An 18-year-old nulligravid woman comes to the office for emergency contraception. The condom broke during sexual intercourse the previous night, and she does not want to become pregnant. The patient and her longtime boyfriend have always used condoms, and their evaluations for sexually transmitted infections have been negative. Her last menstrual period was 2 weeks ago. She takes no medications and does not use tobacco, alcohol, or recreational drugs. Blood pressure is 122/80 mm Hg and pulse is 86/min. BMI is 27 kg/m². Physical examination is normal and a pregnancy test is negative. Which of the following is the most effective emergency contraceptive method for this patient?

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11ec25c8_d9b0_4ebf_bc81_31930ad5f850_MD0003_00 Patients with recent unprotected sexual intercourse or contraception failure (eg, broken condom) are at risk for unintended pregnancy and may be candidates for emergency contraception. The copper-containing intrauterine device (IUD) is the most effective (≥99%) emergency contraception method available. Its insertion within 120 hours (5 days) after unprotected intercourse prevents pregnancy by impairing fertilization (by inducing intrauterine inflammation that is cytotoxic to sperm and ova) and preventing implantation. Age and parity are not contraindications to IUD insertion; therefore, the copper-containing IUD is an appropriate and most effective option for this nulligravid adolescent. IUD In addition, the copper-containing IUD can be left in place to provide continued contraception for up to 10 years but may be removed sooner (ie, whenever the patient desires pregnancy), with immediate return of fertility. (Choice A) Combination oral contraceptives (eg, ethinyl estradiol plus levonorgestrel pills) are commonly used for precoital contraception but can also be used for emergency contraception by taking multiple pills simultaneously to achieve the progestin level required to delay ovulation. However, this method is less effective (47%-89%) and the pills contain estrogen, which typically causes intolerable side effects (eg, severe nausea). (Choices C and E) Levonorgestrel and ulipristal pills are emergency contraception methods that prevent pregnancy primarily by delaying ovulation. Although these medications are more accessible (eg, IUD requires a provider trained in its insertion), they are slightly less effective at pregnancy prevention than the copper-containing IUD and do not offer the benefit of continued contraception. (Choice D) Medroxyprogesterone is a progestin-only contraceptive injection. It inhibits hypothalamic secretion of gonadotropin-releasing hormone (GnRH), which decreases FSH and LH thereby inhibiting ovarian follicle development. This patient already likely has a mature ovarian follicle (based on her last menstrual period); therefore, medroxyprogesterone will not work as emergency contraception. Educational objective: Emergency contraception can be used to prevent pregnancy within 3-5 days of unprotected intercourse and typically works by delaying ovulation or impairing implantation. The copper-containing intrauterine device is the most effective emergency contraception method and may be offered to nulliparous women and adolescents. Emergency contraceptive pills (eg, combination oral contraceptives, levonorgestrel, ulipristal) are less effective. References: Interventions for emergency contraception. (http://www.ncbi.nlm.nih.gov/pubmed/28766313) Emergency contraception review: evidence-based recommendations for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/25254919) Practice bulletin no. 152: emergency contraception. (http://www.ncbi.nlm.nih.gov/pubmed/26287787)

An 18-Year-Old Nulligravid Woman Comes to the Office for Emergency