DOI: 10.1111/1471-0528.

14773 Review article

www.bjog.org

Current controversies with oral emergency

contraception
ST Cameron,a HWR Li,b,c K Gemzell-Danielssonc,d
a
Chalmers Sexual and Reproductive Health Centre, Edinburgh, UK b Department of Obstetrics and Gynaecology, University of Hong Kong,
Queen Mary Hospital, Hong Kong, Hong Kong c Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Centre, The
University of Hong Kong—Shenzhen Hospital, Shenzhen, China d Department of Women’s and Children’s Health, Division of Obstetrics and
Gynaecology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
Correspondence: ST Cameron, Chalmers Sexual and Reproductive Health Centre, 2A Chalmers Street, Edinburgh EH3 9ES, UK.
Email sharon.cameron@ed.ac.uk

Accepted 29 May 2017. Published Online 17 July 2017.

Emergency contraception (EC) is a method to be used in the case Keywords Emergency contraception, levonorgestrel, postcoital
of unprotected sexual intercourse, failure of a regular contraceptive agents, ulipristal acetate.
contraceptive method, or after rape to try to prevent an
Tweetable abstract Controversy about emergency contraception
unintended pregnancy. Oral EC remains surrounded by
restricts access for women.
controversy, much due to myths and misconceptions among the
public, policy makers and healthcare providers. This has resulted Linked article This article is commented on by DK Turok, p. 1956
in restrictions on its availability in many parts of the world and in this issue. To view this mini commentary visit https://doi.org/10.
restrictions on women’s access to it. The aim of this article is to 1111/1471-0528.14852.
provide an evidence-based view on some of these common
controversial issues surrounding oral EC in clinical practice.

Please cite this paper as: Cameron ST, Li HWR, Gemzell-Danielsson K. Current controversies with oral emergency contraception. BJOG 2017;124:1948–1956.

demonstrated.4 A single dose of LNG (1.5 mg) adminis-

Introduction
Emergency contraception (EC) can be provided as either
an oral hormonal method or the copper intrauterine
contraceptive device (Cu-IUD). The Cu-IUD is the most
effective EC with failure rates of <0.1%.1,2 In contrast to
oral methods, the Cu-IUD has both pre- and post-fertili-
sation effects,3 can be used over a wider time period
than oral EC and can be retained for highly effective
ongoing contraception (Table 1). However, the Cu-IUD
may not be the preferred or suitable method for all users
and is also more provider-dependent. Hence oral EC
remains the more commonly used approach.
The first oral EC introduced in the 1960s consisting of
high oral doses of estrogens was phased out due to a high
incidence of estrogen-related adverse effects. In 1974, a
combination of ethinylestradiol (100 lg) and DL-norgestrel
(1 mg) administered within 72 hours of unprotected sexual
intercourse (UPSI) with a repeat dose 12 hours after was
introduced.2 This ‘Yuzpe’ regimen was gradually replaced
by levonorgestrel (LNG) in the 1990s, as fewer adverse
effects and higher clinical efficacy with LNG were
tered within 72 hours of UPSI is the recommended regi-
men for LNG EC.5 Although licensed for use within
72 hours, there is evidence that efficacy may be maintained
up to 96 hours post UPSI.6
In recent years, a single 30-mg oral dose of ulipristal
acetate (UPA), a progesterone receptor modulator (PRM),
has been introduced as EC. The UPA EC regimen is slightly
more effective than LNG as shown by a meta-analysis
(n = 3242) of two randomised controlled comparative tri-
als.7,8 The efficacy of UPA EC is maintained up to
120 hours after UPSI,8,9 which is the recommended time
limit in the product license.
Mifepristone is another PRM that was first studied as
an EC in 199210,11 at a dose of 600 mg taken within
72 hours of UPSI. Subsequently, equivalent effectiveness
as EC was confirmed with lower doses at 10–50 mg.12
According to the latest Cochrane review, mifepristone at
mid-dose (25–50 mg) ranks top among the oral EC
methods in terms of efficacy.1 However, mifepristone
preparations at an EC dose are available in only a few
countries.13

1948 ª 2017 Royal College of Obstetricians and Gynaecologists

 Controversies with oral emergency contraception

Table 1. Current methods of emergency contraception (in order of increasing effectiveness)

Method and regimen Class of drug Recommended Mechanism(s) of action Specific notes on use
time limit after
unprotected
intercourse

Yuzpe method Combined estrogen Up to 72 hours  Inhibiting or  Can be made up by multiple

(Two doses of ethinyl- and progestogen delaying ovulation tablets of combined oral
estradiol 100 lg + contraceptive pills
DL-norgestrel 1 mg  Nausea and vomiting is a
administered common side effect
12 hours apart)  Needs to be administered in
two split doses
Levonorgestrel 1.5 Progestogen Up to 72 hours  Inhibiting or  Fewer side effects than Yuzpe
mg single dose (license limit) delaying ovulation method
Up to 96 hours  Administered as a single dose
(unlicensed)  More effective than Yuzpe
Ulipristal acetate 30 Progesterone Up to 120 hours  Inhibiting or delaying ovulation  Fewer adverse effects than
mg single dose receptor modulator  Possibly disturbs sperm function Yuzpe method
 Possibly disturbs tubal function  Administered as a single dose
 More effective than
levonorgestrel
Mifepristone 25–50 Progesterone Up to 120 hours  Inhibiting or delaying ovulation  More effective than
mg single dose receptor modulator  Possibly disturbs tubal function levonorgestrel
 Possibly disturbs endometrial  Available at EC dose in
receptivity few countries only
Copper intrauterine Intrauterine Up to 120 hours  Copper ions toxic to sperm  Can be retained until
device contraceptive method Or up to 120 hours and oocytes so prevents pregnancy excluded or can
after the earliest fertilisation be kept for ongoing effective
estimated date  Endometrial changes may contraception
of ovulation prevent implantation

Levonorgestrel EC acts by blocking the luteinising hor-

Mechanisms of action of EC
What are the mechanisms of action of EC?
All oral methods of EC are capable of delaying ovulation.
As spermatozoa survive in the female reproductive tract for
up to 5 days, oral EC can prevent pregnancy if it can delay
ovulation long enough for spermatozoa to have lost their
fertilising capacity or are no longer viable.5
The Yuzpe regimen is thought to act by inhibiting or
delaying ovulation.14,15 Other postovulatory mechanisms of
action have been proposed based on epidemiological mod-
elling,16,17 but such evidence was only circumstantial. Some
minor morphological or molecular changes in the endome-
trium following administration of Yuzpe have been
reported in some studies18–20 but not others,15 and the
actual clinical significance of these alterations is uncertain.
The high dose of progestogen in Yuzpe may also thicken
the cervical mucus and impair sperm penetration, but this
is probably not relevant in the context of EC, which is used
some time after the UPSI.21 There are no reported data on
the direct effect of the Yuzpe regimen on sperm or fallop-
ian tube function.
mone (LH) surge and hence inhibiting follicular growth or
delaying rupture. However, it is not effective if adminis-
tered after the onset of the LH surge.22–24 In vitro studies
showed that LNG at concentrations relevant for EC had no
significant effect on sperm function nor fertilisation,25–27
nor on endometrial receptivity and embryo attachment.28,29
Although one in vitro study showed that it might inhibit
muscular contractility of the fallopian tube,30 other data
suggested that LNG inhibited ciliary beat frequency and
muscular contractility only at supra-pharmacological con-
centrations.31 Overall, LNG probably has minimal postovu-
latory actions, if any, and this may explain the observation
that LNG is only effective for EC if administered preovula-
tion but not postovulation.31,32
Mifepristone at a dose of ≥10 mg delays follicular devel-
opment and ovulation, although ovulation usually takes
place eventually.33,34 A small pilot study showed that even
when mifepristone at a dose of 200 mg was administered
after the onset of the LH surge, ovulation was not consis-
tently blocked.35 In vitro studies suggested that mifepristone
at the EC dose may inhibit endometrial receptivity28,29 and

ª 2017 Royal College of Obstetricians and Gynaecologists 1949

 Cameron et al.
muscular contractility of the fallopian tube,28 but not
sperm function or fertilisation.26,28,29,36
Ulipristal acetate exerts its EC action by blocking or
delaying ovulation, and such an effect of UPA remains evi-
dent even when administered after the onset of the LH
surge but before the peak.37 Follicular rupture can be
delayed by at least 5 days after intake of UPA in 100% of
cases when given before the onset of LH surge and in 79%
after the onset but before the LH peak.38 This means that
UPA has a wider window of action than LNG and remains
effective in the immediate preovulatory phase when the risk
of conception is greatest, hence explaining its higher effi-
cacy compared with LNG in clinical trials.8 Postovulatory
administration of UPA at the EC dose may induce some
immunohistochemical and molecular changes in the endo-
metrium,39 but other in vitro studies have shown that UPA
at concentrations relevant for EC do not interfere with
embryo attachment to the endometrium.40,41 UPA at phar-
macological concentrations can suppress ciliary beating and
muscular contractility in fallopian tube,42 as well as modu-
late sperm function by inhibiting sperm hyperactivation,
progesterone-induced acrosome reaction and calcium
influx.26 However, the clinical relevance of these in vitro
findings remains uncertain. Sperm may only take minutes
to reach the fallopian tube after UPSI,23 and this window is
too short for the sperm-targeted action in the EC context.
Furthermore, a recent clinical study (n = 693) indicated
that UPA had significantly higher efficacy as EC when
administered before compared with after ovulation,43 which
implied that postovulatory mechanisms may not contribute
much, if at all, to the action of UPA EC.
Does EC induce a miscarriage or an ectopic
pregnancy?
In theory any postfertilisation mechanisms of action of oral
EC, if they exist, would act before the establishment of
pregnancy, i.e. before embryo implantation. Hence, EC is
not an abortifacient. The rate of miscarriage in clinical tri-
als of EC is no higher than what one might expect to
observe in the general population.8,42 Although in vitro
studies might suggest some action of EC on tubal function,
a systematic review showed no higher incidence of ectopic
pregnancy after oral EC than in the general population.44
Are mechanisms of action important to users?
Survey data from Europe and the USA show that up to
40% of women report not knowing how oral EC
works.45,46 There are few data on whether EC users are
concerned with how EC works. A survey of 500 women in
the UK showed that most were hypothetically prepared to
use an EC pill that might prevent or even disrupt implan-
tation.47 Clearly a method that worked by disrupting
implantation may raise legal issues in many settings, but
1950
would be permissible in countries where ‘menstrual induc-
tion’ (i.e. evacuation of the uterus in women with delayed
menses without laboratory confirmation of pregnancy) is
permitted, such as China.48
Effectiveness of EC
How effective is EC?
There has never been a placebo-controlled trial of oral EC
because of ethical concerns over those assigned to the pla-
cebo group, as EC is widely recognised to reduce unin-
tended pregnancies. This is inferred in most comparative
clinical trials where the pregnancy rates observed after EC
use are lower than what might have occurred in the
absence of EC (based upon data for the risk of conception
on the respective cycle days). However, calculations of
expected pregnancy rates falsely assume that we can accu-
rately determine the phase in the menstrual cycle when
intercourse took place, that women have had just one epi-
sode of UPSI and that sperm have entered the reproductive
tract. In reality, this may not be the case.5,16,17 In a ran-
domised trial (n = 1899), UPA was estimated to have pre-
vented 67% of expected pregnancies whereas LNG was
estimated to have prevented 52%.8 The reported pregnancy
rates in the comparative clinical trials of UPA and LNG EC
were around 1 and 3%, respectively, compared with the
expected rate of 4% (in the absence of EC).5,8 Studies have
also demonstrated lower pregnancy rates with earlier
administration of EC after UPSI, which may be because the
woman is less likely to have already ovulated.5
Does obesity impact on effectiveness of EC?
A secondary analysis of two randomised controlled trials
comparing LNG and UPA EC demonstrated that obesity,
i.e. body mass index (BMI) ≥ 30 kg/m2, increased the risk
for pregnancy after EC, and the risk was more pronounced
with LNG than UPA (four-fold versus two-fold).49 The
same trend was concluded in a pooled analysis of a phase
III study of UPA.50 However, the trials were not designed
to address the issue of BMI on efficacy of EC. In addition,
the numbers of women with obesity were low, as were the
number of pregnancies in this group. Also, in many cases,
height and weight had been self-reported. Furthermore,
previous studies of LNG EC had failed to show an impact
of BMI upon pregnancy rate.51,52 In 2014, the European
Medicines Agency reviewed the available data and con-
cluded that the data were not sufficiently robust to discour-
age women with obesity from using either UPA or LNG
EC.53 More recently, a pooled analysis of randomised con-
trolled trials of LNG conducted by WHO (n = 6873)
reported higher pregnancy rates among women with obe-
sity compared with women of normal weight (although this
was only statistically significant with regression analysis and
ª 2017 Royal College of Obstetricians and Gynaecologists

adjustment for several factors).54 There are also pharma-
cokinetic data indicating that LNG takes a longer time to
achieve steady-state levels in women with obesity compared
with those of normal BMI, which can be overcome by dou-
bling the dose of LNG.55 Conversely, the pharmacokinetics
of UPA is not affected by obesity.56 It is very unlikely that
there will be a definitive randomised controlled trial com-
paring the efficacy of EC in women with obesity versus
those with normal weight, so for now the uncertainty
regarding the impact of BMI on the efficacy of EC remains.
Nonetheless, the current UK guideline recommends that
women weighing >70 kg or with BMI > 26 kg/m2 should
be offered UPA EC or consider a double dose (3 mg) of
LNG EC, although it is not known which of these two
options is more effective.5
How good is advance provision of EC at
preventing unintended pregnancy at population
level?
Population studies and clinical trials of advance provision
of EC (supply to keep at home in case of need) indicate
that use of EC does not reduce rates of unintended preg-
nancy or termination of pregnancy (TOP) at population
level. A Cochrane review of six randomised controlled trials
of over 6300 women with advance supplies of EC com-
pared with standard access failed to demonstrate any
reduction in pregnancy rates at 3, 6 or 12 months.57 This
is probably because many women underestimate their risk
of pregnancy and do not take EC after UPSI even if an
advanced supply is provided.58
Safety of EC
Is EC generally safe to use?
In contrast to the Yuzpe regimen, adverse effects associated
with use of LNG EC or UPA EC are infrequent, minor and
generally well-tolerated. Serious adverse effects are very
rare.5,8 The pattern of adverse effects (e.g. nausea, head-
ache) reported after UPA is similar to that after LNG,8 and
is similar for adults and adolescents.59 A review of the
safety of UPA EC by the European Medicines Agency53
concluded that UPA was so safe that a change in classifica-
tion status from prescription to nonprescription was rec-
ommended and this has been widely adopted in most
European countries.13
Does EC exposure have a harmful effect on a
pregnancy?
A prospective cohort study showed no association between
the use of LNG EC and the risk of major congenital mal-
formation, pregnancy complications or any other adverse
pregnancy outcomes.60,61 Data regarding the effects of UPA
on pregnancy outcome are inevitably limited due to the
ª 2017 Royal College of Obstetricians and Gynaecologists
Controversies with oral emergency contraception
small number of pregnancies reported after UPA EC, and
the fact that many of these unintended pregnancies were
voluntarily terminated. However, the available data from
over one million women who used UPA in the clinical tri-
als and during postmarketing surveillance have been consis-
tent with no increased risk of miscarriage, ectopic
pregnancy or congenital abnormality in babies after UPA
exposure.42
Regarding the Yuzpe regimen, there is some reassurance
extrapolating from a meta-analysis of 12 available prospec-
tive studies on around 6000 exposed women that did not
find any statistically significant association between oral
contraceptive use in early pregnancy and fetal malforma-
tion.62
Indirect evidence from in vitro studies also showed that
LNG or UPA at EC doses had no effect on human blastocyst
viability28,29,41 in spite of sufficient time being allowed for
the embryo to undergo any degenerative changes that LNG
or UPA could possibly cause within the culture system.
Does EC have an adverse effect on breastfeeding?
Emergency contraception is not required before 21 days
postpartum.63 Women who take LNG while breastfeeding
can be advised that they can continue to breastfeed.63,64 A
recent systematic review suggested no adverse effect on
breastfeeding performance or infant outcomes with the use
of progestogen-only contraception.65 Guidelines therefore
advise that women can continue to breastfeed after taking
LNG for EC.66–68
There are no data on effects of UPA on breastfeeding
nor on infant outcomes. As UPA is lipophilic, secretion to
breast milk could be expected. However, levels are likely to
be extremely low and adverse effects are unlikely. The man-
ufacturer advises women to discard breast milk for 7 days
after UPA, which has been endorsed by UK and WHO
guidelines.5,66,67 In contrast, US guidelines advise discard-
ing milk for 24 hours only.68 Even this advice may be
overly cautious as studies of another PRM (mifepristone)
have shown that following 200 mg of mifepristone (which
is four times the EC dose), the peak mifepristone levels in
breast milk are extremely low (<1.5% of maternal levels).69
Does use of EC increase risky sexual behaviour?
There were reservations among users and healthcare provi-
ders against making oral EC available without prescription,
mainly because of the myths that easier access to EC might
compromise the use of regular contraception or promote
risky and irresponsible sexual behaviours.57 However,
numerous studies showed no evidence that availability of
EC resulted in women abandoning regular contraception in
favour of EC.57 In addition, advance provision of EC does
not appear to increase the frequency of UPSI or sexually
transmitted infections.57
1951
 Cameron et al.
Is it safe to use oral EC more than once in the
same cycle?
Follicular development and ovulation are only postponed
after intake of EC, so women are at risk of becoming preg-
nant if further acts of UPSI take place in the same cycle;5
such risk has been reported as three- to four-fold com-
pared with no further UPSI.1,49 Based on the half-life of
LNG and UPA, repeat use of EC is recommended in the
case of further UPSI beyond 24 hours from the last EC
use.66
A study of women taking pericoital LNG-EC repeatedly,
i.e. as required either before or within 24 hours of UPSI as
their main method of contraception, reported a pregnancy
rate of 11 per 100 women-years. It was well tolerated with
a low incidence of adverse effects, and with an efficacy that
is better than no method.70 Nevertheless, women should be
informed that repeated EC use is less effective than a regu-
lar method of contraception and may result in irregular
bleeding.67
In a biomedical study where UPA at EC dose was
administered every 5 or 7 days over a period of 8 weeks,
ovulation was delayed but eventually happened in most
women.71 This was associated with irregular bleeding.
Assessments of endometrium showed morphological
changes associated with PRM exposure. Tests of liver func-
tion, haematinics and thrombotic markers were also nor-
mal. The European Medicines Agency reviewed the data
and concluded that repeat administration of UPA in the
same cycle was safe.53
Contraception after EC
Do women want to start effective contraception
after EC?
It is important that EC users who will remain sexually
active start an effective method of contraception as soon
as possible. If women attend a family planning service or
a general practitioner for EC, then they can be provided
with ongoing contraception at this same visit. Studies
from the UK suggest that up to 50% of women accessing
EC from a family planning service are provided with a
contraceptive method at this time,72,73 and a study from
Sweden showed that over half of women receiving UPA
were using effective contraception 6 months later.74 Of
course, women are increasingly choosing to access EC
from the pharmacy (in countries where this is available
without prescription),13,75 but most pharmacists cannot
provide ongoing hormonal contraception without a pre-
scription. In a survey of women attending UK pharmacies
for EC, 64% indicated that they would value the opportu-
nity to receive a supply of contraception from the phar-
macy.76 A pilot study showed that women provided with
a 1-month supply of a progestogen-only pill along with
1952
EC from a pharmacy were more likely to be using effec-
tive contraception 2 months later than women attending
pharmacies where they only received advice on where to
obtain supplies of contraception (56% versus 16%). Lar-
ger robust studies are needed to determine if this strategy
can increase the uptake of effective contraception after EC
from the pharmacy.77
Is it safe to ‘quick start’ hormonal contraception
immediately after EC?
Guidelines advise that after LNG EC women can start hor-
monal contraception immediately, based on the assumption
that LNG will not interact with hormonal contraception.5
However, UPA is a PRM and so there is a theoretical con-
cern about interaction with progestogen-containing hor-
monal contraception by competition at the progesterone
receptor, as has been shown for other PRMs.78 Two
biomedical studies have addressed the impact of UPA on
hormonal contraception in the presence of a dominant fol-
licle. One showed no adverse impact of UPA on the ability
of combined oral contraception initiated 1 day later to
induce ovarian quiescence, but this study was not designed
to examine any impact of combined oral contraception on
the ability of UPA to delay ovulation.79 The other80
reported that UPA did not affect the contraceptive action
of a desogestrel-only pill on cervical mucus or ovarian qui-
escence. However, an ovulation rate of 45% within 5 days
was reported among women quick-started on the deso-
gestrel-only pill after UPA, compared with 3% among
women taking placebo pills. Hence, immediate start of a
desogestrel-only pill appears to counteract the contraceptive
effect of UPA and expose the individual to the same risk of
pregnancy faced without use of EC. This was a small study
of one type of hormonal contraception, but it is biologi-
cally plausible that this effect may apply more broadly.
Hence, it is advisable to delay initiation of hormonal con-
traception for at least 5 days after UPA,5 although some
suggest that it may be more biologically correct to count
the 5 days from the episode of UPSI (lifespan of spermato-
zoa) rather than from intake of UPA.81 Although UK
guidelines advise that the LNG-releasing intrauterine sys-
tem should not be inserted until pregnancy has been
excluded, there are some data to suggest that starting this
method with LNG-EC may be a reasonable option for
some women.82 More research is required.
The future: can we develop a more effective EC?
Prostaglandins play a critical role in follicle rupture. Pre-
liminary data suggest that addition of meloxicam (a cyclo-
oxygenase inhibitor) to LNG may potentiate its effect in
suppressing ovulation,83 but whether the same applies to
UPA is uncertain, and needs to be explored in large robust
trials.
ª 2017 Royal College of Obstetricians and Gynaecologists

‘Contragestion’ was the term used by contraceptive
researchers in the 1980s to describe a potential method that
could remain effective after ovulation to prevent or disrupt
the establishment of a very early pregnancy at the end of
the luteal phase.84,85 This conveys the concept of an ‘emer-
gency’ method that works throughout the cycle to prevent
pregnancy. Mifepristone combined with misoprostol may
potentially be developed for this purpose in countries
where this is allowed.86
Conclusions
This article provides an evidence-based view on the current
oral EC methods (summarised in Table 1). Myths and mis-
conceptions surrounding oral EC have hampered availabil-
ity, access to, and use of EC by women. The best evidence
shows that oral EC works by delaying ovulation (if that has
not already taken place), is not as effective as many might
believe, is extremely safe and does not lead to women
abandoning regular contraception or increased prevalence
of sexually transmitted infections. So what has all the con-
troversy been about?
All women deserve a second chance to prevent an unin-
tended pregnancy and we need to develop strategies to
maximise the effectiveness of EC. First, use of the Cu-IUD
as the most effective EC should be considered. Further-
more, women should be advised to avoid further UPSI in
the same cycle after oral EC, and should acquire an effec-
tive method of contraception as soon as possible.
More research is required to explore the provision of
ongoing contraception with oral EC from the pharmacy,
and also to investigate the possible impact of obesity on
oral EC. Finally, women deserve a more effective oral EC,
which can prevent pregnancy even after ovulation has
occurred and which could potentially also be used ‘on
demand’. This could be an EC that prevents implantation,
but could also be a contragestive pill that women could
take as and when required and that works throughout the
cycle, although this remains controversial.
Disclosure of interests
Full disclosure of interests available to view online as sup-
porting information.
Contributions to authorship
The authors jointly conceived the idea for the article, con-
tributed to the article and revised and approved the final draft.
Details of ethics approval
Not applicable.
Funding
None.
ª 2017 Royal College of Obstetricians and Gynaecologists
Controversies with oral emergency contraception
Acknowledgements
We would like to acknowledge the Sanming Project of
Medicine in Shenzhen for supporting research at the
Reproductive Medicine Centre, The University of Hong
Kong—Shenzhen Hospital, under the guidance of Professor
Kristina Gemzell-Danielsson.
Supporting Information
Additional Supporting Information may be found in the
online version of this article: &
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For emergency contraception, political gaps are not scientific gaps

DK Turok
Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA

Linked article: This is a mini commentary on ST Cameron et al., pp. 1948–1956 in this issue. To view this article visit
https://doi.org/10.1111/1471-0528.14773

Published Online 6 September 2017.

Emergency contraception (EC) is the
only opportunity for women to pre-
vent an unwanted pregnancy after
unprotected intercourse. Simple com-
passion for women who are in this sit-
uation combined with solid scientific
data to support the safety of oral EC
should be enough to promote strate-
gies to expand access to these medica-
tions as well as the most effective
method of EC, the copper IUD. A wide
array of women’s healthcare organisa-
tions promote increasing EC access to
improve clinical care, a position clearly
supported by the four foundations of
biomedical ethics: autonomy, non-
maleficence, beneficence, and justice.
Ironically, in the political sphere, con-
servative morals are the foundation for
limiting access, despite the conflict with
scientific evidence. In this issue, Drs.
Cameron, Li, and Gemzell-Danielson
present an opportunity for clinicians to
review the data behind public and scien-
tific oral EC controversies.
These controversies can easily be
divided into two groups. The first
group contains issues that despite sci-
entifically sound evidence remain con-
troversial because of religious and
political opposition. In essence, these
issues are not scientifically controver-
sial. Contention exists only because EC
provides greater reproductive auton-
omy and thus clashes with conservative
sexual values, which aim to shame
women having sex for pleasure and
not for procreation. Limiting effective
methods of post coital contraception
supports this position and limits
women’s sexual freedom. This scientifi-
cally uncontroversial group includes
the oral EC mechanism of action,
excellent safety, lack of population
effect, and inability to serve as an
abortifacient. The second group con-
tains topics where scientific evidence is
lacking or imperfect. This group
includes the potential decrease in pro-
gestin containing contraception efficacy
when initiated with ulipristal, methods
to manage the potential negative effect
of obesity on EC efficacy, and whether
the oral EC mechanism of action is
important to users. Ironically, despite
sound evidence, it is this first group
which forms the foundation for oppo-
sition to implementing EC best prac-
tices. As scientists and clinical
researchers have done their work here,
this realm is now the work of policy
experts, advocates, and politicians.
There are many examples of politics
influencing good clinical care, which for
oral EC means improving access and
affordability. Inexpensive over the
counter (OTC) availability of oral EC is
the target for advocates and politicians
on both sides. Whereas oral levonorges-
trel and ulipristal EC products are
available OTC in Europe, a long politi-
cal battle has been waged on this issue
in the USA, where OTC ulipristal is not
even on the horizon. However, promot-
ing regulatory approval is not enough.
Politics can also support pharmacists
who refuse women access to EC or pre-
vent this behaviour. Sexual assault vic-
tims are a critical group in need of EC
and several entities have passed legisla-
tion mandating offering EC when these
women present for medical care.
Finally, EC coverage can be mandated
or restricted through private and gov-
ernment-sponsored medical coverage.
In the USA, a Supreme Court decision
enables private companies to forego EC
insurance coverage for employees based
on moral beliefs even though the court
has acknowledged these are not scientif-
ically valid. In areas of medical contro-
versy, scientific evidence and biomedical
ethics can lead both clinicians and pol-
icy makers in the right direction. In this
case the road clearly leads to increasing
EC access and affordability.
Disclosure of interests
Dr Turok reports grants and personal
fees from Teva pharmaceuticals, outside
the submitted work. Teva distributes
the Paragard copper IUD, a method of
emergency contraception. The ICMJE
disclosure form is available as online
supporting information. &

1956 ª 2017 Royal College of Obstetricians and Gynaecologists