Emergency Contraception

by Anne Neville R.N., R.M., Dip. Past. Psych., Dip. Marriage & Family Therapy C.P.C., Accredited Counsellor National Association of Loss & Grief, A.M.C.C.A., M.A.S.S.T.S.,
Jenny Kearney OAM , and Alison Campbell Rate B.Ed

 

Current promotion of “emergency contraception”.

How it works.

Discussion of contra-indications.

Associated physical and emotional risks.

Recommendations for health workers and student counsellors.

Introduction

Emergency contraception, (formerly known as the 'morning after pill') is used to prevent a pregnancy after recent unprotected intercourse or failed contraception.

Originally, the morning after pill consisted of a large number of contraceptive pills to make up a high progesterone dose, and was usually prescribed within 72 hours of intercourse. In August 2001 the Australian Drug Evaluation Committee recommended that the Minister for Health approve Postinor-2 (levonorgestrel) for registration as "a new dose regime indicated for use as an emergency oral contraceptive within 72 hours of unprotected intercourse" (1).

The effectiveness of emergency contraception is inconclusive, simply because it is not known whether or not the potential for a pregnancy exists at the time of treatment. This also may raise ethical issues for the woman considering taking the treatment.

What is Postinor-2?

Postinor-2 is an emergency contraceptive only. It is not intended as a regular method of contraception. (2) It is the first commercially prepared emergency contraception to be marketed in Australia. Support for increased provision of the emergency contraception led to the de-scheduling of Postinor 2 by the National Drugs and Poisons Schedule Committee in January 2004, allowing it to be dispensed by pharmacists without prescription.

Postinor-2 contains 0.75 mgms of levonorgestrel (3), a synthetic hormone derived from progesterone which is often used in smaller doses in the contraceptive pill (4). It is used to prevent a pregnancy if taken within 72 hours (3 days) of unprotected sexual intercourse. It is more effective the sooner it is taken following unprotected sex. It is not known whether Postinor-2 is effective if taken more than 72 hours after unprotected intercourse (5).

The dosage is 1 750mcg tablet of followed by another tablet 12 hours after the first dose (6).

How does it work?

Postinor-2 is thought to work a number of different ways.
" Affecting sperm mobility (altering the cervical mucous making it more difficult for sperm to access the ovum)
" Preventing or delaying ovulation
" Preventing a fertilized ovum from implanting in the uterus.

Postinor-2 can be used at any time during the menstrual cycle unless the period is overdue. It has been stated the Postinor-2 will not disrupt an already implanted pregnancy. However, anxiety amongst users may be raised about the effects on a developing foetus.

Contradictions to the use of Postinor-2

" Unexplained vaginal bleeding
" Current breast cancer
" Pregnancy
" Hypersensitivity to any of the ingredients of the preparation

Warnings and Precautions

" High Blood Pressure
" Diabetes
" Ischaemic Heart disease
" Stroke
" Past History of Breast cancer
" Vascular Disease

Adverse Effects

" Nausea in about 25% of women
" Vomiting occurs in 5%
" Bleeding patterns may be temporarily disturbed but most women will have their next menstrual period at the expected time
" Some women may experience spotting and bleeding after taking Postinor-2
" Some may experience early or delayed menstruation
" If the next period is more than 7 days overdue pregnancy should be excluded
" Breast tenderness
" Headache
" Dizziness
" Fatigue

Warnings from the World Health Organization, (7).

" "Repeated doses of emergency contraceptive pills in any month can expose a woman to higher doses of steroids than those recommended during one cycle"
" "There may be a higher number of ectopic pregnancies among emergency contraceptive pill failure cases than among a normal pregnant population"
" They "are not recommended for routine use, because of the higher possibility of failure compared to regular contraceptives and the increased risk of side effects"

The W.H.O. says it should only be used as an emergency measure because of the increased possibility of failure compared to other methods of contraception.

Implications of de-scheduling Postinor 2

The move to de-schedule Postinor 2 was prompted by calls to reduce the number of surgical abortions following unprotected intercourse or condom failure, and to ease the burden of unintended pregnancy from unplanned sexual intercourse, rape or sexual assault.

This seems laudable but as usual there is a raft of complex issues underlying this seemingly simple remedy to the problem of an unwanted pregnancy. Anyone considering emergency contraception needs to take into account any implications for the physical and emotional health of the woman or girl.

The recommendation to increase access and availability by selling emergency contraception over the counter with no prescription, thus bypassing the GP, leaves many women at risk. The teenager is more at risk, particularly if she is using emergency contraception regularly. The impulsive and avoidant nature of the adolescent can result in serial use of the emergency contraception that, if unchecked, could have serious implications for her long-term health.

As with the ordinary contraceptive pill, emergency contraception should be administered only in consultation with a doctor. Contra-indications described above such as history of blood clots, anemia, high blood fat levels, breast cancer, uterine cancer, liver disease, migraines, epilepsy, diabetes and others, must be eliminated. A thorough medical check up is advised before a woman goes on the Pill. The same precautions should apply to emergency contraception that is a much higher dosage.

It has been recommended that pharmacists set aside a counselling area within their shop for talking with women and girls seeking Postinor-2. This will be difficult to achieve in real terms, especially for small busy pharmacies. Privacy is an issue for women in this situation. The disclosing of personal health information and the ability of the pharmacist to thoroughly explore her medical history may be restricted by the lack of private facilities. Teenage girls are less likely to reveal personal information where there is a possibility of being overheard.

Chemists do not routinely keep records of over-the-counter drugs and so the danger exists for Postinor-2 to be used as a routine contraceptive. There is a potential for chemist-hopping in order to obtain the drug with no regulation or monitoring.

The fear of potential damage to the foetus should the pregnancy continue will cause increased anxiety and put pressure on the woman or girl to contemplate a surgical abortion, despite her true feelings about abortion.

The action of emergency contraception in preventing implantation of a fertilized ovum is more correctly an early abortion, not contraception. A true contraceptive prevents fertilisation. Emergency contraception, taken up to 72 hours after intercourse, will not always prevent fertilisation. Hence the term "emergency contraception" is a misnomer and only adds (perhaps deliberately) to the attempt to avoid the thought of a 'real abortion'.

At that stage the woman or girl will not know for sure whether she is pregnant. In taking emergency contraception she will be making an abortion decision in a state of ignorance, unable to work through her thoughts, feelings and options because of the demand for haste. Her anxieties will not be allayed for some time because the side effects of the drugs she takes mirror the symptoms of early pregnancy. Future menstrual cycles may be disrupted, further placing her at risk of unintended pregnancy if she is unable to correctly identify her fertile phase.  

Increased promotion of emergency contraception has coincided with the dawning realisation by promoters of condoms for 'safe sex' that contraceptive failure is a huge factor in teenage pregnancy, see:

 However, inappropriate and ineffective contraceptive strategies should not be matched by inappropriate and risky abortion strategies.

Women wish to be in control of their lives. Being in control means having accurate and complete knowledge and understanding about important issues. An individual woman or girl’s decision about her unintended pregnancy should not be made in haste and ignorance of the risks and consequences of the procedures presented to her.

Increased education and availability of contraception has not reduced the rate of unplanned pregnancy. Teenagers, who as a group are the particular target of emergency contraception promotion, are particularly vulnerable to becoming reliant on emergency contraception. Whilst providing emergency contraception may benefit the school counsellor or health provider by giving them the sense that they are doing something for the teenager in crisis, it does not solve the real issues for the girl and may well present her with future health problems and moral dilemmas.

We must address the underlying issues that lead teenagers and women to unconsciously, and often repeatedly, place themselves at risk of becoming pregnant in less than desirable circumstances, see:

Effective intervention would lead them towards the self-awareness and personal skills necessary in order to emerge from the crisis functioning at a higher level and with a greater sense of self-determination and personal control.

We must question whether the the availability of over the counter emergency contraception will only continue to lock these women and girls into destructive patterns of behaviour and delay their search for real help.

1. Therapeutic Goods Administration, www.tga.health.gov.au
2. The Australian Prescription Products Guide 36th Edition 2007
3. US Food and Drug Administration, Carton Text Plan B (levonorgestrel) tablets, 0.75mgms;
4. Kahlenborn, C et al (2002), Postfertilization effect of hormonal emergency
contraception. The Annals of Pharmacotherapy, Vol 36, pp 465-470.
5. The Australian Prescription Products Guide 36th Edition 2007
6. Schering Website - www.women-and-men.de/
7. Emergency contraception: A Guide for Service Delivery. World Health Organization Geneva 1998

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Updated June 2007