Emergency Contraception in the United States Today
November 2, 1998
In a world today where unplanned or unintended pregnancies occur in exuberant numbers there is a great need for a solution. Emergency contraception is one that comes to mind. In the United States approximately 3.2 million of the total six million annual pregnancies are accidental, half of these ending in abortion (Lindberg, 1997). Eighty percent of teen pregnancies are unintended, and each year, one in nine young women aged 15-19 become pregnant; more than half become mothers. Widespread use of emergency contraception could prevent an estimated 1.7 million unintended pregnancies and 800,000 abortions each year ("Planned Parenthood," 1998). As of September 1998, the Federal Drug Administration (FDA), which regulates the introduction of new drugs into the marketplace, has approved a total of 10 brands of combination-hormone pill brands suitable for use as emergency contraception pills. For those who are unable to take the hormone pills there is an option of an intrauterine device. Raising awareness of emergency contraception and allowing health care workers to provide emergency contraception pills to patients who may be at need in the future could dramatically decrease the numbers of unintended pregnancy and all the consequences that result.
Emergency contraceptive pills are ordinary birth control pills containing the hormone estrogen and progestin. They are also called postcoital contraception or "the morning after pill." Emergency contraception Pills (ECP's) can prevent pregnancy after unprotected intercourse by as much as 75% when the first dose is taken within 72 hours and the second dose taken 12 hours later (Klima, 1998). ECP's affect the menstrual cycle. Administering oral contraceptives as emergency contraception at or near time of ovulation, when pregnancy is most likely to occur, appears to disrupt the ovarian function, which results in an absent or dysfunctional luteal phase (Klima, 1998). Another option would be the insertion of a copper intrauterine contraceptive device within 5 days of unprotected intercourse (Skolnick, 1997). The intrauterine device (IUD) causes an inflammatory response, making it difficult for implantation to occur on the endometrium (Klima, 1998).
For thousands of years, human beings have been willing to take the risk of pregnancy while having sexual intercourse to later find themselves searching for a remedy after the fact. Remedies once believed to aid in achieving postcoital contraception include herb douches, sneezing, hopping, jumping, and dancing. These remedies date back to 1500 B. C. (Morgan and Deneris, 1997). In the 1920's scientists found that estrogenic ovarian extracts could prevent pregnancy in mammals (Klima, 1998). This lead to a solution for veterinarians when horses and dogs mated accidentally. In the 1960's clinical use of postcoital estrogen alone was first documented as a treatment for victims of sexual assault (Morgan and Deneris, 1997). In the 1970's, a Canadian physician named Yuzpe began to study the combination of ethinyl estradiol with a progestin. This became known as the "Yuzpe regimen" and is accepted as the gold standard in emergency contraception (Morgan and Deneris, 1997).
The Yuzpe method of emergency contraception is often considered the best regimen because of its lower incidence of side effects as compared to estrogen (Morgan and Deneris, 1997). Although the side effects of ECP's are not serious, they may effect whether a client will be able to complete the regimen which could decrease the effectiveness of the method (Klima, 1998). Nausea is the most common side effect associated with emergency contraceptive use and occurs in 50-70% of women who use the method. In addition, approximately 25% of women will experience vomiting (Klima, 1998). Antiemetics may be given to reduce the nausea and vomiting. Breast tenderness, irregular bleeding, and headaches may also occur. These side affects usually begin to disappear one or two days after the second ECP has been taken ("Planned Parenthood," 1998). Women may also experience a change in the length and timing of their next period. If ECP's are used frequently, periods may become irregular and unpredictable.
The IUD is often considered the most effective form of emergency contraception and the only method that provides long-term contraception. However, because of the risk of pelvic inflammatory disease in women who are at risk for sexually transmitted diseases (STD's) makes it difficult to find women who can be given an IUD (Morgan and Deneris, 1997). In other words, victims of sexual assault or promiscuous women should be discouraged from using an IUD until screening for STD's can be done. Along with STD's, limitations should be made to women who have a history of ectopic pregnancy, or severe dysmenorrhea, or menorrhagia. Some side effects for IUD insertion may include abdominal discomfort, vaginal bleeding or spotting and infection. Possible side effects of IUD use include heavy menstrual flow, cramping, infection, infertility, and uterine puncture ("Planned Parenthood," 1998).
Other types of emergency contraception include "mini-pills" and mifepristone. "Mini-pills" as they are often called are progestin-only pills. They are a good option to those who can not take estrogen and are not good IUD candidates. They may be as effective as the Yuzpe regimen (Davies, 1997). However, the progestin-only method has not been as extensively studied as the combined pills. The progestin-only pills also need to be taken within 48 hours of intercourse to be effective. The future of emergency contraception may depend on the success of mifepristone (RU-486) which is currently being studied for use in the U.S.. It appears to be better tolerated and more effective when used as an emergency contraceptive, not as a medical abortion. The adverse side affects found with combined oral contraceptives occurred less frequently for the groups given mifepristone than those given the Yuzpe regimen. (Morgan and Deneris, 1997). This drug works by binding to the progesterone receptor sites, thus blocking the action of progesterone (Morgan and Deneris, 1997). As this drug becomes available to the U.S., it may become the emergency contraceptive of choice.
It is often a concern to patients whether emergency contraception is an abortifacient. The answer is no (Morgan and Deneris, 1997). In fact, emergency contraception prevents pregnancy and therefore reduces the need for induced abortion. Medical science defines the beginning of pregnancy as the implantation of a fertilized egg in the lining of a women's uterus. Implantation takes place five to seven days after fertilization. Emergency contraceptives work before implantation and not after a woman is already pregnant (Robles, 1998). So, women should be advised that fertilization may not be prevented by ECP's that are taken too late. Should pregnancy occur and it is decided to continue pregnancy, women worry that congenital anomalies may result after using emergency contraception. Unfortunately, there have been no studies that specifically evaluated the risk of congenital anomalies (Klima, 1998). There have been 48 cases of method failure in women who have chosen to continue their pregnancies. Only one infant was born with a congenital anomaly: a missing kidney (Klima, 1998). Thus, there is no reason to suspect that one time emergency use of the pills would be associated with birth defects if the pill fails to prevent pregnancy or if they are taken after a woman is already pregnant.
A study examining the cost-effectiveness of emergency contraceptive pills, minipills and the intrauterine device has been done. The comparison was between a single contraceptive treatment following unprotected intercourse and emergency contraceptive pills provided in advance. The results showed that in a managed care setting, a single treatment of emergency contraception after unprotected intercourse saves $142 with emergency contraceptive pills and $119 with minipills. The copper intrauterine device is not cost-effective as an emergency contraceptive alone, but savings quickly result as use continues. Advance provisions of emergency contraceptive pills to women using barrier contraceptives, spermicides, withdrawal, or periodic abstinence saves from $263 to $498 annually. In conclusion, emergency contraception is cost-effective whether provided when the emergency arises or in advance to be used as needed. Greater use of emergency contraception could reduce the considerable medical and social costs of unintended pregnancies (Trussell, Koenig, and Ellertson, 1997).
The most important step in assisting women in preventing unintended pregnancy is in educating health care providers about emergency contraceptives so that all patients have access to this method (Morgan and Deneris, 1997). A survey performed in 1993 indicated the need for more awareness. Two Hundred Ninety Four reproductive health care providers, family practitioners, and emergency department physicians were surveyed to determine how often they provided emergency contraception in the preceding year. The results suggested that the respondents prescribed emergency contraception an average of 3.4 times in the preceding year with one third of those prescribed for victims of sexual assault. Ninety percent of the respondents never or rarely spoke to their patients about emergency contraception and only 10% had literature available for patients about the method (Klima, 1998). Clearly there was a need for health care providers to be more informative. In 1996 the Reproductive Health Technologies Project and Bridging the Gap Communications began their own education campaign (Klima, 1998). They spread the word about emergency contraception nationwide by use of public service announcements and advertisements in magazines and outdoor venues (Skolnick, 1997). These two organizations also started the Emergency Contraception Hotline. This hotline informs callers about emergency contraceptions and provides information about where to access the service in their area. In addition a website was launched.
For the past 20 years, emergency contraception has been available to women and their health care providers but has been under used for a variety of reasons in part because of health care givers lacking in knowledge and differences within pharmaceutical and governmental agencies (Klima, 1997). Now, with more awareness about emergency contraception, it should be available to any patient who requests it. There is no reason to deny the method based on when in the cycle the unprotected intercourse occurred. Planned Parenthood Federation of America recently changed it's medical standards and guidelines to allow provisions of emergency contraceptive pills to any patient with a history of unprotected intercourse in the past 72 hours and a normal last menstrual period regardless of medical risk factors for oral contraceptives. In addition, they offer their patients who have had a complete history and physical exam in the last year the option of receiving emergency contraceptive pills for use in the future if the need arises (Morgan and Deneris, 1997).
It is important for women to take an active role in controlling their reproductive futures and be able to prevent the crisis of an unintended pregnancy. Discussing emergency contraception with patients regularly will allow them to take part in their health care decisions and diminish stressors that go along with unplanned pregnancies. With that in mind, it is necessary of health care workers to provide patients with complete and accurate information concerning emergency contraception and have access to it. Emergency contraception is known to be safe and effective and could dramatically reduce the startling high numbers of unintended pregnancies and abortions occurring annually in the United States.
Davies, J. E. (1997). A second chance at preventing pregnancy. Using oral contraceptives for emergency contraception. Advance for Nurse Practitioners, 5 (11), 43-47.
Klima, C. S. (1998). Emergency contraception for midwifery practice. Journal of Nurse- Midwifery, 45 (3), 182-189.
Lindberg, C. E. (1997). Emergency contraception: the nurse's role in providing postcoital options. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26 (2), 145-52.
Morgan, K., & Deneris, A. (1997). Emergency contraception: preventing unintended pregnancy. The Nurse Practitioner, 22 (11), 34-48.
Robles, A. (No date). Emergency Contraception [Online]. Available: http://opr.princeton.edu/ec/ecabt.html [1998, October 22].
Skolnick, A. A. (1997). Campaign launched to tell physicians, public about emergency contraception. JAMA, 278 (2), 101-02
Trussell, J., Koenig, J., & Ellertson, C. (1997). Preventing unintended pregnancy: the cost- effectiveness of three methods of emergency contraception. American Journal of Public Health, 87, (6), 932-937).
Author Unknown. (1998, September). Planned Parenthood Federation of America, Inc. [Online]. Available: http://www.pannedplarenthood.org/library/BIRTHCONTROL/EmergContra.htm [1998, October 22].
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