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February 9, 2001
Emergency Contraceptive Pills: Not Just for the Morning After

By Kyre Osborn

Carie Cox

hat do you have in your medicine cabinet? Aspirin, Band-Aids, tampons, a thermometer? Like most women, you're probably prepared for a headache, a cut finger, your period, or a fever. You may also have birth control at the ready -- maybe you have condoms or a diaphragm, a sponge or a package of birth control pills stashed away.

You are less likely, however, to be ready for what to do in case there's a mistake or failure in using your birth control, or in case it is neglected entirely in a moment of revelry. With emergency contraception, you could be. Deemed safe by the FDA, proven reliable in tests, and with a relatively low price tag, emergency contraceptive pills (ECPs) can prevent a pregnancy after sex has occurred.

Lindsay Parsons, 26, obtained ECPs after discovering that the condom had broken during sex with her boyfriend. "I used the pills within 24 hours," says Parsons, who at the time was in Denmark. "When I realized the condom had broken I completely freaked out and insisted that we go to a hospital the next morning and talk to a doctor," Parsons recalls. "I had heard of emergency contraception and wanted to see if we could get it. They had the pills at the hospital; I was really glad they were available."

Stateside, you currently need a prescription to get emergency contraceptive pills, and not every drugstore stocks them. That may change soon. The Women's Capital Corporation, makers of an ECP product called Plan B, is proposing a series of studies to the U.S. Food and Drug Administration (FDA) that could lead to over-the-counter availability of Plan B. The studies are to be completed in 2002.


Though many who are familiar with emergency contraception refer to it as the morning-after pill, a woman can actually begin the regimen directly after unprotected sex has occurred -- or up to 72 hours later.


For now, though, the pills remain an obscure resource for American women despite recent approval of a new ECP brand and the American Medical Association's support for more access to these products. Why? While most health care providers have no objections to ECPs, only a small percentage take the initiative to inform their female patients about them. What's more, many pharmacies do not stock the products, saying demand is not high enough., for instance, stocks only one brand of ECPs. But how can women avail themselves of this option when they don't know about it? It's a frustrating cycle for women who want more control over their reproductive life.

72 hours and counting

Diana Dell, M.D., past president of the American Medical Women's Association and assistant professor of obstetrics/gynecology and psychiatry at Duke University Medical Center, describes emergency contraception as "a pregnancy-prevention technique." The regimen works by providing a brief, intense burst of hormone exposure that can perform any of the following functions: delay or inhibit ovulation, inhibit fertilization, or inhibit implantation. The pills won't harm an existing pregnancy. "Pregnancy occurs with implantation; this is a method for ensuring that implantation doesn't take place," says Dr. Dell. Once the fertilized egg is implanted in the uterine wall, ECPs are ineffective.

Though many who are familiar with emergency contraception refer to it as the morning-after pill, a woman can actually begin the regimen directly after unprotected sex has occurred -- or up to 72 hours later. Because ECPs act to prevent pregnancy, they should not be confused with RU-486 -- the mifepristone pill that can terminate a pregnancy of up to seven weeks - which was approved by the U.S. Food and Drug Administration (FDA) in 2000.

Dedicated ECP products

Before dedicated ECP products hit the market, in the late 1990s, emergency contraception consisted of a combination of birth control pills. This method is still viable; a woman or her health care provider can combine regular birth control pills for the proper dosage. The pill-combination method and dedicated products work the same way. Dedicated ECPs, however, ensure that the proper hormones and correct dose are being administered for the most effective result.

  • Preven: The first dedicated product to be released in the United States, the Preven kit contains a pregnancy test, patient information, and four light-blue pills. The package costs $20-$25, plus the price of a doctor's visit. The pregnancy test is performed before the pills are taken to make sure the woman isn't pregnant already, in which case the pills will be ineffective. The most common side effects of Preven are nausea and vomiting; these can be treated with anti-nausea medications. (If vomiting happens within two hours of taking a dose, some health care providers recommend repeating that dose.) Preven follows the traditional pill-combination method and is 75 percent effective. While these are pretty good odds against pregnancy, the odds are even better with the newest dedicated product, Plan B.

  • Plan B: Plan B was officially put into distribution in August 2000. Unlike Preven, the second dedicated product contains progestin-only pills (also known as minipills). The Plan B kit consists of just two pills -- the first to be taken within 72 hours after intercourse and the next to be taken 12 hours after the first. Plan B is 89 percent effective, and studies show that it causes less nausea and vomiting than Preven. In response to Plan B, the makers of Preven are applying to the FDA for permission to market their own progestin-only kit.

Both Preven and Plan B can be initiated for up to three days after unprotected sex, but consumers are encouraged to take the pills as early as possible. With all ECPs, the effectiveness declines significantly as time passes. Plan B's effectiveness was shown to shoot up to 95 percent when the first dose was taken in the initial 24 hours after intercourse.

Women may experience irregular bleeding after taking ECPs, and some women have their period a few days early or late. If you don't have a normal period within a month, you should get a pregnancy test to make sure you're not pregnant.

Why are ECPs still unknown?

Even with two ECP kits on the market, experts say emergency contraception is still underutilized. Although 100 percent of obstetrician-gynecologists surveyed believe ECPs to be safe and effective, only 10 percent of these doctors regularly tell their patients about them. In turn, women don't know to ask for emergency contraception -- and so the cycle goes.

Sharon Camp, CEO of the Women's Capital Corporation, says that women have to lead the way toward easier access to ECPs. "Women don't know they have a right to ask for this," Camp says. "We need to educate women and healthcare providers and insurance companies and pharmacies, and then [emergency contraception] will become mainstream. But women have to drive the process."

The feds, the drug companies, and the A word

In 1997, the FDA asked drug companies to begin developing dedicated ECPs and approved the use of the traditional pill-combination method. Stating that this method was safe and effective, the agency even publicized the instructions online for creating the proper hormonal combination. (See link below.)

Even after the FDA's request for more ECP dedicated products, however, drug companies didn't rush forward to research or manufacture them. In fact, pharmaceutical companies shied away from packaging birth control pills for use as emergency contraception, due in large part to the fact that some consider emergency contraception to be a method of abortion.

Such a perspective, however, is not supported by the mainstream medical community, including the World Health Organization and the AMA. The mechanism of ECPs is actually similar to a function that common birth control methods -- including the pill, Norplant, and IUDs -- can perform. While these methods are primarily meant to suppress ovulation or fertilization, they can also act after sex has occurred to prevent implantation, like ECPs.

For many women, including Lindsay Parsons, there is a clear distinction between the abortion procedure and emergency contraception. "Every woman has her own beliefs about abortion; for me, it would have bothered me on a personal level to end a pregnancy, even though I am very pro-choice. I preferred to use emergency contraception," says Parsons.

ECPs without a prescription?

Emergency contraception is available by prescription only, and it can take several days to see a doctor and find a pharmacy that carries ECPs -- potentially long enough for the 72-hour window of opportunity to close. To address this problem, the state of Washington pioneered a system whereby women can go directly to a pharmacist for ECPs, rather than to a doctor. Using what is known as a collaborative drug-therapy agreement, Washington physicians delegated authority to pharmacists to prescribe ECPs to women who meet certain assessment criteria. This streamlined system makes it easier for a woman to start the pills after a crisis over the weekend or on a holiday.

But needing a prescription isn't the only thing that makes ECPs hard to obtain. Sheila Greene, 32, visited her doctor the day after she and her boyfriend had a contraceptive accident. "I called my doctor, and she had me come in and sign a release form to get the prescription," Greene remembers, "and that part was easy. I thought getting the prescription would be hardest, but actually, filling the prescription was way more difficult. I couldn't find even one pharmacy to do it." Greene called more than 20 pharmacies in her hometown of Austin, Texas, and none of them had Preven on their shelves. At one pharmacy Greene was met with the retort, "We don't carry that here" after she asked the pharmacist if the store carried ECP kits.

Where to Get ECPs

The easiest way to find ECPs is to visit the directory at the definitive emergency contraception website. The site gives a broad geographical overview of ECP providers -- you can search by area code, zip code, or city and state; or you can search a map of the United States. even lists some providers in Canada. The directory includes hospitals, private doctors, women's health clinics, and others. For those without Internet access, Not-2-Late has a companion hotline: 1-888-NOT-2-LATE.

Your local Planned Parenthood can also provide you with emergency contraception. You can find out where yours is located by visiting their website or by calling 800-230-PLAN.

"I am an educated and an assertive woman," Greene says, "and I couldn't get my hands on emergency contraception when I needed it. What does it take?" Greene did her research on the Internet and discovered how to combine birth control pills -- which she had in the house because she was about to start taking the pill. She couldn't find information about the brand she had but decided to approximate the ECP dose; she took the pills over the course of two days. Greene says she experienced vomiting and nausea, but that "there were no seriously negative effects, and soon afterward I got my period and knew I wasn't pregnant."

Many experts feel that offering the pills over-the-counter is the only way to increase the availability of ECPs. Even the American Medical Association (AMA) supports making emergency contraception easier to obtain. In December 2000, the AMA released a strongly worded statement supporting the use of ECPs and recommending much wider access for women. The AMA stated that it intends to "intensify efforts to improve awareness and understanding about the drugs, and to enhance efforts to expand access to them, including making them more available through hospitals, clinics, emergency rooms, acute care centers, and physicians' offices."

Despite the AMA's support, however, your local health facility may not stock ECPs. Through increasing acquisition of public and private hospitals and clinic systems, the Roman Catholic Church is now the largest private health care provider in the United States. Most Catholic-owned hospitals do not provide female patients with emergency contraception, even in cases of rape or sexual assault. The Vatican has referred to emergency contraception, which went on sale in Italy in the year 2000, as "a form of abortion by chemical means," and a "new hidden form of aggression" against human life.

You can find out which hospitals have ECPs by searching the provider list at (See sidebar).

A second chance

On any given night, it is estimated that 10 million fertile women are having sexual intercourse. And of the roughly 60 million American women aged 15 to 44, almost half have had at least one unintended pregnancy. Only 1 percent of these women have ever used emergency contraception. How many women (and men) -- those who have had a condom break or for some reason failed to use birth control -- didn't wish they could have a second chance? For preventing unwanted pregnancy, emergency contraception pills can be that second chance.

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