Emergency contraception: best practice for pharmacy

Introduction 

Emergency contraception (EC) refers to methods used to prevent pregnancy after condomless sexual intercourse or contraceptive failure. It is a crucial aspect of reproductive healthcare, offering a time-sensitive option to reduce unintended pregnancies. In the UK, EC is accessible through pharmacies, sexual and reproductive health (SRH) clinics and GPs, making community pharmacy a pivotal point of care^​1​.

The latest NHS Digital ‘Sexual and Reproductive Health Services (Contraception)’ report reveals that 94,429 emergency contraception items were supplied by SRH clinics in 2023/2024^​2​. This was a 13% increase compared with 2022/2023 and represents a significant rebound from COVID-19 pandemic-affected years, with the number now back above the pre-pandemic level^​2​. While these figures demonstrate recovery, they also highlight a concerning trend in community pharmacy provision. Community pharmacies dispensed 65,623 EC prescriptions in 2023 — a 11% decline compared with 2022, and a dramatic 69% decrease from 215,000 items dispensed in 2013^​2​. This sustained reduction raises urgent questions about access to timely contraception outside specialist clinics.

EC became available for over-the-counter purchase in UK pharmacies on 1 January 2001, following its reclassification to a pharmacy (P) medicine for women aged 16 years and over^​3​. Subsequently, in 2005, the new pharmacy contract in England included EC as an enhanced service, allowing pharmacies to provide it free of charge under a patient group direction (PGD) in certain circumstances^​4​.

From October 2025, under the community pharmacy funding contract for England, provision of emergency hormonal contraception (EHC) will be added to the community pharmacy contraception service and fees for contraception consultations will be increased to £25^​5​. From March 2026, community pharmacies in England must deliver a specific number of contraception consultations per month, which is yet to be agreed by CPE and the government^​1,6​. 

In Wales, since April 2022 all pharmacies under Wales’s national clinical community pharmacy service are required to offer a set of four services — EC, common minor ailments, emergency medicine supply and flu vaccination — or opt out entirely. This includes expanded access to bridging (i.e. a temporary supply of hormonal contraception to prevent unplanned pregnancy while a person decides on a long-term solution) and “quick‑start” contraception, which can be started at the time of request^​7​.

In Scotland, community pharmacies can provide EHC via PGD and bridging contraception has also been available since November 2021^​8​. Since November 2024, the EHC service has allowed pharmacies to claim a £30 consultation fee, even when supply is not made. For bridging contraception, the service was expanded so that people not registered with a GP can still access it — as long as they live in Scotland^​8​. Scotland’s Pharmacy First service allows individuals to speak to a pharmacist about EC and receive it free of charge, typically without needing an appointment^​9​. 

Pharmacists frequently serve as the first point of contact for individuals who need EC, particularly owing to the convenience and anonymity that pharmacies provide. This places pharmacy teams at the frontline for delivering timely advice, ensuring appropriate selection of EC and facilitating onward referral when necessary. Understanding the types of EC available, their mechanism of action, efficacy and usage timelines is essential for pharmacists to support informed patient choices and optimise outcomes.

Types of emergency contraception 

There are two primary types of emergency contraception used in the UK: oral emergency contraceptive (OEC) pills and the copper intrauterine device (Cu-IUD). The efficacy of emergency contraception is highly time-dependent (see Figure 1^​10​).

Oral emergency contraception

Oral EC should not be confused with the terminology ‘morning-after pill’ — EC can be used for up to five days after unprotected sexual intercourse. These work by inhibiting or delaying ovulation, thus preventing fertilisation^​11​. The majority of women will go on to ovulate later in the cycle and are therefore at risk of pregnancy from subsequent unprotected sexual intercourse. It is essential that women are made aware of this risk and are advised regarding reliable ongoing contraception. Administration of OEC after ovulation has occurred is unlikely to be effective. The effectiveness of both types of OEC listed below could be reduced if a woman is using an enzyme inducer (e.g. certain anticonvulsants)^​12​.

There are two types of OEC available, see Table^​11,12​.

Copper intrauterine device 

The Cu-IUD is the most effective form of emergency contraception, offering over 99% efficacy when inserted up to five days post-unprotected sexual intercourse or within five days of expected ovulation^​13​. Early presentation is encouraged to maximise its effectiveness. A Cu-IUD works primarily by creating a local inflammatory reaction toxic to sperm and ova, thereby inhibiting fertilisation and preventing implantation. A benefit of the Cu-IUD is ongoing contraception for up to ten years; however, insertion requires a trained healthcare professional and carries risks such as uterine perforation and infection. Most women are suitable for a Cu-IUD, including teenagers and women with no previous pregnancies^​14​. It may not be recommended in cases of cervical/endometrial cancers, unexplained vaginal bleeding (could be a sign of a serious condition, such as undiagnosed cancer or polyps), current symptomatic pelvic infection or uterine abnormalities distorting the uterine cavity^​12​. 

Pharmacy teams are essential in ensuring timely access, providing accurate information on options and advising when referral for IUD insertion is appropriate. Awareness of contraindications and potential drug interactions also supports safe supply. 

Referral for Cu-IUD fitting:

• Refer to local sexual and reproductive health clinics, young people’s services or GPs where appropriate;
• If Cu-IUD referral is delayed or uncertain, provide oral EC at the same time as referral;
• Be aware that copper-IUD is usually contraindicated from 48 hours to 28 days postpartum owing to increased risk of perforation^​12​.

Consultation environment and communication

Pharmacists’ supply of EC could raise some complex ethical considerations. Some pharmacists may have personal or religious objections to providing EC, however, professional guidance emphasises the importance of ensuring patients receive timely access to necessary medications, even if it requires referral to another provider^​15​. 

Seeking EC can be a vulnerable experience for patients and they may feel uncomfortable answering questions about their sexual activity. Patients may have had negative experiences when accessing EC in the past; for example, a 2021 study by Turnball et al. highlighted unsupportive attitudes of pharmacy staff, which may be a concern for patients^​16​. However, another mystery shopper study of 30 pharmacies in the UK highlighted in the same year that women were generally positive about their consultation experiences^​17​. It is important to consider the patient’s privacy and use appropriate communication to help put the patient at ease. The consultation advice in the Box below can help facilitate this.

Taking a full history

A structured history is essential to determine if EC is indicated and which method is appropriate. The patient should be given the information to make an informed decision (see Figure 2)^{​12,18,19​}. 

Ongoing contraception

The majority of women will go on to ovulate later in the cycle and are therefore at risk of pregnancy from subsequent unprotected sexual intercourse. It is essential that women are made aware of this risk and are advised regarding reliable ongoing contraception. A Cu-IUD offers immediate and ongoing contraception.

For oral EC:

• Patients taking levonorgestrel can start the progestogen-only pill immediately. They should be advised to avoid unprotected sexual intercourse or use barrier method for two days (or seven days if starting drospirenone).
• Patients taking ulipristal acetate must wait five days before starting hormonal contraception as the presence of progestogen can reduce UPA effectiveness. They should be advised to use condoms or abstain for at least seven days after starting hormonal contraception. Always offer EC as soon as possible — encourage taking the dose in-pharmacy when possible^{​12,18,19​}.

Additional patient counselling 

• Patients should be advised that nausea, headache, changes in bleeding pattern are common side effects of OEC. Vomiting within three hours can impact the efficacy of OEC and the dose should be repeated. Persistent, severe diarrhoea can reduce OEC absorption; alternative emergency contraception such as Cu-IUD should be considered;
• Patients should test for pregnancy three weeks after EC;
• EC does not protect against STIs. Patients should be offered condoms and signposted to STI screening services. Chlamydia screening should be provided if available^​12,18​.

Conclusion 

EC remains a critical service within pharmacy practice, providing a valuable safety net for preventing unintended pregnancies. Pharmacists’ understanding of the available types of EC, mechanisms of action and timing of EC supports informed patient care and contributes to improved sexual health outcomes in the UK.