A 17-year-old girl presents to your office 4 days after the condom slipped off during sexual intercourse with her boyfriend. She has been sexually active with him for about 6 months; she has used condoms “properly” every sexual encounter previous to that and has never been pregnant. She has never been tested for sexually transmitted infections. Her mother is very anxious about the possibility that she may already be pregnant, as they read online that you should take emergency contraceptive pills within 3 days after unprotected intercourse, and she remembers you telling her that when she saw you for her annual examination. At the time of the examination, you had counseled about contraceptive options , including long-acting reversible contraceptives and emergency contraception, but the patient had declined birth control as she had never been sexually active at the time and stated that she was not planning on becoming sexually active in the near future. For that reason, you had not given her a prescription for emergency contraception.

She has no desire to become pregnant as is planning to go away to college next fall. She is an “A” student and is very active in high school choir. The patient and her mother had been discussing making an appointment for a long-acting reversible contraceptive when she disclosed to her mother about the recent unprotected intercourse upon her return from visiting her boyfriend in another state. As they had been staying at a remote location where he was working for the summer, there was no medical clinic or pharmacy accessible to them.

The patient states she feels well, and her past medical history is unremarkable except for obesity (BMI is 30) and some mild gastroesophageal reflux disease, for which she is taking omeprazole for the past few weeks. Her last menstrual period was 2 weeks ago, and her periods come monthly since age 12. She does not smoke. She uses over-the-counter topical medications for her acne, and other over-the-counter medications include only occasional paracetamol for occasional headaches. Her boyfriend is the one who provides the condoms as they are routinely dispensed at his school.

Her mother is asking if it is too late for emergency contraception of any kind. She is concerned about unwanted pregnancy and also sexually transmitted infections. Both the mother and daughter would like to know if she can start birth control immediately after taking care of “this issue.” They are also concerned that her weight would make hormonal contraception less effective and “not an option.”

The adolescent in this case is in need of emergency contraception for unprotected sexual intercourse 4 days prior to her visit to your office. Her mother has accompanied her, is supportive of her decision to see you, and acknowledges her need for a visit today and birth control. Despite recent statistics indicating a decline in teen pregnancy rates in the USA, teen pregnancy is still an undesired outcome of teen behavior in many cases. Many teens hide their sexual activity from adults, and thus their contraceptive use may be sabotaged [1]. The current rate of decrease in teen pregnancy is due mostly to increased, and earlier, education about contraceptive use, including education about long-acting contraceptives and emergency contraception and only minimally due to increased abstinence rates, according to recent studies [2]. About half of 15- to 19-year-old females state they have had sexual intercourse “ever,” with 10% or more reporting they have been forced to have sex. Presently, more than 80% of pregnancies in adolescents are unintended and result from contraceptive nonuse or inappropriate use. The most commonly used method of birth control by teenagers is the condom, followed by oral contraceptive use [3]. Both of these methods have large risks of misuse or failure [4]. Hence, the concerns of your patient and her mother are reasonable.

Adolescent pregnancies , especially unplanned ones, have higher complication risks, including ectopic implantation, placenta previa, pregnancy-induced hypertension, and premature delivery, even with early and proper prenatal care, which may be difficult for adolescents to access. Adolescent mothers are less likely to graduate from school and more likely to live in poverty. The children of adolescents are more likely to have poor health outcomes, including low birth weight and higher rates of infant mortality, as well as lower educational achievement in the long run [5].

Emergency contraception is the only method designed to prevent pregnancy after intercourse. Providers ideally educate teens about contraceptive options , including emergency contraception and its availability prior to the need for it. This patient was educated but did not receive a prescription to have on hand or accessibility to immediate care. Medical literature has shown that women, especially teenagers, are most likely to use emergency contraception when they have it on hand [6]. Indications for the use of emergency contraception include unprotected vaginal intercourse, whether consensual or due to sexual assault, as well as missed doses of regular hormonal contraception. These indications include missing three doses in a row of an active hormonal contraceptive pill, having a contraceptive vaginal ring out for more than 3 h in a week when it should have be in, or having the patch off for more than 24 h in a “patch on week.” Condom breakage or slippage, as in this scenario, is an indication for emergency contraception [6].

This patient’s last menstrual period was about 2 weeks prior to the encounter, putting her at relatively high risk for pregnancy to occur. As she does not desire to become pregnant at this time, emergency contraception should be prescribed. The concern that “it may be too late” is appropriate, but the best response to her mother’s fears is that hormonal emergency contraception is most effective when used within the first 24 h after unprotected intercourse or contraceptive failure. It can, however, be used within 120 h of unprotected intercourse to reduce the risk of pregnancy [6]. Hormonal emergency contraception is useful even with other birth control methods, and its effectiveness does not depend on the other methods (which previously failed). The patient can be prescribed the emergency contraception today and may be a candidate for LARCs (implant or intrauterine device) or oral contraceptives by quick start in addition. Emergency contraception which may be recommended includes the FDA-approved levonorgestrel and ulipristal acetate , off-label use of combination oral contraceptives (“Yuzpe” method), or insertion of a copper IUD.