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Emergency contraception: a matter of dedication and access

Background and epidemiology: We safe and effective for use as emergency whether the unprotected sex was co- have known since 1977 that, if a woman contraception and published the erced. The Yuzpe regimen causes nau- takes 2 tablets of an oral contraceptive dosages.3 In 1998 the first product dedi- sea in 50% of users and vomiting in (norgestrel–ethinyl estradiol) within 72 cated for such use received FDA ap- 19%. Taking each dose with food and hours after having sex and 2 more pills proval and hit the American market. using antinausea medications such as di- 12 hours later, her chances of becoming menhydrinate (50 mg) 30 minutes be- pregnant are significantly and safely re- Clinical management: The most widely fore taking the dose can reduce nausea. duced.1 This Yuzpe method of emer- used hormonal method in Canada is the Pills are completely absorbed within 1 gency contraception became known as Yuzpe regimen (a combination of hour; replacement dosing is needed if “the morning-after pill,” but this is a 100 µg of ethinyl estradiol and 500 µg vomiting occurs within the hour. The misnomer because in reality several pills of levonorgestrel, administered in 2 progestin-only regimen causes nausea are taken together and the method is ef- doses 12 hours apart). Two norgestrel– in 23% of users and vomiting in 6%.5 fective for about 3 days after unpro- ethinyl estradiol tablets are equivalent tected sex. Suggested mechanisms for to 1 dose of the Yuzpe regimen. An- Prevention: Unwanted pregnancies its action include disruption of the cor- other product, a progestin-only method and abortions can be prevented with pus luteum and endometrial changes known as Plan B, is now available in emergency contraception, and several that inhibit implantation. These mecha- Canada. Evidence suggests this method projects are under way to improve wo- nisms work before implantation. has better efficacy and fewer side effects men’s access to it. The United King- Pharmaceutical companies in Eu- than the Yuzpe regimen,4 but it costs dom and New Zealand have taken ini- rope were relatively quick to produce $15 more. tiatives to make it available over the and market dedicated products specifi- These methods prevent about 75% counter. In Washington State and Bri- cally for use as emergency contracep- to 85% of pregnancies that would have tish Columbia, and in a pilot project in tion. PC 4 — 4 pills packaged and sold occurred had emergency contraception Toronto, pharmacists are entering col- specifically for postcoital use — has not been used; this means that about laborative agreements with physicians been available in the United Kingdom 2% of women who use emergency con- and nurse practitioners so that women since 1984. Drug companies in North traception will become pregnant despite can receive emergency contraception America were slower to respond, raising using it. Emergency contraception can directly from pharmacists without vis- issues of liability, effectiveness and be used within 72 hours by any woman iting a doctor first. Physicians are also anticipated reactions from the anti- at risk of pregnancy from a broken con- being encouraged to supply sexually abortion lobby as possible obstacles.2 dom, multiple missed birth-control active women with prescriptions for American physicians, apprehensive pills, unprotected sex, ejaculation on the emergency contraception that can be about prescribing the oral contraceptive external genitalia or sexual assault. Ear- filled and kept at home (with due regard for off-label use, did not do so. As a re- lier treatment improves efficacy; delay- for shelf-life) “just in case.”2 — Erica sult, use of emergency contraception in ing the first dose from 12 to 24 hours Weir, CMAJ North America during the 1980s and after intercourse increases the odds of 1990s lagged behind European use, de- pregnancy by 50%. (Women who pre- References spite growing evidence about its safety sent after 72 hours and within 5 to 7 1. Yuzpe AA, Lancee WJ. Ethinylestradiol and dl- and effectiveness. days of sexual intercourse can be offered norgestrel as a postcoital contraceptive. Fertil Steril 1977;28:932-6. In 1995 several family-planning, re- a copper-bearing IUD if there are no 2. Coeytaux F, Pillsbury B. Bringing emergency 5 productive health and women’s organi- contraindications). contraception to American women: the history zations in the United States made a Emergency contraception should and remaining challenges. Womens Health Issues 2001;11:80-86. concerted effort to increase reproduc- not be used if a woman knows she is 3. Food and Drug Administration. Prescription tive choice, avoid pregnancy and reduce pregnant, although there is no evidence drug products; certain combined oral contra- the need for abortion. One outcome of teratogenicity. Breastfeeding is not a ceptives for use as postcoital emergency contra- ception. Federal Registrar 1997;56:203-10. was a national hotline, launched in contraindication. The progestin-only 4. Task Force on Postovulatory Methods of Fer- 1996, to provide information on emer- regimen is preferred for women with tility Regulation. Randomised controlled trial 5 of levonorgestrel versus Yuzpe regimen of com- gency contraception and promote con- serious risk factors for estrogen use. bined oral contraceptives for emergency contra- sumer awareness and demand. In 1997 A health care professional should ception. Lancet 1998;352:428-33. the US Food and Drug Administration, discuss with the woman the likelihood 5. Dunn S, Davis V. Emergency Contraception — Summary of the Society of Obstetricians and in a historic move, issued a notice de- of pregnancy, the risk of STDs, the Gynaecologists of Canada’s clinical practice claring 6 brands of oral contraceptives need for ongoing birth control and guidelines. Can Fam Phys 2001;47:1261-3.

CMAJ • OCT. 16, 2001; 165 (8) 1095