Healthy living Emergency contraception: what you need to know about the “morning after” pill

The “morning after” pill is a hormonal emergency contraceptive that women can take after contraception has failed or after unprotected sex to avoid an unwanted pregnancy.

The “morning after” pill can be obtained from any pharmacy without a prescription. It is generally only dispensed directly to the person who will be taking it. At night, during the weekend or on bank holidays, emergency pharmacies can be used.

Products with the active ingredients levonorgestrel or ulipristal acetate are approved in Germany. Depending on the active ingredient, the “morning after” pill costs at least 17 or 29 euros. However, prices may fluctuate.

When women get the “morning after” pill prescribed by a doctor before their 22nd birthday, the statutory health insurance will assume the costs. However, a co-payment is required after the woman’s 18th birthday.

Both active ingredients in the “morning after” pill are, in principle, approved for all women of childbearing age. However, girls under the age of 14 normally have to get the consent of their parents or guardians before getting the “morning after” pill. For girls between the ages of 14 and 18, pharmacists themselves can decide, on a case-by-case basis, whether the “morning after” pill can be dispensed without the consent of a parent or guardian.

The probability of getting pregnant is highest 1 to 2 days before ovulation. The “morning after” pill works by suppressing ovulation or delaying it by up to 5 days. This is critical because sperm can remain viable in the female body for up to 5 days following sexual intercourse. If ovulation is prevented within this time-frame, no egg is available for fertilization and so pregnancy can be avoided. However, if ovulation is currently in progress or has already happened, the “morning after” pill is no longer effective. A gynecological examination, such as an ultrasound scan, is the only way to determine with certainty whether a “morning after” pill is needed.

If the woman is at the point in her menstrual cycle where ovulation is imminent, the “morning after” pill containing the active ingredient levonorgestrel is no longer effective. In contrast, products with the ingredient ulipristal acetate remain effective until shortly before ovulation. 

The “morning after” pill does not cause an abortion. It cannot terminate an existing pregnancy. It also offers no protection against sexually transmitted diseases.

As a general rule, the sooner the pill is taken following a contraceptive failure or unprotected sex, the more effectively it can prevent a pregnancy. Depending on which active ingredient is used in the product, the time window for effective use of the “morning after” pill is no more than 3 days (levonorgestrel) or 5 days (ulipristal acetate) after sex.

Should vomiting occur within the first 4 hours after taking it, a new “morning after” pill should be taken as soon as possible.

Women who usually take hormonal contraception and take a “morning after” pill containing the ingredient levonorgestrel should continue their hormonal contraception within 24 hours. They should also use a second method of contraception (such as condoms) or avoid having sex until their next menstrual period begins. Women who take the “morning after” pill with the ingredient ulipristal acetate can resume hormonal contraception after 5 days. They should also use a second contraception method before that and for up to 14 days afterwards.

For breast-feeding women, it should be noted that the agents in the “morning after” pill pass into the breast milk. It is recommended that they stop breastfeeding for at least 8 hours after taking levonorgestrel and for a week after taking ulipristal acetate. Doctors recommend expressing the milk with a pump in order to maintain lactation. However the baby should not drink it.

Taking the “morning after” pill can cause the menstrual period to be delayed. Spotting or heavier irregular bleeding are also possible.

The more common side effects also include:

• dizziness
• headaches and abdominal pain
• chest tightness
• nausea and vomiting 
• muscle and back pain
• fatigue
• mood swings

Doctors advise women with severe asthma who are taking glucocorticoids such as cortisone in tablet form to avoid using the “morning after” pill. This also applies to women who are susceptible to thromboses and women with severe liver function disorders.

The effectiveness of the “morning after” pill is likely to be limited in women who are very overweight (obese). Taking certain other medications at the same time as the “morning after” pill can also make it ineffective. These include St. John’s wort. So tell the pharmacist which medications you are taking.

Moreover, the “morning after” pill is not an option if pregnancy is suspected or has already been confirmed.

Women and girls with statutory health insurance are entitled to free consultation about contraception at a gynecologist’s practice. Contraception can only work effectively if used correctly. Contraception most commonly fails due to mistakes in how it is used. If condoms tear, slide off or remain stuck in the woman’s vagina it is often because they are the wrong size, i.e. the condom is too small or too large.

Proper use also involves getting the air out of the reservoir by squeezing with the fingertips when slipping the condom on. The condom should also be put on before penetrating the vagina, and only taken off when the penis has been fully withdrawn from the vagina.

Anyone who uses the hormonal pill as contraception should be careful to always take the pill at the same time of day. If you find it difficult to remember when to take it, the best idea is to save it on your smartphone. Time differences need to be taken into account, for example while on holiday or a business trip. It should also be noted that vomiting or taking other medication at the same time can interfere with the effectiveness of the contraceptive pill. If you are in any doubt, use an additional method of contraception, such as condoms, until you have finished the pack of pills.

A woman using a vaginal ring or diaphragm should always check that everything is fitted correctly. With a diaphragm, for example, it is important that it lies precisely at the entrance to the womb. It is also important to always use spermicidal gel, as the diaphragm is not effective without it. In addition, the diaphragm should be inserted no more than 2 hours before intercourse and left in place for 8 to 12 hours afterwards.

A gynecologist can check that a contraceptive coil is positioned correctly.

For detailed information about the different types of contraception available, see the familienplanung.de website operated by the Federal Institute for Public Health (Bundesinstitut für Öffentliche Gesundheit, BIÖG).

If the “morning-after” pill is not suitable, for example because of possible side effects, a standard copper coil (IUD) or a copper chain (i.e., a different form of copper intrauterine contraceptive device) can be used as alternatives for emergency contraception. In contrast to the “morning after” pill, the effectiveness of these devices is not impacted by body weight, and so they are also recommended for obese patients. Experts rate these non-hormonal forms of emergency contraception as the most effective.

The copper in a standard copper coil (IUD) or copper chain changes the environment in the uterus and fallopian tubes, making it harder for sperm to fertilize an egg and for a fertilized egg to implant. A hormonal coil, in contrast, is not suitable for use as an emergency contraceptive.

A standard copper coil (IUD) or copper chain for use as emergency contraception need to be inserted into the uterus by a gynecologist. This should be done as soon as possible and no later than 5 days after failed contraception or unprotected sex.

It costs around 120 to 300 euros for a consultation, exam and fitting of a standard copper coil (IUD). It costs between 200 and 350 euros to insert a copper chain. Women covered by statutory health insurance have their costs covered by health insurance funds until their 22nd birthday.

A gynecologist is the best point of contact for any questions you may have about the topic of contraception in general, contraception mishaps and emergency contraception. Men can also get advice from a urological practice.

Information about this topic is also available from the Federal Institute for Public Health (BIÖG), advice centers such as pro familia or specialist portals such as Frauenärzte im Netz (Gynecologists online) (in German).

Free advice on contraception, pregnancy and family planning is also provided on an anonymous basis by recognized advice centers. Visit the website familienplanung.de, operated by the Federal Institute for Public Health (BIÖG), to find advice centers in your area.