TLDR: There are three types of oral emergency contraceptive options (LNG pills, Yupze method, and Ella), plus the copper intrauterine device (IUD), that can be accessed in Canada. Emergency contraceptive (EC) methods are in place to prevent unwanted pregnancy in people who ovulate† when unprotected, receptive intercourse has occurred between folks who have the appropriate internal anatomy to conceive. This piece discusses each EC in detail to explain the differences between them and the advantages and disadvantages of each.
Emergency contraception (EC) refers to methods used to prevent unwanted pregnancy in people who ovulate† when unprotected, receptive penile-vaginal intercourse (PVI) has occurred between folks who have the appropriate internal anatomy to conceive (1). It is important to keep in mind that ECs can be used even if you’re unsure if ejaculation occurred. Pre-ejaculate fluid can contain sperm, and although the research is unclear on whether or not this sperm is capable of motion and can lead to pregnancy, there is no harm in accessing ECs to be safe (2).
This piece is not meant to be a replacement for medical advice. The purpose of this post is to provide you with scientific information about ECs that can help you inform the conversations you have with your healthcare provider(s), and ultimately the decisions you make. You and your doctor should be a team in choosing contraceptive methods that suit your personal needs. With this in mind, this piece will specifically discuss:
Note: this post discusses the menstrual cycle. If you need a refresher on how this works, you can read this article.
When to access emergency contraceptives
Emergency contraceptives should be accessed as soon as possible after unprotected PVI (3). Sperm can survive within the reproductive tract for up to five days, so action should be taken within this timeline. Some situations where ECs should be taken include (but are not limited to):
Unprotected PVI
Incorrect use of contraceptive methods such as:
Dislodgement, tearing, or early removal of condoms, diaphragms, or cervical caps
Incorrect use of oral contraceptives:
Missing three or more combined oral contraceptives in a row
Over three hours late from the usual time of taking the minipill, or missing a day on the minipill
IUD is past expiry or has fallen out
Miscalculating/engaging in PVI during the fertile window, if fertility tracking is the main form of contraception
Sexual assault
To access more information on sexual assault, see our FAQs on:
Types of emergency contraception available
In Canada, there are four over-the-counter options for emergency contraceptives (4, 5). These include Plan B, Norlevo, Option 2, and Next Choice - which all contain levonorgestrel (LNG) as their active ingredient. You can access them through your local pharmacy, without the need to present identification or a prescription (6). These options are available to purchase for all genders and you should not be asked your gender when purchasing. If you are asked, your answer should not affect your access to these over-the-counter options. If you are uncomfortable disclosing information regarding gender identity, please remember that you have the right to decline to share this information.
Although finding published information about the costs of EC is tricky - you can generally expect to pay CAD $15-$60 for EC (7). If you have access to a clinic that specializes in sexual health, you may be able to get it for a subsidized price (5).
There are also prescription options that you can get from your doctor. There are two pill options - which include 1) the Yuzpe method and 2) ulipristal acetate (Ella ®) (7). Copper IUDs are also an option, which have the advantage of providing long-term birth control as well. All of these options are discussed further below.
Please remember that although all of these options can be effective at preventing pregnancy, none will protect you against sexually transmitted infections.
Levonorgestrel (LNG) ECs: Plan B, Norlevo, Option 2, Next Choice
LNG pills are widely considered the ‘gold standard’ for emergency contraception because they are highly effective, well-tolerated, and minimally invasive (8). These pills are sold over-the-counter through your local pharmacy in either a 1.5mg dose or two 0.75mg doses that you take 12 hours apart (6). It is considered effective up until 72 hours after unprotected PVI – studies show that 97.8% of potential pregnancies can be prevented within this timeline (4, 8). However, LNG pills are more effective the closer they are taken to unprotected PVI, so it is important to access them as quickly as you can.
It is uncommon to experience side effects when taking LNG pills, but common side effects may include nausea, bloating, headache, dizziness, cramping, and an abnormal start/end of your period.
LNG pills work by preventing ovulation from occurring (9). Without ovulation, there is no release of the egg into the fallopian tubes, and therefore sperm cannot access the egg for fertilization. Researchers are still unsure of the exact mechanism of how LNG pills work to prevent ovulation (8, 9).
LNG EC pills have been shown to be less effective if taken after the surge in luteinizing hormone (LH) during the ovarian cycle (10). However, it may have other actions - such as affecting sperm motility - that may make it worthwhile to take regardless of where you are in your cycle as there is a chance it still may be effective (3, 9). The LH surge is what causes ovulation (the release of the egg from the ovary) to occur (11). For this reason, LNG ECs may be less effective if ovulation has already occurred within the cycle. If you track your cycle, you may have a better idea of where you are in your ovarian cycle, and this can help you decide if LNG EC pills will work or if you need to look into prescription options. The LNG EC pills also have no effect if implantation of the embryo has already happened (8). If you took an LNG EC pill after implantation, don’t panic! The pill will not cause you to miscarry, nor will it have bad effects on the embryo.
There are some important considerations when taking LNG pills. First, if you weigh over 165 pounds LNG pills may be less effective, and if you weigh over 175 pounds it is considered ineffective (7). If you fall into this category - keep reading, there’s plenty of other options that will work for you! Second, these pills are often referred to as the ‘morning-after pill’. This is a misleading statement, because as mentioned before they should be taken as soon as possible after unprotected PVI (8). LNG pills are more effective at preventing pregnancy the sooner you take them. If you know you’re about to have unprotected PVI, you can even take LNG pills right before!
Yuzpe method: LNG + estrogen
The Yuzpe method, introduced in the 1960s, was the first oral form of EC available (8). This method involves taking a combined oral contraceptive (COC) with a dose of LNG. The method will then be repeated 12 hours later. There are multiple different combinations and doses that can be taken, which is why this method requires a prescription by a doctor (6).
Side effects are usually mild and may include nausea, bloating, headache, cramps, dizziness, and changes to your normal menstrual cycle. The Yuzpe method has been shown to be more likely to cause nausea and vomiting than other EC pills (8). It is typically a less popular option of EC because it is less effective and more likely to cause side effects than other options. However, it is still considered a valid option for EC.
This method is estimated to be around 75% effective at preventing pregnancy (12). It is important to note that it is more effective the sooner you take it post-PVI. It is also only effective for up to 72 hours afterwards (6). If you have passed this timeline, it’s okay! Keep reading for other EC options that will help prevent pregnancy after the 72 hour time period has passed.
Ulipristal Acetate (UA): Ella ®
Ulipristal acetate is the newest EC pill on the market, gaining its Health Canada approval in 2015 (7). Unlike LNG pills, these pills require a prescription (4, 5). This EC pill is taken in a single dose of 30mg (6, 8). UA is the most effective pill option, with a 98.7% success rate (4). The additional benefits of UA are that it is effective for up to 5 days after a contraceptive emergency, and there are no known weight restrictions that impact its effectiveness (4).
Like LNG pills, the side effects of taking UA are rare and usually mild (8). The potential side effects of UA are the same as LNG.
UA works on progesterone receptors to either 1) mimic progesterone effects or 2) prevent progesterone effects, depending on where you are in your ovarian cycle (8). It hasn’t been determined yet exactly how UA functions to prevent pregnancy, but the current research suggests that its effect on progesterone receptors (i.e. sites where progesterone can bind in the body) can work to prevent ovulation and/or change the endometrium in a way that doesn’t support implantation (10). Unlike LNG pills, UA pills are effective even after the LH surge has occurred, likely due to its effect on the uterine lining. However, similar to LH pills, UA pills are ineffective if implantation has already occurred. They will have no effect on the pregnancy and will not cause miscarriage. Animal studies have also suggested that UA doesn’t increase the chances of birth defects in babies who were exposed in-utero. One thing to note, however, is that if you take UA while breastfeeding, it is important that you discard any milk produced and not give it to the baby for a week after taking the pill.
If you regularly use progestin-based birth control, such as the ‘mini-pill’, it is important to know that taking UA could impact the pills effectiveness for a few days after. This can happen because both the mini-pill and UA exert their action through progesterone receptors. If UA is already having action on these receptors, the progestin in the birth control may be blocked from exerting its effects. With this in mind, extra precautions should be taken if you choose to have PVI within a few days of taking UA.
Copper Intrauterine Device (IUD) as EC
Copper IUDs are the most effective, but typically the least sought-after EC option. Many folks aren’t even aware that the copper IUD can be used as an emergency contraceptive, therefore missing out on a great EC option (13). If inserted within five days of unprotected intercourse, copper IUDs are over 99% effective at preventing pregnancy (6, 10). It is also highly effective at any period in the ovarian cycle, in contrast to the LNG pills. The copper IUD has the added benefit of providing you with long-term contraception - between three and 10 years, depending on which one you choose (14).
Copper IUDs release copper ions - which are involved in many normal physiological processes - which work to prevent pregnancy in one of two ways (13). They can work pre-fertilization by disrupting sperm function. This makes it difficult for the sperm to reach the egg and successfully fertilize it.
If fertilization has already occurred, the copper ions make the uterine lining non-receptive to a fertilized egg. In order for the egg to develop into a fetus, it needs to implant itself into the uterine lining. There is also a theory that copper IUDs cause an inflammatory response that can also work to prevent implantation of the fertilized egg.
If you are considering a copper IUD - check out this article by my friend, Kayla Benjamin.
Emergency contraception for transgender men
This section contains important information for trans men who have not had gender-affirming bottom surgery (i.e. removal of uterus and/or ovaries), if you have had PVI. If you are on testosterone hormone replacement therapy, there is a good chance your period may stop occurring. However, even without a monthly period there is still a chance that ovulation is happening, and you could still get pregnant (15). If this applies to you, it is important that you seek ECs if unprotected, receptive PVI has happened. Please be assured that EC pills and the copper IUD will not have feminizing effects on your body. The copper IUD is a good option if you regularly have unprotected PVI, but the process of insertion and post-insertion bleeding may be a triggering and gender dysphoric experience. Ultimately, it is up to you to figure out what (if any) EC you are comfortable with! If you have had gender-affirming bottom surgery, you will not be at risk for pregnancy!
†People who ovulate are born with a uterus, ovaries, fallopian tubes, and produce the necessary hormones to undergo ovulation and menstruation.
Thank you so much for taking the time to read our article! We hope you appreciated the effort that went into bringing it to you today. As a small not-for-profit, we are heavily reliant on generous donations to helps us stay afloat. Please consider donating to help ensure we can regularly provide health information for young people across Canada. Every donation makes an impact!
References
Cameron ST, Li HWR, Gemzell-Danielsson. Current controversies with oral emergenc .contraception. BJOG [Internet]. 2017 Jun [cited 2021 Apr]; 124(13): 1948-56. Retrieved from: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14773?casa_token=PfNuqiJY7e8AAAAA%3AhFEt2Vyu7xFnSseuenolBZ9vgsrRiI4Gk9KLhYNOL5S3JQCrzrkz
Kelly MC. Pre-ejaculate fluid in the context of sexual assault: a review of the literature from a clinical forensic medicine perspective. Forensic Science International [Internet]. 2021 Jan [cited 2021 Apr]; 318. Retrieved from: https://www.sciencedirect.com/science/article/pii/S0379073820304588?casa_token=CqB54kl7HvAAAAAA:SDkcK2Ad40TljZXnf1QGlFv4ZRiVnJIQXxNPiVKSfHNMndn-DINmbEC1WPDnpJ2q5HRqFLGc
Hapangama D, Glasier AF, Baird DT. The effects of peri-ovulatory administration of levonorgestrel on the menstrual cycle. 2001 Mar [cited 2021 Apr]; 63(3):123-9. Retrieved from: https://www.sciencedirect.com/science/article/pii/S001078240100186X?casa_token=BVSag9cteR4AAAAA:1QvH1mGkpwIoSDcy9BzqvEmEGqiPCFGzVK-E1xnf_xiy_ZtgD7JDqOQDVRJp59NM9bsQWkm0
Chao Y, Frey N. Ulipristal versus levonorgestrel for emergency contraception: a review of comparative clinical effectiveness and guidelines. CADTH [Internet]. 2018 Nov [cited 2021 Apr]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK538737/
The Society of Obstetricians and Gynaecologists of Canada. Emergency contraception. Sex & U. Retrieved from: https://www.sexandu.ca/contraception/emergency-contraception/
World Health Organization. Emergency contraception. WHO Fact sheets [Internet]. 2018 Feb [cited 2021 Apr]. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/emergency-contraception
Chaumont A, Foster AM. The not so over-the-counter status of emergency contraception in Ontario: a mixed methods study with pharmacists. Facets [Internet]. 2017 May [cited 2021 Apr]. Retrieved from: https://www.facetsjournal.com/doi/full/10.1139/facets-2017-0024
Matyanga CMJ, Dzingairai B. Clinical pharmacology of hormonal emergency contraceptive pills. International Journal of Reproductive Medicine [Internet]. 2018 Oct [cited 2021 Apr]. Retrieved from: https://www.hindawi.com/journals/ijrmed/2018/2785839/
Durand M, Cravioto MC, Raymond EG, et al. On the mechanisms of action of short-term levonorgestrel administration in emergency contraception. Contraception [Internet]. 2001 Oct [cited 2021 Apr]; 64(4): 227-34. Retrieved from: https://www.sciencedirect.com/science/article/pii/S0010782401002505?casa_token=d1MxNdbaC3UAAAAA:lghG8vsZpOj3N5nhyNW37I2Qd6F9Xo1849Hhq2w4-7XmCAgGz9Qd9P0-tCFgeqWUJFNX7vTM
Cleland K, Raymond EG, Westley E, Trussel J. Emergency contraception review: evidence-based recommendations for clinicians. Clin Obstet Glynecol [Internet]. 2014 Dec [cited 2021 Apr]; 57(4): 741-50. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216625/
Thiyagarajan DK, BAsit H, Jeanmonod R. Physiology, Menstrual Cycle. StatPearls [Internet]. 2020 Sept [cited 20201 Apr]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK500020/#article-24987.s3
Trussel J, Rodriguez G, Ellertson C. Updated estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception [Internet]. 1999 Mar [cited 2021 Apr]; 59(3): 147-51. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/10382076/
Turok DK, Godfrey EM, Wojdyla D, Dermish A, Torres L, Wu SC. Copper T380 intrauterine device for emergency contraception: highly effective at any time in the menstrual cycle. Human Reproduction [Internet]. 2013 Oct [2021 Apr]; 28(10):2673-76. Retrieved from: https://academic.oup.com/humrep/article/28/10/2672/622225?login=true
Healthwise Staff. Intrauterine device (IUD) for Birth Control. MyHealth.Alberta.ca. 2020 Feb [cited 2021 Apr]. Retrieved from: https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=tw9516
Harris M, Cleland K. Clinical minute: Emergency contraception for transgender or gender nonbinary patients. Besider Providers. 2020 Dec [cited 2021 Apr]. Retrieved from: https://providers.bedsider.org/articles/clinical-minute-emergency-contraception-for-transgender-or-gender-nonbinary-patients
Comments