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Summary Table

Domain	Details
Definition	A contraceptive method used within 5 days of unprotected or inadequately protected sexual intercourse to reduce the risk of unintended pregnancy
Types	(1) Emergency Contraceptive Pills (ECP): Levonorgestrel (LNG), Combined estrogen-progestin (Yuzpe method), Ulipristal Acetate (UPA); (2) Copper IUD (Cu-T)
Indications	Sexual assault, unprotected intercourse, contraceptive failure (condom rupture, missed pills, late injection, IUD expulsion, failed withdrawal)
Mechanism	Primarily prevents or delays ovulation; does NOT cause abortion
Time Window	Oral ECP: within 5 days (earlier = more effective); Copper IUD: within 5 days of unprotected intercourse (or up to 5 days post-ovulation if ovulation timing can be estimated)
Most Effective Method	Copper IUD insertion as emergency contraception
Key Contraindication	Pregnancy (category NA for pills, category 4 for Copper IUD)
Keywords	"Kondar," "postcoital contraception," "morning-after pill," unprotected intercourse within 5 days, sexual assault, condom breakage

1. Mechanism of Action

Emergency contraceptive pills work primarily by preventing or delaying ovulation. This is the central teaching concept and the most tested point: ECPs do not terminate an established pregnancy, they do not disrupt implantation, and they are not abortifacients. Both the Kemenkes and BKKBN guidelines explicitly state this.

Levonorgestrel (LNG) is a synthetic progestogen. At the high doses used in emergency contraception, it suppresses the LH surge, thereby blocking follicular rupture. If ovulation has already occurred, LNG has no meaningful effect on fertilization or implantation, which is why timing matters greatly: the earlier LNG is taken after unprotected intercourse, the higher its efficacy.

Ulipristal Acetate (UPA) is a selective progesterone receptor modulator. Unlike LNG, UPA can delay ovulation even after the LH surge has already begun, which gives it a wider effective window. This is why UPA maintains higher efficacy at 72 to 120 hours compared to LNG, and why it is preferred in women with BMI above 25 kg/m², a population in which LNG performs no better than placebo according to the Kemenkes guideline footnotes.

Copper IUD works through a different pathway entirely. The copper ions released from the device create a sterile inflammatory reaction within the uterus that is toxic to sperm. This impairs sperm motility and viability, preventing fertilization. Because its mechanism is not ovulation-dependent, it is the most effective form of emergency contraception and retains full efficacy across the entire 5-day window. It also transitions directly into a long-acting reversible contraceptive method.

2. Types and Dosing Regimens

Copper IUD as Emergency Contraception

The Copper IUD (Cu-T 380A) can be inserted within 5 days of unprotected intercourse. The guidelines add an important nuance: if the timing of ovulation can be estimated, the IUD may be inserted more than 5 days after intercourse, as long as insertion occurs within 5 days after ovulation. This distinction may appear in vignettes involving women who track their cycles.

Emergency Contraceptive Pill Regimens

Type	Formulation	Dose (1st)	Dose (12 h later)	Notes
Dedicated LNG pill	1.5 mg LNG per tablet	1 tablet	0	Single-dose regimen; preferred progestin-only option
Dedicated LNG pill	0.75 mg LNG per tablet	2 tablets	0	Both tablets taken at once
Progestin-only daily pill (0.03 mg LNG)	Regular progestin-only pill	50 tablets	0	High pill count but safe
Progestin-only daily pill (0.0375 mg LNG)	Regular progestin-only pill	40 tablets	0	High pill count but safe
Dedicated combined pill	0.05 mg EE + 0.25 mg LNG	2 tablets	2 tablets	Yuzpe method
Combined OCP (low-dose)	0.03 mg EE + 0.15 mg LNG	4 tablets	4 tablets	Yuzpe method with standard COCs
Combined OCP (standard)	0.05 mg EE + 0.5 mg norgestrel	2 tablets	2 tablets	Yuzpe method with standard COCs
Ulipristal Acetate	30 mg UPA per tablet	1 tablet	0	Single dose; effective up to 120 hours

The exam loves the detail that when dedicated emergency contraceptive pills are unavailable, regular oral contraceptive pills can be substituted using the Yuzpe method. The required pill count changes depending on the formulation. Test-writers may present a scenario where a woman presents to a rural clinic without dedicated ECP stock and ask what to give and how many tablets.

3. Medical Eligibility Criteria

Pill ECP Eligibility (WHO Categories)

Condition	Combined (Yuzpe)	LNG	UPA
Pregnancy	NA	NA	NA
Breastfeeding	1	1	1
History of ectopic pregnancy	1	1	1
Obesity (BMI 30 or above)	1	1	1
Severe cardiovascular disease (IHD, stroke, thromboembolism)	2	2	2
Migraine	2	2	2
Severe liver disease (including jaundice)	2	2	2
CYP3A4 inducers (rifampicin, phenytoin, carbamazepine, phenobarbital, efavirenz, St. John's wort)	1	1	1
Repeated ECP use	1	1	1
Sexual assault	1	1	1

Category key: 1 = can be used without restriction; 2 = generally usable (benefits outweigh risks); 3 = not recommended; 4 = contraindicated.

A critical teaching point: pregnancy is listed as "NA" (Not Applicable), not as a contraindication. This reflects the fact that ECPs will not harm an existing pregnancy. They simply have no role to play once pregnancy is established.

Note the Kemenkes guideline specifically flags that pill ECP may be less effective in women with BMI 30 kg/m² or above compared to those with BMI below 25, but this is an efficacy concern, not a safety concern. The category remains 1. For overweight or obese patients, consider UPA (superior efficacy over LNG in this group) or Copper IUD (efficacy unaffected by BMI).

Copper IUD Eligibility for EC Use

Condition	Category
Pregnancy	4 (contraindicated)
Sexual assault with high STI risk	3 (not recommended)
Sexual assault with low STI risk	1

This is a high-yield distinction. In a sexual assault victim, the decision to use a Copper IUD depends on the STI risk profile. If the patient is at high risk for STIs (e.g., unknown assailant, multiple attackers, anal or genital trauma), the Copper IUD is category 3 and pills are preferred. If STI risk is low, the IUD is category 1.

4. Indications and Contraceptive Failure Scenarios

Indication	Details
Sexual assault	Always an indication
Unprotected intercourse	No contraceptive method used at all
Condom failure	Not applied correctly, slipped off, or ruptured
Diaphragm failure	Torn, cracked, or removed too early
Fertility awareness error	Miscalculation of the fertile window
Failed withdrawal	Ejaculation occurred before withdrawal
IUD expulsion	Spontaneous expulsion of an existing IUD
Missed combined OCP	3 or more pills missed, or started the new pack 3 or more days late after the pill-free interval
Late monthly injection	More than 1 week late
Late 3-monthly injection	More than 4 weeks late

The numbers to memorize: 3 missed pills, 1 week late for monthly injection, 4 weeks late for 3-monthly injection.

5. Starting or Switching to Ongoing Contraception After EC

This is where the guidelines have dense, testable content. The rules differ depending on whether the patient took LNG/combined ECP versus UPA, because UPA interacts with progestogen-containing contraceptives.

After LNG or Combined ECP (Yuzpe)

Ongoing Method	Timing	Backup Needed?
Implant	Same day as ECP	Yes, 7 days
Combined or progestin injectable	Same day as ECP	Yes, 7 days
Combined or progestin-only pill	Same day as ECP	Yes, 7 days
Copper IUD	Same day as ECP	No

The principle is simple: any hormonal method can be started immediately on the same day, but the patient needs 7 days of additional contraception (abstinence or condoms) because the new method takes time to suppress ovulation independently.

After Ulipristal Acetate (UPA)

Ongoing Method	Timing	Backup Needed?
Implant	Day 6 after UPA	Yes, from the day UPA was taken until 7 days after implant insertion
Combined or progestin injectable	Day 6 after UPA	Yes, from the day UPA was taken until 7 days after injection
Combined or progestin-only pill	Day 6 after UPA	Yes, from the day UPA was taken until 7 days after starting the pill
Copper IUD	Same day as UPA	No

The key concept here is the drug interaction between UPA and progestogens. UPA is a progesterone receptor modulator; if exogenous progestogen is introduced while UPA is still active, the two agents antagonize each other and both become less effective. That is why the guideline mandates a 6-day waiting period before initiating any progestogen-containing method after UPA.

The Copper IUD is the exception because it contains no hormones and therefore does not interact with UPA. It can be placed on the same day.

6. Side Effects and Practical Pearls

Emergency contraceptive pill side effects are generally mild and self-limiting:

Side Effect	Notes
Nausea and vomiting	More common with Yuzpe (combined) than with LNG or UPA
Irregular vaginal bleeding	Spotting or change in expected menstrual timing
Fatigue	Transient

If vomiting occurs within 2 hours of taking the ECP dose, the dose must be repeated. However, routine prophylactic anti-emetics before ECP use are not recommended by either guideline.

LNG-only pills and UPA are preferred over the Yuzpe method precisely because they cause less nausea and vomiting.

Repeated or frequent use of ECPs is not inherently dangerous for women classified as category 1 for that method. However, repeated use can lead to menstrual irregularity and is a signal that the patient should be counseled toward a regular contraceptive method. For women with conditions classified as category 2, 3, or 4 for regular combined or progestin-only pills, frequent and repeated ECP use may carry additional risk.

7. Differential Comparison

Feature	Levonorgestrel (LNG)	Ulipristal Acetate (UPA)	Copper IUD
Mechanism	Delays ovulation (pre-LH surge only)	Delays ovulation (effective even after LH surge onset)	Spermicidal inflammatory reaction
Time window	Up to 120 h (efficacy drops after 72 h)	Up to 120 h (maintains efficacy throughout)	Up to 5 days post-intercourse (or 5 days post-ovulation)
Efficacy in obesity (BMI above 25)	Reduced; no better than placebo at BMI above 25	Higher efficacy than LNG in this group	Unaffected by BMI
Most effective overall?	No	Intermediate	Yes (most effective EC method)
Hormonal interaction	None with subsequent hormonal method	Interacts with progestogens (6-day wait)	None
Transition to long-term method	Same day	Day 6	Immediate (already a long-term method)
Nausea risk	Low	Low	N/A (not a pill)
Requires trained provider?	No	No	Yes (insertion procedure)
Also provides ongoing contraception?	No	No	Yes (up to 10-12 years)

8. Traps and High-Yield Pearls

The most common way students lose points on emergency contraception questions is by confusing the switching rules after UPA versus after LNG. If a vignette shows a woman who took UPA and then asks when she can start her implant or injectable, the answer is day 6, not the same day. The reasoning is the drug-drug interaction: UPA is a progesterone receptor modulator, and simultaneous progestogen exposure reduces the efficacy of both agents.

A second classic trap is the BMI question. A vignette may present an obese woman (BMI above 25 or 30) requesting emergency contraception. Students who choose LNG will miss that, per the Kemenkes algorithm footnotes, LNG performs no better than placebo at higher BMI values. The correct answer is either UPA (better efficacy at high BMI) or Copper IUD (efficacy completely independent of body weight).

Third, students often forget that the Copper IUD is the most effective emergency contraceptive and that it doubles as immediate long-acting contraception. In any vignette where the patient has no contraindications to IUD placement and is within the time window, the IUD is the best answer, especially in a woman who also needs ongoing contraception.

Fourth, the vomiting rule: if a patient vomits within 2 hours of oral ECP, the dose must be repeated. But prophylactic anti-emetics before ECP ingestion are not standard practice per these guidelines.

Finally, remember the eligibility distinction for Copper IUD use after sexual assault. High STI risk makes the IUD category 3 (not recommended); low STI risk keeps it at category 1 (unrestricted). This is the only scenario where the Copper IUD for EC is relatively contraindicated, and test-writers use it to check whether students are thinking about the clinical context beyond just the time window.

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