TABLE. J1. Classifications for emergency contraception, including the copper intrauterine device, ulipristal acetate, levonorgestrel, and combined oral contraceptives.

Condition	Category				Clarification/Evidence/Comment
	Cu-IUD	UPA	LNG	COC
Personal Characteristics and Reproductive History
Pregnancy	4	NA	NA	NA	Clarification (IUD): The IUD is not indicated during pregnancy and should not be used because of the risk for serious pelvic infection and septic spontaneous abortion. Clarification (ECPs): Although this method is not indicated for a patient with a known or suspected pregnancy, no harm to the patient, the course of pregnancy, or the fetus if ECPs are inadvertently used is known to exist. Evidence: Evidence suggests that poor pregnancy outcomes are rare among pregnant women who used ECPs during conception cycle or early in pregnancy (4).
Breastfeeding	1	1	1	1	Evidence: Breastfeeding outcomes do not seem to differ between women exposed to LNG and those who are not exposed (4). One pharmacokinetic study demonstrated that LNG passes to breast milk but in minimal quantities (4). UPA and its active metabolite, monodemethyl-ulipristal acetate, are present in human milk in small amounts; no evidence is available on effects of UPA emergency contraception exposure on infants or children who are breastfed (5).
Past ectopic pregnancy	1	1	1	1	—
Obesity (BMI ≥30 kg/m2)	1	2	2	2	Clarification (ECPs): ECPs might be less effective among persons with BMI ≥30 kg/m2 than among persons with BMI <25 kg/m2. Despite this, no safety concerns exist. Evidence: Limited evidence from secondary data analyses suggests that women with BMI ≥30 kg/m2 experience an increased risk for pregnancy after use of LNG compared with women with BMI <25 kg/m2. Two analyses suggest that women with obesity might also experience an increased risk for pregnancy after use of UPA compared with those without obesity, although this increase was not significant in one study (6).
History of bariatric surgery This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).
a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy)	1	1	1	1	—
b. Malabsorptive procedures: decrease absorption of nutrients and calories by shortening the functional length of the small intestine (Roux-en-Y gastric bypass or biliopancreatic diversion)	1	1	1	1	Comment: Bariatric surgical procedures involving a malabsorptive component have the potential to decrease oral contraceptive effectiveness, perhaps further decreased by postoperative complications such as long-term diarrhea, vomiting, or both. Because of these malabsorptive concerns, an emergency IUD might be more appropriate than ECPs.
Cardiovascular Disease
History of severe cardiovascular disease (ischemic heart disease, cerebrovascular attack, or other thromboembolic conditions) This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).	1	2	2	2	Comment: The duration of ECP use is less than that of regular use of COCs or POPs and thus would be expected to have less clinical impact.
Rheumatic Diseases
Rheumatoid arthritis
a. Not receiving immunosuppressive therapy	1	1	1	1	—
b. Receiving immunosuppressive therapy	2	1	1	1	—
Neurologic Conditions
Migraine	1	1	1	2	Comment: The duration of ECP use is less than that of regular use of COCs and thus would be expected to have less clinical impact.
Gastrointestinal Conditions
Inflammatory bowel disease (ulcerative colitis or Crohn’s disease)	1	1	1	1	—
Severe liver disease (including jaundice) This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).	1	2	2	2	Comment: The duration of ECP use is less than that of regular use of COCs or POPs and thus would be expected to have less clinical impact.
Solid Organ Transplantation
Solid organ transplantation This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).
a. No graft failure	1	1	1	1	—
b. Graft failure	2	1	1	1	—
Other
Repeated ECP use	—	1	1	1	Clarification (ECPs): Frequently repeated ECP use might be harmful for persons with conditions classified as category 2, 3, or 4 for CHC or POC use. Evidence: In one case-control study, risk for ectopic pregnancy compared with intrauterine pregnancy did not increase after repeated use of LNG ECPs compared with nonuse (4).
Sexual assault	2	1	1	1	Clarification (IUD): Persons who have experienced sexual assault are at increased risk for STIs, including HIV infection. According to CDC STI treatment guidelines, routine presumptive treatment of chlamydia, gonorrhea, and trichomonas is recommended after sexual assault (2). Persons with current purulent cervicitis, chlamydial infection, or gonococcal infection should not undergo IUD placement (category 4).
CYP3A4 inducers (e.g., bosentan, carbamazepine, felbamate, griseofulvin, oxcarbazepine, phenytoin, rifampin, St. John’s wort, topiramate, efavirenz, and lumacaftor)	1	2	2	2	Clarification (ECPs): Strong CYP3A4 inducers might reduce the effectiveness of ECPs. Evidence: According to labelling information, rifampin markedly decreases UPA levels by ≥90%, which might decrease its efficacy (5). Therefore, theoretical concerns extend to use of other CYP3A4 inducers as well as to COC and LNG ECPs, which have metabolic pathways similar to those of UPA. A small pharmacokinetic study found that concomitant efavirenz use decreased LNG levels in women taking LNG ECPs (1.5 mg) by 56% compared with LNG ECPs alone (7).

Abbreviations: BMI = body mass index; CHC = combined hormonal contraceptive; COC = combined hormonal contraceptive; Cu-IUD = copper intrauterine device; CYP = cytochrome P450; ECP = emergency contraceptive pill; IUD = intrauterine device; LNG = levonorgestrel; NA = not applicable; POC = progestin-only contraceptive; POP = progestin-only pill; STI = sexually transmitted infection; UPA = ulipristal acetate.