Emergency Contraception

The United States has the highest unplanned pregnancy rate amongst the industrialized nations. Half of all pregnancies in the US are unplanned and many of those pregnancies end in abortion. Information and access to effective contraception prevents unplanned pregnancies and decreases the abortion rate. However contraceptive failures, unprotected sex, and sexual assault do occur. In these instances access to emergency contraception (EC) can prevent unintended pregnancy. However misconceptions, difficulty in access and politics are barriers to obtaining EC.

The initial approach to emergency contraception was described in the 1970’s by Dr. Yuzpe using pills with high doses of both estrogen and progestin within 72 hours of unprotected intercourse. For years physicians would use combinations of already available oral contraceptive pills to achieve the effective dose. Currently there is an FDA approved pill called "Preven" that contains the effective dosage of hormones. Preven reduces the chance of pregnancy to 2%. There is no evidence that if pregnancy occurs there will be any harm to the fetus. However the regimen has a common side effect of nausea and vomiting.

Plan B is the newest form of EC approved by the FDA. It consists of 2 doses of a progestin taken 12 hours apart. Used within 72 hours of unprotected intercourse it reduces the risk of pregnancy to 1% with a lower incidence of nausea and vomiting than the estrogen and progestin pills.

EC works by delaying or preventing ovulation, interfering with the movement of the egg or sperm in the fallopian tube, interfering with fertilization or altering the lining of the uterus so implantation of a fertilized egg cannot occur. EC has no effect on an already implanted egg and therefore does not cause abortions. In fact it prevents abortion by preventing unplanned pregnancies. If EC is taken by a woman who is unaware she is already pregnant there are no harmful effects to the developing fetus.

EC is safe for the woman who uses it. In fact there is no evidence of harm even in women who may not be good candidates for long term use of oral contraceptives.

As with many topics surrounding women’s reproductive issues political concerns have restricted access to EC. Some pharmacies have refused to stock the drug; some pharmacists will not dispense it. There have even been instances where women presenting to emergency rooms after a rape have been denied EC. Currently a prescription is required to obtain EC which means a consult with a physician or other licensed health care provider is required. The nature of sexual behavior means that many episodes of unprotected intercourse will occur on nights and weekends when easy access to providers is limited. Because of the safety of the medication and difficulties in access it has been recommended to the FDA that EC be available over the counter.

A recent article in the New England Journal of Medicine by 3 prominent physicians raised a significant concern that politics is influencing the FDA’s recent decision to postpone changing Plan B to over the counter (OTC) status. They point out that any other drug with the same record of safety and efficacy as Plan B would have received approval for OTC status. The scientific evidence overwhelmingly supports the OTC status of Plan B. However the delay in approval apparently comes from conservative groups who believe that changing this drug to OTC status will encourage sexual promiscuity. There is no evidence to support this concept and the authors rightly argue that approval by the FDA of any drug to be available OTC including EC should be based on science not political considerations.

Women who have a contraceptive failure, unprotected intercourse or who are victims of sexual assault should be assured that EC used within 72 hours can safely prevent pregnancy. As not currently available OTC, women should consider having a prescription for EC available. This measure is recommended by the American College of Obstetricians and Gynecologists. All women should discuss their contraceptive needs with their physicians. Improving access to all forms of contraception will reduce the incidence of unplanned pregnancies and ultimately decrease the incidence of abortion.