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EDITORIALS: Mira Harrison-Woolrych, Andrea Duncan, Jeannette Howe, and Conamore Smith Improving access to emergency contraception BMJ 2001; 322: 186a [Full text]

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Rapid Responses published:

emergency intercourse

Fazlur Rahman   (30 January 2001)

EHC from pharmacists; a missed opportunity for STI reduction

Trevor Stammers   (31 January 2001)

Why hormonal contraception should be prescription-only

Paul Thomas   (6 February 2001)

slot machine better than confused mission

Adrian Midgley   (9 February 2001)

A good position for that slot machine

Trevor Stammers   (17 February 2001)

Emergency Contraception: An Euphemism

Cecilio Gomez Almodovar   (7 October 2001)

emergency intercourse 30 January 2001
Fazlur Rahman, physician chennai Send response to journal: Re: emergency intercourse	Emergence contraception has no place at all, if we avoid the instinct: EMERGENCY INTERCOURSE. But wait for marriage, dignify the act and respectfully protect the natural course of events, the growth of a pristine pure, unspoilt and unadulterated soul, that has the potential to change today's rotten life style and the bad concept of population explosion.
EHC from pharmacists; a missed opportunity for STI reduction 31 January 2001
Trevor Stammers, Tutor in General Practice, St. George's Hospital Medcial School Send response to journal: Re: EHC from pharmacists; a missed opportunity for STI reduction	I have an open mind as to whether the predicted reduction in unplanned pregnancies and abortions will in fact result from pharmacy access for emergency contraception.(1) I hope this will be the outcome, but the possibility of risk displacement rendering this move ineffective in the same way as has been postulated for condom use(2), makes this far from certain. What is certain is that the opportunity for STI detection and risk reduction has been totally missed. It is well-documented that a tunnel- vision approach to reducing unplanned pregancy may do nothing to reduce STI risk(3)and can increase it. Many, if not most, women in need of EHC will also be at risk of STIs. If, in taking a history to explore the need for EHC, a doctor did not also gently explore STI risk and advise the patient appropriately, I would consider it sub-standard practice and possibly even negligent. The web- site pharmacy training programme highlighted in the editorial only mentions STIs in the context of EHC not providing any protection against them. No questions are advised to assess STI risk and no information is to be provided on how to obtain further help on diagnosis and management. Even mandatory provision of a simple leaflet mentioning possible STI risk and giving the details of the nearest GU medicine departments would be better than nothing. As it is, a woman who obtains EHC from a pharmacy is unlikely to be offered any chance whatsoever of having a concurrent STI investigated and treated promptly. STI rates will continue to increase in the UK yet again as a predictable and direct result of a scheme introduced with insufficient planning and training for pharmacists. When concerns about STIs were raised by some of those involved in the Manchester pilot scheme, they were simply ignored. The trauma of a diagnosis of chlamydia(4)is clearly of little interest to those who want to make buying EHC as easy as buying a toothbrush. 1. Harrison-Woolrych M, Duncan A, Howe J, Smith C. Improving access to emergency contraception BMJ 2001 322 186-7 2. Richens J, Imrie J, Copas A Condoms and seat belts: the parallels and the lessons Lancet 2000 355 400-3 3. Whaley A Preventing the high-risk behaviour of adolescents:focus on HIV/AIDS transmission, unintended pregnancy or both? J Adolesc Health 1999 24 376-82 4. Duncan B, Hart G, Scoular A, Bigrigg A. Qualitative analysis of psychosocial impact of diagnosis of chlamydia trachomatis: implications for screening BMJ 2001 322 195-99
Why hormonal contraception should be prescription-only 6 February 2001
Paul Thomas, GP principal Gipping Valley Practice, Suffolk Send response to journal: Re: Why hormonal contraception should be prescription-only	Dear Sir, Emergency Hormonal Contraception Mira Harrison et al. confirm the change to the legal status of emergency hormonal contraception is designed to improve access, supposedly to reduce the high number of unwanted pregnancies in the United Kingdom (1). The recent Lord’s debate confirms that many consider such drugs should not be available from retail pharmacy outlets where they are supplied anonymously on demand. I am not sure that the government has fully considered the implications of the loss of prescription-only status since this is not the only mechanism that can be used to improve access. Patients may indeed have problems accessing these products from the NHS since this ofetn requires a written prescription and then a visit to a pharmacy but I doubt patients genuinely experience difficulty in accessing their NHS GP who can also offer more effective alternatives. Pharmacists, nurses and indeed many other health professionals are entirely capable of issuing medicines safely but I understood prescription -only status ensures that one individual - the patients doctor - is fully aware of a particular medicine's use on any patient and the context in which it is used. The "promiscuous” 15-year-old girl (highlighted by Trevor MacDonald on television) is at considerable risk of human papilloma virus infection and will require screening for other STDs but now there is no mechanism to alert the patient's doctor to its use or overuse, her promiscuity or to any evidence of sexual abuse. Many therefore feel such drugs should remain "prescription only" because of the loss of continuity and appropriate follow up when any product is transferred to the P-List, or indeed, issued by a school nurse. The status of many drugs has been changed to the pharmacy list in order to reduce NHS costs while also increasing the profits of pharmacy corporations but in this case many clearly believe it is at the expense of an unacceptable risk in the deterioration of the long-term physical, mental and social health of young-women and a paradoxical increase in the number of unwanted pregnancies due to over reliance on a very inefficient method of contraception. Far simpler and much safer would be for EHC to be included in the items listed under paragraph 44.5 of the NHS Statement of Fees and Allowances or if the state refuses to provide such treatment to allow for its private sale by NHS doctors with no change to its legal status. In this way if it is the most appropriate management all doctors could provide EHC directly to their patients at the time of need (2). Yours sincerely, P D Thomas (1) Mira Harrison-Woolrych, A Duncan, J. Howe & C. Smith; Improving access to emergency contraception BMJ 2001; 322:186 ( 27 January ) (2) Thomas P D, Dispensing doctors; BMJ 1992; 305: 650
slot machine better than confused mission 9 February 2001
Adrian Midgley, GP Exeter Send response to journal: Re: slot machine better than confused mission	People get easily confused when they try to make rules for other people's contracecption. The mission is to prevent preventable unintended pregnancies. Every additional bit of clutter or baggage added to the process of getting the woman and the post-coital pill to coincide in time and space as soon after coitus as is reasonably possible reduces the chance of success. More logical to put the Progestogen MAP in slot machines and show the contact detils of the STD clinic on the front of it than to only provide it on condition a lecture is listened to. And the above touting for medico-legal business is best buried as well.
A good position for that slot machine 17 February 2001
Trevor Stammers, Tutor in General Practice St. George's Hospital Medical School Send response to journal: Re: A good position for that slot machine	The mission is to reduce both unwanted pregnancies and STIs. All too often, hastily introduced plans to reduce one actually increase the other,(1) hence my plea. I actually agree that an emergency-pill slot machine with the address of the local STI clinic displayed on it may be a better overall plan than OTC pharmacy sales without any mention of STI risk. With the routine positioning of such machines right next to condom machines, they would also be a timely reminder that condom failure is the most common reason for the use of emergency contraception in the first place. 1. Whaley A Preventing the high-risk sexual behaviour of adolescents:focus on HIV/AIDS transmission, unintended pregnancy or both? J Adoles Health 1999 24 376-382
Emergency Contraception: An Euphemism 7 October 2001
Cecilio Gomez Almodovar, Calle Abtao 9, 7º B, Madrid-28007 (Spain) Community Health Centre Buenos Aires Send response to journal: Re: Emergency Contraception: An Euphemism	SIR.-Emergency contraception (EC) is defined as a number of methods used by women within a few hours or a few days to prevent pregnancy (1). Pregnancy, as it is known, is the condition of having, inside the body, a developing embryo or fetus after the union of a ovum and a spermatozoon (2). In the Dr Harrison-Woolrych´s editorial, it is indicated, correctly, that EC is intended for use after intercourse but before blastocyst implantation (3). We want to stress that this last phase starts, aproximately, a week after the begining of pregnancy, marked by the union of the two gametes. So, these regimens included in EC (Yuzpe and Levonorgestrel in doses of 0.75 mg, given twice, twelve hours apart, within 72 hours after intercourse) can act either preventing pregnancy (before fertilization) or interrupting it (after fertilization). In other words, these preparations have not only contraceptive mechanisms of action but early abortifacient too. Obviously, Emergency contraception is not a proper denomination for these methods but only an euphemism, as it was considered in other letter published in this journal, some years ago (4). In Spain, where we work, Levonorgestrel is licensed for EC use since March in this year, and pharmacists have to supply it, compulsorily, to anybody who ask for it with a medical prescription. However, the spanish constitution recognizes freedom of ideology and religion for everybody, included pharmacists. That is why some of them have started proceedings against that order. We are not interested in discussing the convenience of supplying these drugs by medical prescription only or over the counter. But we think it is neccessary to respect the conscience objection of those pharmacists who refuse to sell preparations with potential abortifacient effects. AUTHORS: Almodovar CG Family Phisician. Community Health Centre Buenos Aires. Madrid (Spain). cecilio.gomez@eresmas.net Fdez-Pacheco L Family Phisician. Community Health Centre Buenos Aires. Madrid (Spain). BIBLIOGRAPHY: 1-Consortium for Emergency Contraception. Emergency contraceptive pills: a resource packet for health care providers and programme managers. December 1996. 2-Dorland, Newman WA. Dorland´s Illustrated Medical Dictionary. Philadelphia. Saunders, 1994. 3-Harrison-Woolrych M, Duncan A, Howe W, Smith C. Improving access to Emergency contraception. BMJ 2001;322:186-187. 4-Davis P. Emergency Contraception. BMJ 1991;302:1082-1083.