Emergency contraceptive pills (here called "ECPs"), are an oral drug containing high doses of hormones found in regular oral contraceptive pills, which, when taken after unprotected sexual intercourse, may prevent pregnancy from occurring.
There are several ways ("mechanisms of action") by which such drugs may work. Depending on the time during the menstrual cycle that they are taken, this drug may inhibit or delay ovulation, inhibit tubal transport of the ovum or sperm cell, interfere with fertilization, or, in cases where it fails to prevent fertilization, prevent implantation. In this respect, emergency contraceptive pills work by triggering the same hormonal changes in the body as regular birth control pills or even breastfeeding but they require much higher doses and are less effective than ongoing hormonal contraceptives.
The phrase "morning-after pill" is a misnomer that is falling out of use due to the fact they are licensed for use up to 72 hours after sexual intercourse. Emergency contraception or "emergency contraceptive pills" is the phrase preferred by the medical community. There are issues for pro-life activists of whether fertilisation or implantation constitute the start of pregnancy, and while U.S. & UK law considers the pregnancy to begin with implantation (ca. 1 week after fertilization), the pro-life viewpoint claims fertilisation should be regarded as the beginning of life, and that ECPs cause a chemical abortion, particularly if taken after the 72 hour period. (See Controversy section for more detail.)
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Types of ECP's
Emergency hormonal contraception is available in two main forms: the original version is the combined or Yuzpe regimen which uses large doses of both estrogen and progesterone taken as two doses at 12 hour intervals. This technique is believed to be approximately 75% effective depending on how soon it is taken after unprotected intercourse. With this regimen being less effective, and causing more side effects, than the more recently introduced progesterone-only method, specific products are being withdrawn (Preven (United States, Schering PC4 (United Kingdom) and Tetragynon (France).
The progesterone-only method uses the progesterone levonorgestrel in a dose of 1.5 mg, either as two 750 microgram doses 12 hours apart, or more recently, as a single dose. This method is now known to be more effective (up to 89 percent) and better tolerated (less nausea or vomiting) than the Yupze method [1], and is available in the U.S. and Canada as Plan B, in the UK as Levonelle, and in France as NorLevo.
"Dedicated products" such as Plan B and Levonelle are specifically designed and marketed as emergency contraceptive pills. It is also possible to obtain the same dosage of hormones, and therefore the same effect, by taking a number of normal Progesterone only pills.
They are most effective the sooner they are taken[2]. Whilst the licensing (in the UK) is for the original 3days investigated by the WHO[3], subsequent WHO study suggested good effectiveness continued for upto 120 hours (5days)[4]. Doctors (in the UK) would though follow the licensing and advise alternative method for those between 72-120hours (see below).
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ECPs as a birth control method
Emergency birth control cannot be recommended as the main means of birth control because it is not as effective as any ongoing method of contraception. It also does not protect against sexually transmitted diseases. However, it is used by some as a back-up when other means of contraception have failed for example, if one has forgotten to take her birth control pill or when a condom is torn during sex. It is also a first line of treatment for victims of sexual assault.
Contraindications & Interactions
Emergency contraception pills should not be used by those with severe liver disease or the very rare condition of porphyria.
The herbal preparation of St John's wort and enzyme-inducing drugs (e.g. antiepileptics or rifampicin) may reduce the effectiveness of ECP and a larger dose may be required (Levonorgestrel 1500mcg initial dose and an extra 750mcg after 12 hours) else consider the use of an IUD (see below).
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Side effects
There are rarely encountered, but may include headache, stomach ache, breast tenderness, vaginal 'spotting' of blood and dizziness. The next period may be a few days earlier or later than expected.
Non-pill types of emergency contraception
An alternative to emergency birth control is the intrauterine device (IUD) which can be used up to 5 days (In some cases 7 days [6]) after unprotected intercourse to prevent pregnancy. Insertion of an IUD is more effective than use of Emergency Contraceptive Pills, reducing the risk of pregnancy following unprotected intercourse by more than 99%. IUDs may then be left in place following the subsequent period to provide contraception for a number of years (3-10 depending upon type and country-specific licensing - see IUD ).
International availability
As of early 2001, women of age 16 and higher may obtain the morning-after pill in the United Kingdom without prescription. This was challenged by an anti-abortion group, but the High Court of Justice of England and Wales let the rule stand in April 2002.
In 2000, the American Medical Association issued a non-binding recommendation that morning-after pills be available over the counter without prescription in the U.S. On December 16, 2003, an advisory committee to the Food and Drug Administration (FDA) recommended that the pill be made available over the counter. The committee voted 23 to 4 that the drug should be sold over the counter and 27 to 0 that the drug could be safely sold as an over-the-counter medication. However, in May of 2004 the FDA refused this strong recommendation and prohibited over-the-counter sale. The FDA claimed that this was due to limited experimental data on the effects of such pills on girls under 16 years of age, but critics have accused the FDA of basing the decision on political pressure. [8] One year later, a new application from the makers of Plan B requested over-the-counter status for women aged 16 and older, but the January 2005 deadline for the FDA decision on this application has come and gone without a decision. The FDA had more recently pledged to rule on the application by September 1st, 2005, but this deadline has been extended for at least 60 days. However, in the United States, as of June 2005, seven states (California, Washington, Alaska, Hawaii, New Mexico, Maine, and New Hampshire) had passed laws permitting trained pharmacists to dispense emergency contraception without a doctor's prescription.
In a number of instances across the United States, pharmacists have refused to give women emergency contraception even with a legal prescription. These pharmacist refusals have created great controversy. Pro-life pharmacists who believe that emergency contraception is equivalent to abortion, or who, for personal moral or religious reasons oppose the use of birth control pills for unmarried women, or at all, have in a number of instances across the United States asserted a right of conscience to refuse to fill those prescriptions. The American Pharmacists Association has proposed conscience clauses or refusal clauses that would allow pharmacists to opt out of filling prescriptions they found morally offensive as long as they referred women to other pharmacists who would fill the prescription.
Women's rights and pro-choice organizations have expressed concern that in many parts of the country there may not be reasonably accessible alternatives to fill a prescription; and that having a prescription refused is intimidating and upsetting to women who are likely to be in a crisis situation. As well, in the instance of emergency contraception, there is a short window of time during which EC is effective. Advocates for women say that conscience clauses are often overly broad, and that women have a right to medically appropriate, effective, and legal reproductive health services without being refused such services because of the medical professional's personal beliefs.
In May 2004, Canada's Health Minister announced that Plan B would soon become available from pharmacists in all provinces without a prescription. This occurred on April 28, 2005. The new system would still require the person to buy the pills directly from the pharmacist.
In January 2000, France decided to dispense Emergency birth control in junior and high schools by school nurses without prescription, because of high rates of undesired pregnancies among teenaged girls; after strong opposition from the Catholic Church, and much debate around the fact the teenager could later suffer from the doubt of not knowing whether fertilization had occurred or not, the decision was overruled by a court in July 2000. The French parliament changed the relevant law in October 2000 and now school nurses are again able to dispense the drugs. The emergency contraceptive pill NorLevo is now available in France without prescription, without parent authorization, and free of charge for teenagers under the age of 18 since January 9, 2002.
Emergency contraception is available without prescription in the following 41 countries: Albania, Australia, Belgium, Benin, Cameroon, Canada, China, Congo, Denmark, Estonia, Finland, France, French Polynesia, Gabon, Ghana, Guinea-Conakry, Iceland, India, Israel, Ivory Coast, Jamaica, Latvia, Lithuania, Madagascar, Mali, Mauritania, Mauritius, Morocco, Netherlands, New Zealand, Norway, Portugal, Senegal, South Africa, Sri Lanka, Sweden, Switzerland, Togo, Tunisia, Turkey, and the United Kingdom.
Controversy in relation to abortion
The morning-after pill should not be confused with mifepristone (also called Mifeprex, and formerly known as RU-486), an abortifacient which is taken to end a pregnancy after implantation has occurred. The morning-after pill must be taken before implantation, or it will have no effect.
The morning-after pill may, however, prevent the implantation of an embryo in cases where it fails to prevent fertilization in the first place. Although the United States Food and Drug Administration, National Institutes of Health, the American College of Obstetricians and Gynecologists) and other health agencies define pregnancy as beginning with implantation, some pro-life medical professionals, embryology texts, and activists argue that preventing implantation is unethical, as the blastocyst (early-stage embryo) then dies instead growing into a fetus and, ultimately, being carried to term.
Recent medical studies in animals (the rat and the monkey) were inconclusive as to how often or whether the morning-after pill prevents implantation; however, this mechanism of action cannot be ruled out in all cases, as it is impossible to prove a negative. Therefore, women who believe it is immoral to prevent a fertilized egg from implanting may wish to avoid use of this drug.
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Issues against
Because such drugs are considered to be abortifacient by pro-life groups, it has been the object of controversy within the wider abortion debate. Other controversial aspects are the effect of such pills on a later-term fetus and the possible ability of EPCs to cause birth defects.
Pro-Life groups dominantly Christian opposers of abortion in all cases (including embryonic stem cells) claim that such pills are "abortion pills", rather than "contraceptive pills." As knowing the actual age of a pregnancy can be difficult, controversy over gestational age boundaries have been controversial, and both sides have claimed different definitions of the relevant terms.
Following, there have likewise been some discrepancies regarding the very term "conception". In a statement by the American Association of Pro-Life Obstetricians & Gynecologists (AAPLOG), regarding the controversial morning-after pill, AAPLOG claims:
"[Again,] one must be careful of the terminology. Many now speak of "conception" as that moment when the human blastocyst, the early ball of approximately 100 cells, implants in the mother's uterus (womb). The time from actual fertilization (sperm and egg unite in the Fallopian Tube) until implantation, a period of about 7-10 days, is ignored, even though no genetic change occurs in the cells during this time period. Many family planning specialists who have supported the terminology change can thus rationalize that the destruction of the human embryo between fertilization and implantation should be labeled "contraception," rather than "early abortion."
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Issues for
Different drugs also have variant effects, as they may use different mechanism for action, and dosages of hormone. In May of 2005, a study was published confirming that Plan B absolutely does not have an effect on implantation. http://www.popcouncil.org/publications/popbriefs/pb11(2)_3.html
Emergency Contraception's Mode of Action Clarified: (Journal of Biomedicine, May 2005, Vol. 11, No. 2)
In addition, manufacturers of oral contraceptives have long claimed that the Pill provides three lines of defense against pregnancy: It prevents ovulation (most of the time), blocks sperm by thickening cervical mucus, and, should all else fail, theoretically reduces the chances that a fertilized egg will implant in the uterus by hormonally altering the uterine lining.
However, it is not known if this post-fertilization effect actually happens. "There is no evidence that the Pill's effect on the uterine lining interferes with implantation or has a post-fertilization effect," says contraception expert Felicia Stewart, MD, codirector of the Center for Reproductive Health Research and Policy in San Francisco. "Documenting it would be a very difficult research task."
David Grimes, MD, a clinical professor in obstetrics and gynecology at the University of North Carolina School of Medicine, says the Pill and other hormonal contraceptives work primarily by preventing ovulation.
Consensus comes from a surprising source. "The post-fertilization effect was purely a speculation that became truth by repetition," says Joe DeCook, MD, a retired OB/GYN and vice president of the American Association of Pro-Life Obstetricians and Gynecologists. "In our group the feelings are split. We say it should be each doctor's own decision, because there is no proof."
Further clouding the issue is the fact that even among women trying to become pregnant--women obviously not taking the Pill embryos naturally fail to implant 40 to 60 percent of the time. These are eliminated upon the next menstruation.
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