Evidence-based recommendations on emerging contraceptive methods and extended-use practices for family planning programmes
What this guideline saysGMJ summary
This WHO guideline evaluates five emerging contraceptive methods and alternative usage practices for potential inclusion in national family planning programmes: mifepristone for emergency contraception (EC), ormeloxifene, quinestrol-containing pills, extended or continuous use of combined oral contraceptives (COCs), and extended use of etonogestrel (ETG) implants.
WHO recommends adding mifepristone 10–50 mg to the EC method mix (moderate-certainty evidence). Extended or continuous COC use up to 6–12 months is suggested as acceptable (low-certainty evidence). ETG implants may be used up to 5 years rather than 3 years (very low-certainty evidence). However, WHO recommends against adding quinestrol-quingestanol and quinestrol-norgestrel to the contraceptive mix due to safety concerns, and suggests against ormeloxifene until high-quality safety and efficacy evidence is available.
These recommendations aim to expand contraceptive choice particularly in low- and middle-income countries. Methods recommended for inclusion may subsequently be integrated into the WHO Medical Eligibility Criteria (MEC) and Selected Practice Recommendations (SPR) guidelines once they meet the thresholds for those normative guidelines.
Key pointsfor clinicians
- Mifepristone for EC: strong recommendation to add 10–50 mg (preferably 10–25 mg) single dose, taken as soon as possible and within 5 days after unprotected sex; likely results in 12 fewer pregnancies per 1000 women vs levonorgestrel and 22 fewer per 1000 vs Yuzpe regimen
- Ormeloxifene: conditional recommendation <em>against</em> adding to method mix; evidence is very low certainty, Pearl Index 0.48–4.2 per 100 woman-years, and serious adverse events are uncertain due to inadequate reporting
- Quinestrol-quingestanol: strong recommendation <em>against</em> adding; 2 cases of VTE per 1684 users, high side-effect burden (58.8% dizziness, 50.3% leucorrhoea); very low-certainty evidence
- Quinestrol-norgestrel: strong recommendation <em>against</em> adding due to potential serious adverse events and very low-certainty evidence (pregnancy rate 3.87%)
- Quinestrol-levonorgestrel: conditional recommendation <em>against</em> adding; pregnancy rate 2.7%, but adverse events unknown and evidence is of low certainty
- Extended or continuous COC use: conditional recommendation for extended regimens up to 6 months or continuous up to 1 year; likely results in 1 fewer unintended pregnancy per 1000 women, more amenorrhoea, fewer bleeding-only days but more spotting-only days; VTE/DVT risk similar to cyclic regimens
- ETG implant extended use: conditional recommendation for use up to 5 years (vs 3 years); Pearl Index 0/100 woman-years in studies through year 5; very low-certainty evidence but no safety signals detected; manufacturer label updated to 5-year duration in January 2026
- Pharmacovigilance required for quinestrol-containing products where in use, with monitoring for adverse events, especially given reports of maternal deaths and VTE in five countries
Summary of recommendations for expanding contraceptive optionsextracted from the guideline
| Intervention | Recommendation | Strength & certainty |
|---|---|---|
| Mifepristone 10–50 mg for EC | Add to method mix | Strong / Moderate |
| Ormeloxifene | Suggest against adding | Conditional / Very low |
| Quinestrol-quingestanol | Recommend against adding | Strong / Very low |
| Quinestrol-norgestrel | Recommend against adding | Strong / Very low |
| Quinestrol-levonorgestrel | Suggest against adding | Conditional / Low |
| Extended/continuous COCs up to 6–12 months | Suggest for use | Conditional / Low |
| ETG implant use up to 5 years | Suggest for use | Conditional / Very low |
What changed in this edition
- New guideline (first edition 2026); establishes the Expanding Contraceptive Options (ECO) framework to evaluate emerging contraceptive methods and practices not yet in MEC/SPR guidelines
- Provides pathway for methods to transition from ECO to MEC once they meet criteria: approval by WHO stringent regulatory authority, use across multiple countries/regions, high-quality evidence on effectiveness and safety, demonstrated programmatic impact
- Based on scoping review of survey responses from 958 individuals in 141 Member States plus expert consultations conducted October 2023–June 2025
- Guideline Development Group meetings held June 2024 and June 2025 with 20 experts from 16 countries representing all six WHO regions
ApplicabilityGeorgia and the region
For Georgia and the South Caucasus, this guideline is highly relevant. Mifepristone for EC is already approved in Armenia and could expand access in Georgia and Azerbaijan. Extended COC regimens require no new procurement, only policy change and provider training, making them immediately feasible. ETG implant extension to 5 years (following the January 2026 manufacturer label update) could reduce health-system burden and improve access in rural areas. National programmes should assess regulatory pathways for mifepristone EC, develop counselling materials for extended COC regimens (emphasising bleeding-pattern changes), ensure implant removal capacity remains accessible through year 5, and establish pharmacovigilance if quinestrol-containing products are circulating informally. The recommendations support Georgia’s goal of expanding contraceptive choice as part of universal health coverage and sexual and reproductive health rights.
Questions this guideline answers
What dose of mifepristone should be used for emergency contraception?
WHO recommends a single dose between 10 and 50 mg, with 10–25 mg preferred if available. It should be taken as soon as possible after unprotected sex and within 5 days (120 hours). Compared to levonorgestrel, mid-dose mifepristone (25–50 mg) likely results in 12 fewer pregnancies per 1000 women and low-dose (10–25 mg) results in 5 fewer per 1000.
Can combined oral contraceptive pills be taken continuously without the usual 7-day break?
Yes. WHO suggests that COCs can be used for extended durations (active pills for more than 28 days followed by a planned hormone-free interval, up to 6 months) or continuously (every day without breaks, up to 1 year) as well as their standard cyclical use. This likely results in no difference in pregnancy rates but more amenorrhoea, fewer bleeding-only days, and more spotting-only days. VTE/DVT risk appears similar to cyclic use. Counselling about expected bleeding patterns is essential.
Why does WHO recommend against quinestrol-containing contraceptive pills?
WHO recommends strongly against quinestrol-quingestanol (Quin-Quin) and quinestrol-norgestrel (Quin-NG), and conditionally against quinestrol-levonorgestrel (Quin-LNG) due to very low- to low-certainty evidence and reports of serious adverse events (including maternal death, VTE, bleeding disorders) from media and five countries. Studies from the 1970s–1990s reported 2 VTE cases per 1684 Quin-Quin users and high side-effect rates (58.8% dizziness, 44% vomiting, 50.3% leucorrhoea). Pharmacovigilance is urged where these products are in use.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 1st edition, 2026
- Status
- Current
- Published
- 2026-09-23
- Languages
- English (translations into six UN languages in preparation through WHO regional offices)
- Scope
- Emergency contraception, oral contraceptives, subdermal implants; emerging methods and alternative usage practices for potential inclusion in national contraceptive method mix
- Audience
- Policy-makers, family planning programme managers, health workers, scientific community; for informing national family planning and reproductive health programmes
- Pages
- 78
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789240124578
- Evidence
- GRADE methodology; systematic reviews of RCTs and observational studies; evidence-to-decision frameworks; certainty of evidence rated as high, moderate, low or very low; values and preferences from global systematic review and youth consultations (>5000 participants, all WHO regions)
- Next review
- Minimum 5 years (2031); interim updates via WHO Continuous Identification of Research Evidence (CIRE) process if new evidence emerges; may add new methods or transition methods to MEC/SPR as they meet criteria
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