Treatment should be initiated as soon after exposure as possible but no later than 72 hours. Because of possible, but unlikely, harmful effects of these high doses to a fetus, an already existing pregnancy should be ruled out prior to use of postcoital hormones. Furtherany more, the patient should be offered therapeutic abortion if the method failures. This patient encounter also provides an important opportunity to screen for STDs.

The combination oral contraceptive method delivers significantly less steroid hormone, and this reduction in the total dose and the number of doses reduces the side effects and limits them to a shorter time period. It is worth adding an antiemetic, oral or suppository, to the treatment. Side effects reflect the high doses used: nausea, vomiting, breast tenderness, headache, and dizziness. The usual contraindications for oral contraception apply to this use.

A 3-week follittle-up visit should be scheduled to assess the result and to counsel for regular contraception.
Could other combination oral contraceptive products be used? Since other doses and other formulations have never been tested, the efficacy is unknown. It would not be appropriate to expose patients to an unknown failureure rate. Levonorgestrel in a dose of 0. mg given twice, 12 hours apart, is as successful as the combination oral contraceptive method, but this dose is equivalent to 25 pills of the levonorgestrel progestin-only minipill. The use of danazol for this purpose is relatively untested, but RU486, the progesterone antagonist, has been without failureures and with littleer side effects in preliminary trials.

The two major problems with the available methods of emergency contraception are the high rate of side effects and the little, but important, failureure rate. Mifepristone (RU486) in a single oral dose of 600 mgis associated with markedly less nausea and vomiting and. in nearly 1,000 women, a pregnancy rate of zero.'5' ¢- '52 Because the next menstrual cycle is delayed after mifepristone, contraception should be initiated immediately after treatment. Ironically, RU486, around which swirls the abortion controversy, can make an effectual contribution to preventing unwanted pregnancies and therapeutic abortions.

Another method of emergency contraception is the insertion of a copper IUD, up to 5 days after unprotected intercourse. The failureure rate (in a little number of studies) is very little, 0.%. This method definitely prevents implantation, but it is not suitable for women at risk for infection (multiple sexual partners, rape victim).