(www.acog.org/About-ACOG/ACOG- individuals at risk of pregnancy, it is average cost of UPA in studied
Departments/Long-Acting- important for young men to be pharmacies was approximately $50.
Reversible-Contraception). counseled on this method as well as Another study of pharmacy
on condom use and the regular use of availability of UPA was conducted in
other contraceptive methods so that Massachusetts and reported that 7%
OTHER CLINICAL CONSIDERATIONS they can communicate with their at- of pharmacies surveyed had UPA in
Initiating Contraception After Use of risk partners about optimal stock.44
ECPs contraceptive use.
Although EC methods are indicated
Although there is no specific for use only in patients at risk of
contraindication for repeated use of ADOLESCENTS AND EC: AWARENESS pregnancy, previous AAP policy
EC, it should be emphasized to AND ACCESS statements advised that educating
patients that ECPs are intended for Data from the CDC indicate that the adolescent male patients is
emergency use and routine use of use of EC by female teenagers who important.45 Evidence suggests that
ECPs to prevent pregnancy is not as had sexual intercourse at least once most male teenagers are not
effective as the regular use of other has increased over the past decade knowledgeable about EC.45–47 One
forms of contraception. Ongoing from 8% in 2002 to 22% in 2011 to study conducted among an older
hormonal contraceptives may be 2013.2 This increase is likely related adolescent and young adult
initiated or resumed immediately to regulatory changes that increased population (ages 18–25 years)
after use of levonorgestrel ECPs or nonprescription access to recruited from a Job Corps site and
the Yuzpe method; however, condoms levonorgestrel EC during this time. a free clinic in Los Angeles surveyed
or abstinence should be used in Despite the FDA approval of male and female participants and
addition for 7 days for back-up levonorgestrel for over-the-counter found that 18% of male participants
protection.25 Initiation of ongoing access without an age restriction, reported having a partner who had
hormonal contraceptives after the use additional access barriers remain. In previously used EC.48 Significantly
of UPA should be delayed for 5 days its most recent survey, the American fewer male than female participants
to minimize the risk of interference Society for Emergency Contraception in that study reported having
with UPA activity.25 Prescriptions or found that only 64% of pharmacies received information about EC from
a supply of hormonal contraceptives have ECPs in stock on their shelves, a health care provider. Another study
can be given at the time of UPA and among those that do, nearly half of a younger convenience sample of
provision; however, patients should use a lock of some kind requiring sexually experienced adolescent male
be instructed not to initiate them employee assistance to obtain it from participants (ages 13–24 years) in
until 5 days after the dose of UPA. In the shelf.16 Additionally, despite Denver reported that only 42% had
addition, as with levonorgestrel or multiple brand-name and generic heard of EC.49 One study explored
the Yuzpe method, patients should be products on the market, the cost of how willing young men are to accept
counseled to abstain from intercourse levonorgestrel ECPs remains at $40 to an advanced supply of EC in a clinic
or use condoms for 7 days after the $50, on average. This cost may be setting and found that a majority who
initiation of ongoing contraception or prohibitive, so pediatricians are were offered EC accepted it.46
until the start of their next period, encouraged to be aware of other It is important that information about
whichever occurs first.25 resources for patients to obtain EC be included in all contraceptive
affordable ECPs, which may include and STI counseling for adolescents
Assessing for STI Risk college health services, school-based wherever these visits occur: the
The discussion of EC methods with clinics, or Title X clinics. Insurance primary care office, the emergency
patients must include the fact that coverage may help with the cost department, specialty clinics, or
none of these methods protect from barrier; however, coverage may vary inpatient units. Discussions should
STIs. Because of the cooccurring risk by plan. In addition to the cost include indications for use and how
of STIs, offering STI testing at the visit barrier, some stores also continue to patients can access EC in a timely
for EC or encouraging patients to enforce an unjustified age restriction fashion. Yet, provider communication
schedule follow-up visits for STI on purchase.16 about EC remains low and differs by
testing or treatment are advisable. In Access to UPA is also often limited. patient characteristics. Findings from
addition, follow-up visits are an One study in Hawaii reported data a nationally representative sample of
important time to discuss options for from a secret-shopper study of sexually active 15- to 24-year-old
ongoing contraception, abstinence, pharmacies throughout the state that women in the 2011–2015 National
and consensual intercourse. Although found that less than 3% had UPA in Survey of Family Growth found that
EC is exclusively for use by stock at the time of the request.43 The provider communication about EC
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PEDIATRICS Volume 144, number 6, December 2019 5during a visit for a pelvic examination medical discourse indicates that knowledgeable about the rights of the
or Papanicolaou test was infrequent personal values of physicians and adolescent with regard to consent for
(19%) compared with pharmacists continue to affect access contraception in their state and
communication about birth control to EC, particularly for ensure that adolescents are aware of
(67%) and differed by patient adolescents.59–63 Some physicians these rights. Pediatricians can also be
characteristics, including race and/or decline to provide EC to teenagers, an important source of information
ethnicity and insurance status.50 For regardless of the circumstance,20 and for parents to help them
example, a higher proportion of non- others may provide EC only if sexual communicate with their adolescents
Hispanic black (25%) and Hispanic assault has occurred.20,64 These and to educate them about the
(27%) women reported receiving decisions by physicians and importance of contraception and
provider counseling about EC than pharmacists have important adverse other prevention strategies to reduce
did non-Hispanic white (14%) consequences for adolescents in their risks associated with sexual activity if
women. Reasons for differences in the ability to access EC. their adolescents make the decision
reporting of counseling by race and/ to have sex.
or ethnicity have not been identified A physician’s decision to provide EC
by research to date. Adolescents with at a time of need but not in advance
disabilities (both physical and of need may be related to the SUMMARY AND RECOMMENDATIONS
cognitive) and their families should physician’s beliefs about whether it is
We recommend the following.
be counseled on EC as part of routine acceptable for teenagers to have
anticipatory guidance,51 especially sex.20 Often, physicians hold 1. Pediatricians should be aware that
conflicting values when approaching sexual behavior is prevalent
because data suggest that children
reproductive health issues with among teenagers and that many
with disabilities have 2 times the risk
teenagers. Physicians may object to sexually active teenagers may be
of being sexual assaulted compared
unprotected intercourse or the victims of sexual assault.
with children without disabilities.52
intercourse outside of marriage, but Despite the availability of
Offering advance prescription of ECPs
they may also feel the need to prevent hormonal and long-acting
is encouraged.
unwanted pregnancy among contraceptives, the pregnancy
Laws allowing minors to consent to teenagers. It is important that prevention methods most
birth control services, including EC, pediatricians are aware of the ways in commonly used by US teenagers
without parents and rights to which the underlying beliefs they are condoms and withdrawal. EC is
confidentiality vary by state. The bring to their clinical practice affect an important back-up method to
Guttmacher Institute regularly the care that they provide. which all teenagers should have
updates information on the general access.
categories of reproductive health The AAP has issued a policy
2. Indications for use of EC include
services to which minors can consent statement on refusal to provide
unprotected or underprotected
by state.53 Minors in special information or treatment on the basis
intercourse, such as failure to use
circumstances, such as those in the of conscience, stating that
any form of contraception; sexual
foster care or juvenile justice systems, pediatricians have a duty to inform
assault; and imperfect
may face unique barriers to access their patients about relevant, legally
contraceptive use (eg, condom
and confidentiality.54 State laws available treatment options to which
breakage or slippage and missed
regarding reporting age of consent for they object and have a moral
or late doses of oral contraceptive
sexual activity and mandated obligation to refer patients to other
pills, contraceptive patch,
reporting of sexual activity involving physicians who will provide and
contraceptive ring, or injectable
minors also vary by state.55 educate about those services.65
contraception).
Pediatricians may also encounter 3. Pediatricians should provide ECPs
PERSONAL BELIEFS FOR PHYSICIANS situations in which adolescents and (levonorgestrel or UPA) or Cu-IUD
AND PHARMACISTS their parents differ in their insertion to adolescents and young
Despite the fact that hormonal EC will acceptance of sexual intercourse and adults who are in immediate need
not disrupt an established pregnancy contraception. Recognizing the of EC. In addition, the AAP
and studies showing that access to EC importance of parents and families to recommends that pediatricians
does not make it more likely that adolescent health and helping provide prescriptions and/or
adolescents will engage in more sex adolescents make decisions with a supply of ECPs (with refills and
or less likely that they will use which they are comfortable can be condoms) so adolescents have
condoms or other challenging. In these cases, it is them on hand in case of future
contraceptives,56–58 public and important for pediatricians to be need (ie, advanced provision).
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6 FROM THE AMERICAN ACADEMY OF PEDIATRICSWhen a visit is not possible, ECPs Cu-IUD is not affected by weight. coverage of EC without cost
can safely be prescribed over the Patients who do not wish to use sharing to further reduce cost
phone without requiring a Cu-IUD or do not have access to barriers.
a pregnancy test. IUD insertion should be offered EC
4. ECPs are most effective in pills regardless of their weight.
LEAD AUTHORS
decreasing risk of pregnancy when 8. Repeat episodes of unprotected
used as soon as possible, but may Krishna K. Upadhya, MD, MPH, FAAP
sex during the same cycle after the
be used up to 120 hours after use of ECPs increase the risk of
unprotected or underprotected pregnancy because they work by COMMITTEE ON ADOLESCENCE, 2016–2017
intercourse. Adolescents should be delaying ovulation. Adolescents Cora C. Breuner, MD, MPH, FAAP,
instructed to use EC as soon as who use ECPs should be counseled Chairperson
possible after unprotected to abstain or use another method Elizabeth M. Alderman, MD, FAAP, FSAHM
intercourse and to then schedule Laura K. Grubb, MD, FAAP
to prevent pregnancy until their
Laurie L. Hornberger, MD, MPH, FAAP
a follow-up appointment with next period. Ongoing hormonal Makia E. Powers, MD, MPH, FAAP
their primary provider to address contraceptives may be initiated Krishna K. Upadhya, MD, FAAP
the need for STI testing and immediately after the use of Stephenie B. Wallace, MD, FAAP
ongoing contraception. levonorgestrel ECPs or the Yuzpe
5. Advanced provision of ECPs method. Ongoing hormonal LIAISONS
increases the likelihood that contraceptives should not be Liwei L. Hua, MD, PhD – American Academy
teenagers will use EC when initiated sooner than 5 days after of Child and Adolescent Psychiatry
needed, reduces the time to use, the use of UPA to minimize the Margo Lane, MD – Canadian Pediatric Society
and does not decrease condom or risk of interference with UPA Meredith Loveless, MD – American College of
Obstetricians and Gynecologists
other contraceptive use. activity. Nonhormonal methods
Seema Menon, MD – North American Society
Levonorgestrel ECPs are available (eg, condoms) may be initiated of Pediatric and Adolescent Gynecology
to male and female patients immediately after ECP use. Lauren B. Zapata, PhD, MSPH – Centers for
regardless of age without 9. The AAP recommends that all Disease Control and Prevention
a prescription but may be adolescents receive counseling
expensive when purchased over about EC as part of routine
the counter and are often covered STAFF
anticipatory guidance in the
by insurance with a prescription. Karen Smith
context of a discussion on sexual
UPA is available by prescription James Baumberger, MPP
health and family planning
only. Pediatricians should be regardless of current intentions
aware that the stock of available for sexual behavior. In addition, it
ECPs, especially UPA, may vary by ABBREVIATIONS
is important that information
pharmacy and that local patterns about EC be included in all AAP: American Academy of
of availability, cost, insurance contraceptive and STI counseling Pediatrics
coverage, and sources of low-cost for adolescents wherever these CDC: Centers for Disease Control
EC in their practice area may affect visits occur, including emergency and Prevention
the ability of their patients to departments, clinics, and hospitals. Cu-IUD: copper intrauterine device
obtain recommended services. Information provided should EC: emergency contraception
6. When a dedicated ECP product or include indications for use and ECP: emergency contraceptive pill
Cu-IUD are not options, the use of options for access, including over- FDA: US Food and Drug
combined oral contraceptive pills the-counter availability and Administration
for EC (Yuzpe method) may be advance prescription or supply if IUD: intrauterine device
recommended. Adverse effects available in the clinic. It is STI: sexually transmitted infection
may include nausea, vomiting, and important that pediatricians also UPA: ulipristal acetate
abdominal pain, and provide this counseling to
coadministration of an antiemetic adolescents with physical and
may be considered with this cognitive disabilities and their
method. parents. At the policy level, REFERENCES
7. Meta-analyses have suggested that pediatricians should advocate for 1. Shen J, Che Y, Showell E, Chen K, Cheng
both levonorgestrel and UPA may low-cost or free, nonprescription L. Interventions for emergency
be less effective in individuals access to ECPs for teenagers contraception. Cochrane Database Syst
who are overweight. Efficacy of the regardless of age and insurance Rev. 2017;8(8):CD001324
Downloaded from www.aappublications.org/news by guest on July 31, 2021
PEDIATRICS Volume 144, number 6, December 2019 72. Martinez GM, Abma JC. Sexual activity, 13. Yuzpe AA, Thurlow HJ, Ramzy I, Leyshon Available at: https://ec.princeton.edu/
contraceptive use, and childbearing of JI. Post coital contraception–A pilot news/HRA_Ella_PR.pdf. Accessed
teenagers aged 15–19 in the United study. J Reprod Med. 1974;13(2):53–58 January 7, 2019
States. NCHS Data Brief. 2015;(209):1–8 23. von Hertzen H, Piaggio G, Ding J, et al;
14. Meyer JL, Gold MA, Haggerty CL.
3. Martinez G, Copen CE, Abma JC. Advance provision of emergency WHO Research Group on Post-ovulatory
Teenagers in the United States: sexual contraception among adolescent and Methods of Fertility Regulation. Low
activity, contraceptive use, and young adult women: a systematic dose mifepristone and two regimens of
childbearing, 2006–2010 national review of literature. J Pediatr Adolesc levonorgestrel for emergency
survey of family growth. Vital Health Gynecol. 2011;24(1):2–9 contraception: a WHO multicentre
Stat 23. 2011;(31):1–35 randomised trial. Lancet. 2002;
15. Rowan A. Obama administration yields
360(9348):1803–1810
4. Kann L, McManus T, Harris WA, et al. to the courts and the evidence, allows
Youth risk behavior surveillance - emergency contraception to be sold 24. Rodrigues I, Grou F, Joly J. Effectiveness
United States, 2015. MMWR Surveill without restrictions. Available at: of emergency contraceptive pills
Summ. 2016;65(6):1–174 https://www.guttmacher.org/gpr/2013/ between 72 and 120 hours after
06/obama-administration-yields-courts- unprotected sexual intercourse. Am
5. Trent M, Clum G, Roche KM. Sexual and-evidence-allows-emergency- J Obstet Gynecol. 2001;184(4):531–537
victimization and reproductive health contraception-be-sold. Accessed
outcomes in urban youth. Ambul 25. Curtis KM, Jatlaoui TC, Tepper NK, et al.
January 7, 2019 U.S. selected practice
Pediatr. 2007;7(4):313–316
16. American Society for Emergency recommendations for contraceptive
6. Helton JJ, Gochez-Kerr T, Gruber E. Contraception. Inching towards use, 2016. MMWR Recomm Rep. 2016;
Sexual abuse of children with learning progress: ASEC’s 2015 pharmacy access 65(4):1–66
disabilities. Child Maltreat. 2018;23(2): study. Available at: http://
157–165 26. American College of Obstetricians and
americansocietyforec.org/uploads/3/4/ Gynecologists. Practice Bulletin No. 152:
7. Casteel C, Martin SL, Smith JB, Gurka 5/6/34568220/asec_2015_ec_access_ emergency contraception. Obstet
KK, Kupper LL. National study of report_1.pdf. Accessed February 13, Gynecol. 2015;126(3):e1–e11
physical and sexual assault among 2017
27. Cleland K, Zhu H, Goldstuck N, Cheng L,
women with disabilities. Inj Prev. 2008; 17. Sills MR, Chamberlain JM, Teach SJ. The Trussell J. The efficacy of intrauterine
14(2):87–90 associations among pediatricians’ devices for emergency contraception:
8. Lindberg L, Santelli J, Desai S. knowledge, attitudes, and practices a systematic review of 35 years of
Understanding the decline in regarding emergency contraception. experience. Hum Reprod. 2012;27(7):
adolescent fertility in the United States, Pediatrics. 2000;105(4, pt 2):954–956 1994–2000
2007–2012. J Adolesc Health. 2016; 18. Golden NH, Seigel WM, Fisher M, et al. 28. Wu S, Godfrey EM, Wojdyla D, et al.
59(5):577–583 Emergency contraception: Copper T380A intrauterine device for
9. US Department of Health and Human pediatricians’ knowledge, attitudes, and emergency contraception:
Services. Healthy People 2020 opinions. Pediatrics. 2001;107(2): a prospective, multicentre, cohort
objectives: family planning. Available at: 287–292 clinical trial. BJOG. 2010;117(10):
https://www.healthypeople.gov/2020/ 19. Lim SW, Iheagwara KN, Legano L, Coupey 1205–1210
topics-objectives/topic/family-planning/ SM. Emergency contraception: are 29. Turok DK, Godfrey EM, Wojdyla D, et al.
objectives. Accessed September 30, pediatric residents counseling and Copper T380 intrauterine device for
2018 prescribing to teens? J Pediatr Adolesc emergency contraception: highly
10. Ott MA, Sucato GS; Committee on Gynecol. 2008;21(3):129–134 effective at any time in the menstrual
Adolescence. Contraception for 20. Upadhya KK, Trent ME, Ellen JM. Impact cycle. Hum Reprod. 2013;28(10):
adolescents. Pediatrics. 2014;134(4). of individual values on adherence to 2672–2676
Available at: www.pediatrics.org/cgi/ emergency contraception practice 30. Turok DK, Sanders JN, Thompson IS,
content/full/134/4/e1257 guidelines among pediatric residents: et al. Preference for and efficacy of oral
11. American College of Obstetricians and implications for training. Arch Pediatr levonorgestrel for emergency
Gynecologists. ACOG Committee Opinion Adolesc Med. 2009;163(10):944–948 contraception with concomitant
No. 735: adolescents and long-acting 21. Batur P, Cleland K, McNamara M, Wu J, placement of a levonorgestrel IUD:
reversible contraception: implants and Pickle S; EC Survey Group. Emergency a prospective cohort study.
intrauterine devices. Obstet Gynecol. contraception: a multispecialty survey Contraception. 2016;93(6):526–532
2018;131(5):e130–e139 of clinician knowledge and practices. 31. Moreau C, Trussell J. Results from
Contraception. 2016;93(2):145–152 pooled Phase III studies of ulipristal
12. Abma JC, Martinez GM. Sexual activity
and contraceptive use among 22. Pharma HRA. FDA advisory committee acetate for emergency contraception.
teenagers in the United States, unanimously recommends approval of Contraception. 2012;86(6):673–680
2011–2015. Natl Health Stat Rep. 2017; HRA pharma’s ulipristal acetate for 32. Glasier A, Cameron ST, Blithe D, et al.
(104):1–23 emergency contraception. 2010. Can we identify women at risk of
Downloaded from www.aappublications.org/news by guest on July 31, 2021
8 FROM THE AMERICAN ACADEMY OF PEDIATRICSpregnancy despite using emergency contraceptive pills: a randomized trial. Children With Disabilities. Maltreatment
contraception? Data from randomized Obstet Gynecol. 2000;95(2):271–277 of children with disabilities. Pediatrics.
trials of ulipristal acetate and 2007;119(5):1018–1025
42. Workowski KA, Bolan GA; Centers for
levonorgestrel. Contraception. 2011; 53. Guttmacher Institute. Minors’ access to
Disease Control and Prevention.
84(4):363–367 contraceptive services. 2018. Available
Sexually transmitted diseases
33. Kapp N, Abitbol JL, Mathé H, et al. Effect treatment guidelines, 2015. MMWR at: https://www.guttmacher.org/state-
of body weight and BMI on the efficacy Recomm Rep. 2015;64(RR-03):1–137 policy/explore/minors-access-
of levonorgestrel emergency contraceptive-services. Accessed April
43. Bullock H, Steele S, Kurata N, et al.
contraception. Contraception. 2015; 5, 2018
Pharmacy access to ulipristal acetate
91(2):97–104 54. Dudley TI. Bearing injustice: foster care,
in Hawaii: is a prescription enough?
34. US Food and Drug Administration. FDA Contraception. 2016;93(5):452–454 pregnancy prevention, and the law. Law
communication on levonorgestrel Justice. 2013;28(1):77–115
44. Brant A, White K, St Marie P. Pharmacy
emergency contraceptive effectiveness 55. US Department of Health and Human
availability of ulipristal acetate
and weight. Available at: https://www. Services. Statutory rape: a guide to
emergency contraception: an audit
fda.gov/Drugs/DrugSafety/Postmarke state laws and reporting requirements.
study. Contraception. 2014;90(3):
tDrugSafetyInformationforPatientsa 2004. Available at: https://aspe.hhs.gov/
338–339
ndProviders/ucm109775.htm. Accessed report/statutory-rape-guide-state-laws-
January 3, 2019 45. Committee on Adolescence. Emergency and-reporting-requirements. Accessed
contraception. Pediatrics. 2012;130(6): April 12, 2018
35. Curtis KM, Tepper NK, Jatlaoui TC, et al.
1174–1182
US medical eligibility criteria for 56. Stewart HE, Gold MA, Parker AM. The
contraceptive use, 2016. MMWR 46. Garbers S, Bell DL, Ogaye K, Marcell AV, impact of using emergency
Recomm Rep. 2016;65(3):1–103 Westhoff CL, Rosenthal SL. Advance contraception on reproductive health
provision of emergency contraception outcomes: a retrospective review in an
36. US Food and Drug Administration.
to young men: an exploratory study in urban adolescent clinic. J Pediatr
Highlights of prescribing information:
a clinic setting [published online ahead Adolesc Gynecol. 2003;16(5):313–318
ella (ulipristal acetate) tablet. Revised
of print April 17, 2018]. Contraception.
March 2015. Available at: www. 57. Gold MA, Wolford JE, Smith KA, Parker
doi:10.1016/j.contraception.2018.04.005
accessdata.fda.gov/drugsatfda_docs/ AM. The effects of advance provision of
label/2015/022474s007lbl.pdf. Accessed 47. Marcell AV, Waks AB, Rutkow L, et al. emergency contraception on
January 3, 2019 What do we know about males and adolescent women’s sexual and
emergency contraception? A synthesis contraceptive behaviors. J Pediatr
37. US Food and Drug Administration.
of the literature. Perspect Sex Reprod Adolesc Gynecol. 2004;17(2):87–
Highlights of prescribing information:
Health. 2012;44(3):184–193 96
Plan B One-Step tablet (levonorgestrel)
1.5mg for oral use. Revised July 2009. 48. Schrager SM, Olson J, Beharry M, et al. 58. Raine TR, Harper CC, Rocca CH, et al.
Available at: www.accessdata.fda.gov/ Young men and the morning after: Direct access to emergency
drugsatfda_docs/label/2009/021998lbl. a missed opportunity for emergency contraception through pharmacies and
pdf. Accessed January 3, 2019 contraception provision? J Fam Plann effect on unintended pregnancy and
Reprod Health Care. 2015;41(1):33–37 STIs: a randomized controlled trial.
38. Halpern V, Raymond EG, Lopez LM.
Repeated use of pre- and postcoital 49. Richards MJ, Peters M, Sheeder J, Kaul JAMA. 2005;293(1):54–62
hormonal contraception for prevention P. Contraception and adolescent males: 59. Conard LA, Fortenberry JD, Blythe MJ,
of pregnancy. Cochrane Database Syst an opportunity for providers. J Adolesc Orr DP. Pharmacists’ attitudes toward
Rev. 2010;(1):CD007595 Health. 2016;58(3):366–368 and practices with adolescents. Arch
39. Ellertson C, Webb A, Blanchard K, et al. 50. Liddon N, Steiner RJ, Martinez GM. Pediatr Adolesc Med. 2003;157(4):
Modifying the Yuzpe regimen of Provider communication with 361–365
emergency contraception: adolescent and young females during 60. Grimes DA. Emergency contraception:
a multicenter randomized controlled sexual and reproductive health visits: politics trumps science at the U.S.
trial. Obstet Gynecol. 2003;101(6): findings from the 2011–2015 National Food and Drug Administration.
1160–1167 Survey of Family Growth. Contraception. Obstet Gynecol. 2004;104(2):
2018;97(1):22–28 220–221
40. Percival-Smith RK, Abercrombie B.
Postcoital contraception with dl- 51. Murphy NA, Elias ER. Sexuality of 61. Pruitt SL, Mullen PD. Contraception or
norgestrel/ethinyl estradiol children and adolescents with abortion? Inaccurate descriptions of
combination: six years experience in developmental disabilities. Pediatrics. emergency contraception in newspaper
a student medical clinic. Contraception. 2006;118(1):398–403 articles, 1992-2002. Contraception.
1987;36(3):287–293 2005;71(1):14–21
52. Hibbard RA, Desch LW; American
41. Raymond EG, Creinin MD, Barnhart KT, Academy of Pediatrics Committee on 62. Karasz A, Kirchen NT, Gold M. The visit
et al. Meclizine for prevention of nausea Child Abuse and Neglect; American before the morning after: barriers to
associated with use of emergency Academy of Pediatrics Council on preprescribing emergency
Downloaded from www.aappublications.org/news by guest on July 31, 2021
PEDIATRICS Volume 144, number 6, December 2019 9contraception. Ann Fam Med. 2004;2(4): contraception. Fam Pract. 2005;22(3): Pediatr Emerg Care. 2014;30(2):
345–350 280–286 84–90
63. Fairhurst K, Wyke S, Ziebland S, Seaman 64. Miller MK, Mollen CJ, O’Malley D, 65. Committee on Bioethics. Policy
P, Glasier A. “Not that sort of practice”: et al. Providing adolescent statement–Physician refusal to provide
the views and behaviour of primary sexual health care in the information or treatment on the basis
care practitioners in a study of pediatric emergency department: of claims of conscience. Pediatrics.
advance provision of emergency views of health care providers. 2009;124(6):1689–1693
Downloaded from www.aappublications.org/news by guest on July 31, 2021
10 FROM THE AMERICAN ACADEMY OF PEDIATRICSEmergency Contraception
Krishna K. Upadhya and COMMITTEE ON ADOLESCENCE
Pediatrics 2019;144;
DOI: 10.1542/peds.2019-3149 originally published online November 18, 2019;
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Krishna K. Upadhya and COMMITTEE ON ADOLESCENCE
Pediatrics 2019;144;
DOI: 10.1542/peds.2019-3149 originally published online November 18, 2019;
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