Insert logo of authorising body
Additional organisational logo(s) as agreed locally
This Patient Group Direction (PGD) must only be used by registered community
pharmacists who have been named and authorised by their organisation to practice
under it. The most recent and in date final signed version of the PGD should be used.
Patient Group Direction
for the supply and/or administration of
Levonelle® 1500 microgram tablets
by registered community pharmacists for
Emergency Hormonal Contraception
in Cheshire and Merseyside
Version number: 1.0
Change history
Version
number
Change details
Date
PGD development
Name
Job title and organisation
Signature
Date
Signature
Date
Signature
Date
Lead author
Lead doctor (or dentist)
Dr Nicola Mullin
Lead pharmacist
Helen Stubbs
Representative of other
professional group using PGD
Jayne Fortune
Other members of the PGD
working group
Dr Ifeoma Onyia
Dr Jane Wilkinson
Dr Joanna Cartwright
Melanie Carroll
PGD authorisation
Name
Job title and organisation
Senior doctor (or dentist)
Senior pharmacist
Senior representative of
professional group using the
PGD
Person signing on behalf of
authorising body
PGD adoption by the provider
Name
Signatures to be determined
locally, if relevant
Job title and organisation
Training and competency of registered community pharmacists
Requirements of registered community pharmacists working under
the PGD
Qualifications and
professional
registration
Initial training
Community Pharmacists currently registered with the General
Pharmaceutical Council (GPhC), who are working in a pharmacy
contracted to NHS England (Mersey) or NHS England (Cheshire,
Warrington and Wirral)
The Pharmacist must have completed the following Continuing
Pharmacy Post Graduate Education (CPPE) open learning
packs:
Safeguarding: a guide for the pharmacy team
Contraception
Emergency Hormonal Contraception
Undertake appropriate training for working under Patient Group
Directions (PGDs) for the supply and administration of
medicines.
Must handle all requests for emergency hormonal contraception
in a sensitive and non-judgmental manner, and act in
accordance with guidance issued by the General
Pharmaceutical Council on consent, raising concerns and
confidentiality.
Competency
assessment
The pharmacist must satisfy the requirements of CPPE SelfAssessment of Competence for Community Pharmacy for
Emergency Contraception
The Pharmacist must have achieved the competency levels
specified in the NICE Competency Framework for Health
Professionals using Patient Group Directions
http://www.nice.org.uk/mpc/goodpracticeguidance/GPG2.jsp
Ongoing training
and competency
Provide a regular self assessment declaration of competency
every two years or sooner if appropriate.
It is the responsibility of the pharmacist to undertake Continual
Professional Development
Clinical condition
Clinical condition or
situation to which
this PGD applies
Inclusion criteria
Prevention of pregnancy from unprotected sexual intercourse (UPSI)
e.g. no contraception used or failure of usual method
Any woman of child bearing age, presenting within 120 hours of UPSI
(use after 72 hours is outside the Product Licence but is allowed under
this PGD)
Failure of normal contraceptive method (see Appendix E)
Severe diarrhoea and/or vomiting which may have reduced oral
contraceptive efficacy
A woman presenting up to 72 hours who does not fit the criteria for
ellaOne®
A woman presenting after 72 and up to 120 hours who chooses not to
be referred to another healthcare provider for ellaOne® or for whom
ellaOne® is contraindicated
A woman being referred for an intrauterine device (IUD)
Women who have previously been supplied with levonorgestrel during
the cycle in question
A relevant history should be taken to establish whether the woman is
actually or possibly pregnant, and a pregnancy test performed if
appropriate (se Appendix C).
Valid consent. Refer to GPHC guidance on consent. If a woman is
under 16 years of age there should be an assessment of Fraser
Ruling of Competence’ or valid parent/guardian consent
(see
Appendix D).
Exclusion criteria
A woman presenting following most recent UPSI more than 120 hours
(NB – IUD may still be an option)
No valid consent, as above or treatment refused
Confirmed pregnancy (if pregnancy suspected please see Appendix c
for action)
Knowingly supplying to a third party on behalf of client
Known hypersensitivity to levonorgestrel or any ingredient contained
in the product (note tablets contain lactose) has experienced any
severe clinical problems with progestogens, apart from nausea
Less than 21 days post partum
A woman who is being referred for ellaOne®
ellaOne®:
Any woman who is going to take ellaOne® should not receive
Levonelle® immediately prior to this so there are some ellaOne
considerations which need to be take into account before
deciding to NOT provide Levonelle®.
Please refer to Appendix G it is essential that you have
established the pathway for the woman for obtaining ellaOne®
before deciding not to issue Levonelle®.
Cautions (including
any relevant action to
be taken)
An IUD is the most effective means of post coital contraception
and this option must be discussed with the woman. In instances
where an IUD is acceptable to the woman, continue to supply
Levonelle® 1500 in case the IUD fitting is not done or proves
unsuitable.
If pregnancy is suspected. Take a sexual and menstrual history (see
Appendix C) it may be appropriate to do a pregnancy test. If this is
negative the emergency hormonal contraception may be given under
this PGD where the woman presents within 120 hours of the last
UPSI. If it is not possible to do a pregnancy test to be accurate and no
other contraindication exist, supply Levonelle.
If there are multiple episodes of UPSI during the cycle in question the
above applies but in addition refer to the GP or Community Sexual
and Reproductive Health Clinic for advice.
If Levonelle is used more than once in a cycle, need to advise the
woman that she may have a delayed period or irregular bleeding.
Patients currently taking enzyme inducing drugs:
Enzyme inducers e.g. carbamazipine, griseofulvin, phenytoin,
primidone and other barbiturates, ritonavir, topiramate, nevirapine,
rifabutin, rifampicin or St John’s Wort – see section on drug dosage
Patients currently taking anticoagulant drugs: The anticoagulant
effects may be altered following treatment with levonorgestrel. Women
must be advised to give extra attention to anticoagulant monitoring.
Failure of levonorgestrel and ectopic pregnancies: The Medicine and
Health Care Products Regulatory Agency (MHRA) has advised that
the possibility of an ectopic pregnancy must be considered in
particular in women with a previous history of ectopic pregnancy,
fallopian tube surgery or pelvic inflammatory disease.
Women with a history of any of the following: any current liver disease
Unexplained vaginal bleeding
Vomiting associated with previous taking
Acute active porphyria
Should be issued with Levonelle® 1500 and referred for clinical
advice.
If the woman vomits within 2 hours of taking Levonelle® 1500 the
course may be repeated, provided that the new dose is still within 120
hours of the most recent episode of UPAI in that cycle. Anti-emetics
may be recommended. Alternatively the woman may be referred for
an IUD.
If the new dose would be later than 120 hours after the most recent
episode of UPSI in that cycle, it may still be possible to fit an IUD.
Refer to a Community Sexual and Reproductive Health doctor or GP if
you believe the woman fits this criteria.
Medicines containing levonorgestrel may increase the risk of
ciclosporin toxicity
There is no evidence to date that the hormones used postcoitally carry
any risk of teratogenicity should the method fail and a pregnancy
occur.
Note: non liver enzyme inducing antibiotics DO NOT interact with
levonorgestrel.
Arrangements for
referral for medical
advice
Know the referral pathway into local sexual and reproductive health
services or how to contact the local lead doctor for sexual and
reproductive health for medical advice.
Action to be taken if
patient excluded
Document exclusion criteria, discuss alternative measures and refer to
a Community Sexual and Reproductive Health doctor or GP as
appropriate. For those presenting more than 120 hours after UPSI an
IUD may be an option. Warn the woman that a delay in starting
treatment may compromise its efficacy
Visitors from countries outside the EU are entitled to access this free
service on the NHS.
Action to be taken if
patient declines
treatment
Record decision in the patient clinical record
Discuss alternative and refer to a Community Sexual and
Reproductive Health clinic or GP
Details of the medicine
Name, form and
strength of medicine
Levonorgestrel 1500 microgram tablet
( Levonelle 1500®)
Legal category
Indicate any off-label
use (if relevant)
Route/method of
administration
POM
Dose and frequency
Quantity to be
administered and/or
supplied
Maximum or
minimum treatment
period
Adverse effects
Records to be kept
May be taken from 73-120 hours following UPSI
Oral
The earlier in the 120 hour period the tablets are taken the greater
the efficacy.
It is recommended that the woman takes the tablet(s) whist in the
pharmacy
If the tablet(s) are not taken in the pharmacy:
Advise the woman to take the tablet(s) as soon as possible
Highlight the presence of a patient information leaflet in the pack(s)
The pack(s) should be labelled with the woman’s name, date of
issue, directions for use, the pharmacy address and ‘keep out of
reach of children’.
1500 micrograms or 3 gram if a double dose is required, as a single
course
Either
• One tablet to be taken as a single dose as soon as possible
after UPSI or
• Two tablets to be taken as a single dose as soon as possible
after UPSI for a patient taking enzyme-inducing drugs (or
within 28 days of stopping) or with severe malabsorption
problem.
This advice is outside the terms of the product licence but is in
accordance with the Clinical Effectiveness Unit of the Faculty of
Sexual and Reproductive Healthcare Guidance (FSRH)
As often as required, although women returning for repeat dosage
should be advised to seek a reliable ongoing method of
contraception from their GP or Community Sexual and Reproductive
Health clinic
Vomiting 1%, nausea 14%
Alteration in timing of next period
For less frequent undesirable effects affecting<1% of patients see
patient Information Leaflet, Summary of Product Characteristics and
current BNF
A consultation proforma for the 'Supply and Administration of
Levonelle 1500®' must be fully completed and signed for all
consultations, irrespective of whether a supply is made.
This can be a paper or electronic version (or both).
A Fraser Ruling Assessment of Competency' form must be
completed for all women under 16 years of age.
Consultation and Fraser Ruling proformas must be signed by the
pharmacist and the woman.
Patient information
Written information to be
given to patient or carer
Follow-up advice to be
given to patient or carer
Give woman a copy of any relevant patient
information leaflet and discuss as required e.g.
failure rate (1-3 women out of100 will become
pregnant despite taking EHC. An IUD has negligible
failure rate)
Supply woman with appropriate leaflets and
information about local Sexual and reproductive
Health Services
Explain other available treatment option including an
IUD.
Explain treatment and administration including
advice if vomiting occurs.
Advise the patient that the drug given at this
consultation for this episode of UPSI, will have no
effect for previous risks 9UPSI) i.e. more than 120
hours ago.
Advise that if vomiting should occur within 2 hours of
taking Levonelle 1500 to seek immediate advice from
a Community Sexual and Reproductive Health clinic,
pharmacist or GP.
Advise patient that she could still become pregnant,
If next period is delayed by more than 7 days or is
abnormal in any way (light, heavy or painful0, patient
should seek medical advice.
If a pregnancy has occurred, following failure of
levonorgestrel treatment, the patient should contact a
Community Sexual and Reproductive Health clinic or
GP for further advice.
Seek medical advice if there is any lower abdominal
pain because this could signify an ectopic
pregnancy, although women who become pregnant
after taking EHC are not at higher risk of ectopic
pregnancy compared to women who have not taken
EHC.
Stress the need to use a reliable ongoing method of
contraception.
Discuss sexually transmitted infection risk and
condom use.
If further dose(s) are given in the same cycle, the
woman should be advised that levonorgestrel may
cause disturbance of subsequent cycles.
For breast feeding mothers: a very small amount of
levonorgestrel is excreted in breast milk, although
there is no evidence that this is harmful.
Emergency contraception is an occasional method. It
should in no instance replace a regular method of
contraception.
Appendices
Appendix A Key references
1. Emergency Contraception Guidelines, Faculty of Sexual & Reproductive Health
Clinical Effectiveness Unit (2012) http://www.fsrh.org
2. Faculty of Sexual & Reproductive Healthcare Guideline “Missed pill
recommendations” May 2011
3. GPhC Guidance – Consent 2012, Raising Concerns 2012 , and Confidentiality
2012
4. http://www.pharmacyregulation.org/standards/guidance
5. Summary of Product Characteristics for Levonelle 1500® available on
www.medicines.org.uk accessed 3rd February 2013.
6. Current BNF chapter 7.3.1
7. Drug Interactions with ellaOne® Faculty of Sexual & Reproductive Healthcare
Clinical Guidance (updated 2012)
8. NICE Good Practice Guidance on Patient Group Directions and the
Competency framework for healthcare professionals using Patient Group
Directions http://www.nice.org.uk/mpc/goodpracticeguidance/GPG2.jsp
Appendix B – Community Pharmacist’s agreement to practise under the
levonorgestrel 1500mg PGD for Community Pharmacists
I have read and understood the Patient Group Direction and agree to supply and/or
administer this medicine only in accordance with this PGD.
Full Name (print)
GPhC number
Signature
Date
Appendix C - Clinical Condition Notes
A relevant medical history must include:






Age
Date of first day of last menstrual period, and normal cycle length
Number of hours since intercourse and day of cycle on which unprotected intercourse took
place (first day of period = day 1 of cycle)
Any other episodes of unprotected intercourse since last period
Past medical history, current medication
Pregnancy tests if suspected
Reasons for usual method failure may include:

Misplaced / dislodged diaphragm / incorrect insertion / torn / removed too early.

Condom breakage /leakage /ejaculation on external genitalia.

IUD failure – complete or partial expulsion or removal considered necessary

Miscalculation of fertility awareness method

Reduced contraceptive protection because of e.g. severe diarrhoea and vomiting which may
have reduced oral contraceptive efficacy

Missed or late contraceptive pill COC or Progestogen only contraceptive (POP) (further
notes available in BNF chapter 7.3.1)

If the combined vaginal ring (CVR) (NuvaRing ®)
o
o
o
o
Has been left in for more than 4 weeks
A new ring has not been inserted following the 7day break
If the ring has been expelled from the vagina either spontaneously or during intercourse
and not replaced within 3 hours
Expelled more than once per cycle

Allowed more than 14 weeks (98 days) to elapse since the last medroxyprogesterone
acetate (Depo Provera) contraceptive injection.

Has vomited within 2 hours of taking levonorgestrel 1500microgram tablet (see use outside
Product Licence)

Using contraceptive patch which becomes partially or fully dislodged or missed the change
day (refer to current SPC for further advice)

Barrier method failure in women on the COC/POP/Progestogen implants or CVR who are
also taking liver enzyme inducing drugs (and for 28 days after stopping the liver enzyme
inducing drugs).
Appendix D
Advice to Young People Under 16
In considering the provision of advice or treatment on contraception, doctors and other professional
staff need to take special care not to undermine parental responsibility and family stability. The
doctor or other professional should therefore always seek to persuade the young person to tell the
parents or guardian (or other person in loco parentis), or to let her inform them, that contraceptive
advice is being sought and the nature of any advice or treatment that is given. It should be most
unusual for a doctor or other professional to provide advice or treatment in relation to contraception
to a young person under 16 without parental knowledge or consent.
Exceptionally, there will be cases where it is not possible to persuade the young person either to
inform the parents or to allow the doctor or other professional to do so. This may be, for example,
where family relationships have broken down. In such cases, a doctor or other professional would
be justified in giving advice and treatment without parental knowledge or consent, provided he
followed the Fraser Guidelines.
FRASER GUIDELINES
In law young people under 16 years are entitled to confidentiality in the same way as over 16 year
olds. In 1985 Lord Fraser established the current legal position that a doctor or other professional
can give contraceptive advice or treatment to a person under 16 without parental consent providing
they are satisfied that:





The young person will understand the risks and benefits of the treatment offered and the
advice given.
The young person cannot be persuaded to tell his or her parents or allow a health
professional to inform them that he or she is seeking contraception advice.
The young person is likely to begin or continue having intercourse with or without
contraceptive treatment.
Unless he or she receives contraceptive advice the young person’s physical or mental health
is likely to suffer.
It is in the young person’s best interests to give them contraceptive advice or treatment.
Reference Gillick v West Norfolk & Wisbech Area Health Authority (1984) AC 1121 ALL ER

Where there are concerns about children and young people’s welfare appropriate actions should
be taken to address those concerns, working to agreed local policies and procedures. Refer to
Safeguarding Children Flow Chart for Referral.
MEDICOLEGAL ASPECTS
Medical legal aspects regarding supply to under 16 year olds
1. It’s illegal for them to be having sex.
Answer: It is illegal for a man to have sexual intercourse with a girl under age 16 years. The girl
is not committing any offence. The historical background to this Act was the need to have some
structure to prevent child prostitution.
2. You are aiding and abetting an illegal act.
Answer: Taking action after an event to minimise its ill consequences cannot be interpreted as
aiding and abetting-any more than the investigation and treatment of sexually transmitted
infection would be.
The medical Defence Union opinion is that aiding and abetting would only be involved if a person
actually were present at the time of the sexual intercourse and was encouraging it.
3. The Age of Consent is 16 years.
Answer: In English Law the validity of consent depends upon the capacity of the person to
understand. The House of Lords considered the specific case of consent to contraceptive
treatment in a ruling (Gillick v West Norfolk and Wisbech Area Health Authority and the
Department of Health and Social Security, delivered October 1989). Attached is the advice
which was issued after this by the Department of Health in the Handbook of Contraceptive
Practice 1990 edition, pages 92 and 93.
Note that the exceptional nature of providing emergency contraception under protocol to young
persons under 16 is confirmed by the actual numbers seen and considered under the protocol,
compared to the numbers of older women.
Note also the young person is fully entitled to confidentiality. The guidance in paragraph 2 is that
a doctor or other professional should always seek to persuade the young person to tell, or to
permit to inform. No information should be given without the young person’s consent and
consent to disclosure given under pressure or undue persuasion would not be valid.
The pharmacists training package includes a role play of the type of discussion which is valid and
appropriate.
4. It shouldn’t be allowed for the very young, it will just encourage them.
Answer: Note that there is a lower age limit for sale of alcohol and for sale of cigarettes, but no
lower age limit for the sale of condoms. Any deterrent effect in differential use is not immediately
obvious!!
Rosemary Kirkman
Senior Lecturer in Family Planning, University of Manchester
Hon Consultant, Mancunian Community Family Planning Services
Contraceptive advice and treatment for young people under 16
(HN(81)5/LASS(81)2 has now been replaced by the following text which forms the Appendix to
HC(86)1/HC(FP)(86)1/LAC(86)3 “Family Planning Services for Young People” issued in March 1986
– this also applies to England and Wales only).
1. The following guidance draws the attention of health authorities and others concerned to the
considerations doctors and other professionals need to have in mind when providing contraceptive
advice and treatment to young people under 16, and to the circumstances in which such advice and
treatment can be given without parental knowledge or consent. The guidance results from a review
of that in Section G of the Memorandum of Guidance on the Family Planning Service, as specified
in the Appendix to HN(81)5 and LASSL(81)2, in the light of the House of Lords, decision in the case
of Gillick v West Norfolk and Wisbech Area Health Authority and the Department of Health and
Social Security delivered last October.
2. In considering the provision of advice or treatment on contraception doctors and other
professional staff need to take special care not to undermine parental responsibility and family
stability. The doctor or other professional should therefore always seek to persuade the young
person to tell the parents or guardian (or other person in loco parentis)*, or to let him inform them,
that contraceptive advice is being sought and the nature of any advice or treatment that is given. It
should be most unusual for a doctor or other professional to provide advice or treatment in relation
to contraception to a young person under 16 without parental knowledge or consent.
3. Exceptionally, there will be cases where it is not possible to persuade the young person either to
inform the parents or to allow the doctor or other professional to do so. This may be, for example,
where family relationships have broken down. In such cases, a doctor or other professional would
be justified in giving advice and treatment without parental knowledge or consent, provided he was
satisfied:
 that the young person could understand his advice and had sufficient maturity to understand
what was involved in terms of the moral, social and emotional implications;
 that he could neither persuade the young person to inform the parents, nor to allow him to
inform them, that contraceptive advice was being sought;
 that the young person would be very likely to begin, or continue having, sexual intercourse with
or without contraceptive treatment;
 that without contraceptive advice or treatment, the young person’s physical or mental health, or
both would be likely to suffer;
 that the young person’s best interests require him to give contraceptive advice, treatment or both
without parental consent.
4. Decisions about whether to prescribe contraception in such cases are for a doctors clinical
judgement, if a doctor who is not the young person’s general practitioner has formed the view, after
due consideration of the points made above, that it is in the best interest of the young person to
prescribe contraception without parental knowledge or consent, it may be advisable and helpful for
him, with the young person’s agreement, to discuss the matter in confidence with her own general
practitioner before making his decision.
5. In organising contraceptive services for young people, health authorities may find it helpful to
make separate, less formal arrangements that those for older age groups. The staff should be
experienced in dealing with young people and their problems.
*Where the parental rights and duties in respect of a young person are vested in the local authority
(by virtue of a care order or a parental rights resolution under Section 3 of the Child Care Act 1980)
the authority must be treated as the young person’s parents for the purposes of giving consent to
medical treatment in respect of a young person under 16. Where the authority does not have
parental rights, the natural parent’s rights are not affected. Where a young person has been
committed to the care of a local authority under wardship proceedings, the consent of the High
Court must be obtained by the local authority. Where a local authority shares the parental rights
and duties with another person, the consent of the local authority is sufficient unless the other
person indicates an objection.
APPENDIX E
RECOMMENDATIONS FOR EHC USE WITH POTENTIAL FAILURES OF VARIOUS
CONTRACEPTIVE METHODS
Combined pills
21 active tablets
Week 1 – If 2 or more pills are missed in the first week of pill taking and client
has had UPSI either in the pill free week or in the first 7 days of the packet give
Levonelle. Following this the COC should be continued with additional barrier
contraception until pills have been taken on 7 consecutive days.
Week 2 and 3 – If 2 or more pills are missed in the middle or last week of pill
taking the woman should be advised to continue taking her pills and use condoms
for 7 days in case of further missed pills. If there are not 7 pills left in the pack
following the missed pills she should continue with the next pack without her usual
7 day break. If the pill free interval is avoided in this way she does not need
emergency contraception.
If there is uncertainty over which pills have been missed, EC should be given,
along with advice to continue taking the pill and use a barrier method until a
further 7 consecutive pills have been taken.
Levonelle is indicated if there has been a failed barrier method or UPSI during or
within the 7 days after a vomiting or severe diarrhoeal illness.
Levonelle is indicated if there has been a failed barrier method or UPSI during, or
in the 28 days following, the use of liver enzyme inducing drugs.
Progestogen-only Indicated if one or more POPs have been missed or taken more than 3 hours late
and UPSI has occurred in the 2 days following this. The POP should be continued
pill (POP)
with additional barrier contraception until pills have been taken correctly on two
consecutive days. Exception is Cerazette which can be taken up to 12 hours late
without loss of contraceptive cover.
Levonelle is indicated if there has been a failed barrier method or UPSI during or
within the 2 days after a vomiting or severe diarrhoeal illness.
Indicated if there has been a failed barrier method or UPSI during, or in the 28
days following, the use of liver enzyme inducing drugs.
Intrauterine
device
If complete or partial expulsion is identified or mid cycle removal of the IUD is
deemed necessary EC should be considered.
EC is also indicated if the device has expired (more than 5 or 10 years since
insertion, depending on type).
Medroxyprogeste
rone acetate
(Depo-provera)
Indicated if the contraceptive injection is late (more than 14 weeks from the
previous injection) and UPSI has occurred.
Progestogen-only Indicated if there has been a failed barrier method or UPSI during, or in the 28
days following, the use of liver enzyme inducing drugs, or if the implant has
implants
expired (more than 3 years since insertion).
Potential contraceptive failures which do NOT warrant EHC use
Combined pills
21 active tablets
No indication if only one COC pill has been missed from the first 7 pills in a pack,
as long as the last 7 pills in the previous pack were taken without omissions.
Additional barrier contraception for 7 days is recommended, in case of further
omissions.
No indication if pills have been missed from the middle 7 pills in the pack as long
as the first 7 pills were taken correctly. The COC should be continued to the end
of the pack. Additional barrier contraception for 7 days is recommended, in case
of further omissions.
No indication if pills have been missed from the last 7 pills in the pack as long as
the next pack is started without a pill-free interval. Additional barrier contraception
for 7 days is recommended, in case of further omissions.
Depo-provera
No indication if Depo provera is given up to 2 weeks late (up to 14 weeks from the
previous injection). The injectable can be given and no additional barrier method
is required.
Reference: FFPRHC Guidance: Missed pill advice
Appendix F
EMERGENCY CONTRACEPTION
Client requesting emergency contraception (EC)





o
o
o
o
o
take full contraceptive, sexual and menstrual history, including sexually transmitted infection (STI)
exclude existing pregnancy and medical contra-indications to various EC methods
check current/recent use of enzyme-inducing drugs
check whether client has used hormonal emergency contraception (HEC) in this cycle already
establish:
number of episodes of unprotected sexual intercourse (UPSI) in this cycle
timing of earliest and most recent UPSI in relation to last menstrual period (LMP)
timing of intercourse in relation to incorrect contraception use, including in pill/patch/ring free week
earliest possible date of ovulation (=14 days before period, based on shortest possible cycle)
timing of earliest and most recent UPSI in relation to earliest possible date of ovulation
Reassurance
EC not required
EC not suitable
EC required
Less than 5 days since earliest UPSI
Copper-IUD preferred/more suitable
Hormonal EC preferred option
Ulipristal acetate (ellaOne )




0 to 120 hours since earliest UPSI
no hormonal EC taken this cycle
not on liver enzyme-inducing drugs
not on stomach acid reducing drugs
(eg: H2 antagonist/PPi)
Should only be used once per cycle
(see SPC)


Levonorgestrel
©
(Levonelle 1500)

0 to 72 hours since earliest UPSI


May use more than once in cycle

*
*
*
*
*
If EC given because of UPSI:
advise condom use for remainder of cycle
discuss ongoing contraception and provide method for future use
after levonorgestrel use: consider ‘quick-starting’* ongoing hormonal contraception
(=starting method at time of giving levonorgestrel). PT in 3 weeks advisable
after ulipristal acetate use: start ongoing hormonal contraception at next period
If EC given because hormonal contraception failure:
continue with pill/patch/vaginal ring. Additional condom use for 1 week after
levonorgestrel, or for 2 weeks after ulipristal. PT in 3 weeks advisable
If current enzyme inducing drug use:
give double dose of levonorgestrel*. Don’t use ulipristal (SPC advice). Consider copperIUD
If breast feeding:
can use levonorgestrel. Avoid breastfeeding for 7 days after ulipristal acetate use
Avoid concomitant use of levonorgestrel and ulipristal acetate
* unlicensed dose
Lead reviewer: Dr Nicola Mullin
Date: March 2013
Version: 1
PT in 3 weeks
More than 5 days since earliest UPSI
Discuss hormonal EC and copper-intrauterine
device (copper-IUD)
©
PT = Pregnancy
test
SPC = Summary
of Product
Characteristics
STI = sexually
transmitted
infection
HSH = Highland
Sexual Health
PPI = proton
pump inhibitor

may best inserted up to 5 days
after 1 UPSI
if timing of ovulation can be
estimated copper-IUD may be
inserted beyond 5 days of
UPSI, as long as it does not
occur beyond 5 days of
earliest possible date of
ovulation
most effective EC method and
provision of ongoing
contraception
most suitable method if on
enzyme-inducers
if separate appointment for
insertion (or referral to
HSH/GP) needed, give interim
hormonal EC
consider prophylactic
azithromycin if STI risk
if requested remove copperIUD with next period or when
no pregnancy risk and start
alternative contraception
All EC methods
 full counselling, including sideeffects, action to be taken if
vomiting within 2 to 3 hours
(hormonal EC only), etc.
 provide written information
 accurate documentation
 consider STI testing
 follow-up as appropriate
Contributors: CMSHN Reproductive Health Working Group
Review Date: March 2015
Warning: document uncontrolled when printed
APPENDIX G - ELLAONE®▼ CONSIDERATIONS
It is essential that the pathway for accessing EllaOne ®▼ is established before deciding not to
issue Levonelle.
EllaOne®▼is indicated

0-72 hours – if the client presents within the immediate 48 hours prior to calculated
ovulation there is evidence to suggest EllaOne®▼ has greater efficacy. Day of ovulation is
calculated from the normal cycle length minus 14 days.

73-120 hours – licenced oral preparation and preferred product if client not accessing an
IUD.
EllaOne®▼ is contra-indicated
 If there has been UPSI longer than 120 hours ago in the cycle in question whether or not
Levonelle® / EllaOne®▼ was prescribed on that occasion.

Where Levonelle® / EllaOne®▼ have already been taken in the cycle in question.

Suspected existing pregnancy

Severe asthma

Renal/hepatic impairment

Severe malabsorbtion

Use of enzyme inducing drugs, proton pump inhibitors, antacids or H2 receptor
antagonists

Lactose / galactose intolerance

Lapp lactase deficiency or glucose-galactose malabsorbtion
In these circumstances issue Levonelle® 1500 and if appropriate refer for an IUD.