Obgyn · Year 3 · from Obgyn
Case 2: Emergency Contraception Request
Patient Demographics
- Age: 19 years
- Sex: Female
- Occupation: Freshman in college
Chief Complaint
"The condom broke last night and I need the morning-after pill."
History of Present Illness
The patient presents to the student health clinic requesting emergency contraception. She reports that a condom broke during intercourse approximately 18 hours ago. Her partner did not withdraw and ejaculated inside the vagina. She is very worried about becoming pregnant and wants to know her options.
Gynecologic History
- Menarche: Age 12
- Cycles: Regular, 28-30 days
- LMP: 12 days ago (mid-cycle - near ovulation)
- Sexually active: Yes, one partner
- Contraception: Condoms only
- Prior pregnancies: None
- No STI history
Past Medical History
- Asthma (uses albuterol inhaler PRN)
- Weight: 165 lbs (75 kg)
- Height: 5'4"
- BMI: 28.3 kg/m2
Risk Assessment
- Unprotected intercourse 18 hours ago
- LMP 12 days ago (likely near ovulation - HIGH risk)
- Needs emergency contraception urgently
Emergency Contraception Options
| Method | Timing | Efficacy | Weight Considerations | Access |
|---|---|---|---|---|
| Copper IUD | Up to 120 hours | >99% | Not affected | Prescription, clinic insertion |
| Ulipristal (ella) | Up to 120 hours | Best oral EC | Effective at higher weights | Prescription |
| Levonorgestrel (Plan B) | Up to 72 hours (some efficacy to 120h) | 85% at 72h | May be less effective >75 kg | OTC |
Counseling Discussion
Given Her Weight (75 kg):
- Levonorgestrel may have reduced efficacy above 75 kg
- Copper IUD is most effective option overall
- Ulipristal acetate maintains efficacy better than levonorgestrel at higher weights
Patient Concerns:
- "I don't want an IUD right now"
- "Can I just get a pill?"
- "Is this the same as the abortion pill?" (Addressed: No, EC prevents pregnancy, does not terminate existing pregnancy)
Patient Decision: Ulipristal Acetate (ella)
Prescription:
- Ulipristal acetate 30 mg PO x 1 dose, take now
- Most effective oral EC, especially for mid-cycle exposure and at her weight
Key Counseling:
- Take the pill as soon as possible
- May experience nausea, headache, fatigue, menstrual irregularity
- Period may come early or late
- If no period within 3 weeks, take a pregnancy test
- Important: Wait at least 5 days before starting hormonal contraception (ulipristal blocks progesterone receptors)
- Use condoms or abstain in the interim
Ongoing Contraception Discussion
"Let's talk about preventing this from happening again."
Options Discussed:
- Hormonal IUD (most effective, long-acting)
- Copper IUD (non-hormonal option)
- Subdermal implant (most effective reversible method)
- Combined OCP, patch, or ring (would need backup for first 7 days)
Patient's Plan:
- Interested in the pill but wants to think about IUD
- Started on combined OCP today (will wait 5 days after ulipristal before first pill)
- Given condoms for interim protection
- Return visit scheduled for IUD discussion
Follow-up (3 weeks later)
- Menstrual period arrived on time
- Not pregnant
- Started OCPs as planned
- Decided to continue with OCPs for now, may consider IUD in future
Teaching Points
- Copper IUD is the most effective emergency contraception (>99% effective up to 5 days)
- Ulipristal acetate is the most effective oral EC, especially for higher-weight patients
- Levonorgestrel EC is available OTC but may have reduced efficacy >75 kg
- All EC should be taken as soon as possible after unprotected intercourse
- EC is a bridge - always discuss ongoing contraception
- Ulipristal requires a 5-day delay before starting hormonal contraception
Clinical Image
Image Description: Comparison of emergency contraception options showing the copper IUD (most effective), ulipristal acetate pill, and levonorgestrel pill with their respective efficacy rates and time windows for use.
Attribution: Educational illustration. Public domain medical education resource.