The evidence from both population studies and clinical trials of advance provision of EC (supply to keep at home in case of need) would indicate that use of EC does not reduce unintended pregnancy rates or abortion rates at population level. Indeed, a Cochrane review of six RCTs of over 6300 women (with one or more supplies of EC at home) compared to standard access, failed to demonstrate any reduction in pregnancy rates at 3, 6 or 12 months [29].

In Norway, availability of LNG for EC from the pharmacy without prescription was associated with 30-fold increase in sales over 10 years, but the abortion rate remained unchanged over this time [30]. Similarly, in Great Britain, abortion rates continued to increase up to 2008, some 7 years after availability of LNG for EC from the pharmacy [31]. However, abortion rates are influenced by many factors and demographic changes in society with earlier age of coitarche, later age at first birth, relationship break ups and divorce may mean that women now spend a greater proportion of their reproductive lives at risk of unintended pregnancy. Also, we know from the clinical trials of advance provision of EC that women do not use EC for every episode of unprotected sex [29].

Studies conducted in UK, France and Denmark amongst women requesting abortion have shown that 12 % of women have used EC in the conception cycle to try to prevent the pregnancy [32–34]. Furthermore, a survey of women requesting abortion in the UK showed that although availability of LNG EC at ‘no cost’ from the pharmacy did not affect this percentage, in spite of most respondents being aware that EC was free at the pharmacy [32].

Research has also shown that women often fail to recognize that they are at risk of pregnancy, neglect the risk or are deterred from using EC due to stigma, or misconceptions about the method [33, 34]. It has also been suggested that the increase in EC use may be amongst women who are least at risk of an unintended pregnancy, but are anxious about that risk [30]. In addition, we do know that many women may have more episode(s) of sex in the same cycle after using EC, and that further sex increases the risk of pregnancy [25].

Given the higher risk of pregnancy if further sex occurs in the same cycle after EC, it is important that women start an effective method of ongoing contraception as soon as possible. The term ‘quick start’ is used to denote starting a method of contraception at any point in the menstrual cycle, without waiting for the next menses. If women attend a family planning (FP) service for EC, then they can be provided with ongoing contraception at this same visit. A study from the UK suggested that 23 % of women attending a FP service for EC chose to start effective contraception, usually the combined oral contraceptive pill [11]. Of course, women are increasingly choosing to access EC from the pharmacy (in countries where this is available without prescription), and most pharmacists cannot provide hormonal contraception without a prescription. A pilot study from the UK examined two pharmacy -based interventions designed to facilitate access to effective contraception after EC [35]. It randomised 12 pharmacies to provide women with either (i) standard care, i.e., pharmacist provides EC as usual (LNG), or (ii) pharmacist supplied a 1 month supply of the progestogen only pill (POP) with EC – so that women could start the POP immediately and have up to 1 month to arrange an appointment with their usual care provider for effective ongoing contraception or (iii) women had a rapid access pathway to the local FP for contraception upon presentation of their empty EC box. Women in this study consented to be contacted by the researcher 8 weeks later to determine what method of contraception they were using. Although, it was a small study with just under 60 participants in each of the arms of the study, there was a significantly higher proportion of women in the POP (52 %) and rapid access arm (52 %) using effective contraception than in the standard care arm alone (16 %). This suggests that provision of a POP or rapid access to a FP could prove to be an effective measure to increase the uptake of effective contraception after EC from the pharmacy. In addition, the POP is a very safe method of contraception and could be provided more easily than a combined oral contraceptive pill. Larger robust studies in this area are therefore needed.

UPA is a progesterone receptor modulator (PRM), and PRMs may interfere with the action of progestogen containing contraception. There is concern therefore that UPA may affect the efficacy of UPA or vice versa. Guidelines from the Faculty of Sexual and Reproductive Healthcare UK advise that women can commence hormonal contraception after UPA, but should rely on additional barrier contraception or abstain for 14 days if the method is a COC [36]. This is based upon an estimated 7 days to clear UPA (based upon its half life of 32 h) plus a further ‘theoretical’ 7 days to induce ovarian quiescence with a COC.

A recent placebo-controlled RCT that examined the effects of quick starting a COC after UPA in healthy volunteers with a follicle of at least 13 mm in size (equivalent to mid follicular phase), showed that there was no difference between UPA and placebo in either the proportion of women who achieved ovarian quiescence on a COC nor the number of days to achieve quiescence [37]. This study design was such that it could not determine whether the COC might impact upon the ability of UPA to delay ovulation. A further RCT study has examined the effects of starting a progestogen only pill (POP) containing desogestrel, the day after theUPA or placebo [38]. This study demonstrated that althoughUPA did not affect the contraceptive actions of this POP (ovarian suppressionandcervical mucus), that the POP did affect the ability of UPA to delay ovulation [38]. In view of this, guidelines advise that women should not start a hormonal method of contraception for at least five days after using UPA for EC [39].

Prostaglandins play a critical role at the time of follicle rupture and the cyclo- oxygenase- 2 inhibitor meloxicam inhibits prostaglandin synthesis. A pilot RCT comparing the effect of the EC dose of LNG plus meloxicam versus LNG and placebo on follicle rupture when administered to healthy female volunteers in the pre-ovulatory phase of the cycle demonstrated that there was no ovulation at 5 days (i.e., lifespan of spermatozoa in the female reproductive tract) in 39 % of participants receiving LNG and meloxicam vs. 16 % of those receiving LNG and placebo [40]. This suggests that perhaps a combination of meloxicam and LNG might increase the efficacy of LNG for EC. It is also possible that meloxicam combined with UPA might increase the efficacy of UPA further. Large robust trials are now required.

A Cochrane review demonstrated that mid doses of mifepristone (25–50 mg) are more effective than LNG [25]. Studies have also shown that higher doses of mifepristone (200 mg) have profound effects on endometrial secretory development that may prevent implantation [41, 42]. Further research into the development of more effective oral ECs is therefore warranted.