Question:

A 16-year-old girl comes to the office for emergency contraception. She had unprotected sexual intercourse last night and is worried that she may become pregnant. Her last menstrual period was 1 week ago, and she has had regular menses since menarche. Physical examination is normal and urine pregnancy test is negative. After various emergency contraceptive options are discussed, the patient asks for a pill option and that her parents not be notified about this visit. In most states, which of the following is the most appropriate management of this patient?

Obtain parental consent prior to providing emergency contraception

Prescribe misoprostol (prostaglandin E1) pills

Provide levonorgestrel pill

Reassure patient that pregnancy is unlikely and no emergency contraception is required

Supply a short course of high-dose oral contraceptives

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Explanation:

Emergency contraception
Method	Timing after intercourse	Efficacy	Contraindications
Copper-containing intrauterine device	0-120 hr	>99%	Wilson disease Active pelvic infection Severe uterine cavity distortion
Progestin-releasing intrauterine device	0-120 hr	>99%	Breast cancer Active pelvic infection Severe uterine cavity distortion
Ulipristal	0-120 hr	98%-99%	None
Oral levonorgestrel	0-72 hr	92%-98%	None
Oral contraceptives*	0-72 hr	75%-89%	None
*Combined estrogen/progestin oral contraceptive pills containing levonorgestrel or norgestrel.

Patients with recent unprotected intercourse may be candidates for postcoital or emergency contraception (EC) for pregnancy prevention. Pregnancy status determines eligibility for EC use:

Patients with a positive pregnancy test are not candidates for EC because implantation has already occurred.
In contrast, patients with a negative pregnancy test are still at risk for unintended pregnancy and are candidates for EC (Choice D).

The levonorgestrel pill (ie, Plan B) is the most readily available form of EC; the high dose of progestin in these pills prevents pregnancy by inhibiting the LH surge, thereby delaying ovulation. Additional mechanisms include cervical mucus thickening and thinning of the endometrial lining. Levonorgestrel pills are highly effective (ie, up to 94%); however, effectiveness decreases over the course of 72 hours (ie, as low as 59%). Therefore, levonorgestrel pills should be provided as soon as possible after unprotected intercourse. Most states allow adolescents to receive confidential care for contraception, pregnancy, and sexually transmitted diseases without parental consent (Choice A).

(Choice B) In patients with a positive pregnancy test (ie, implanted pregnancy), misoprostol (prostaglandin E1) can be used for medical abortion or pregnancy termination by stimulating uterine contractions. Misoprostol does not prevent pregnancy and, therefore, is not used for EC.

(Choice E) Combination oral contraceptives, commonly used for precoital contraception, may also be used for EC by taking multiple pills simultaneously to achieve the progestin level required to delay ovulation. However, the high estrogen content typically causes intolerable side effects (eg, severe nausea), and this method is less effective (ie, 47%-89%) than levonorgestrel pills.

Educational objective:
The levonorgestrel pill (ie, Plan B) are a readily available and effective emergency contraception option that prevent pregnancy by delaying ovulation. In most states, adolescents seeking pregnancy prevention options may receive confidential medical care without parental consent.