Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Emergency contraception--both sides of the coin
- Charu Chanana (15 September 2006)
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Missing the point
- Iain C Reeves (16 September 2006)
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Emergency contraception is not just for the morning after
- Richard Ma (16 September 2006)
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Emergency Contraception- Missing the Opportunity?
- John S Ashcroft (16 September 2006)
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Emergency contraception: worth the fuss.
- Somasundari Gopalakrishnan (18 September 2006)
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Some other forgotten factors in the EC debate
- Trevor G Stammers (18 September 2006)
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Waking up to the morning-after pill
- Eurica Califorrniaa (24 September 2006)
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Family planning failure: is it right to blame emergency contraception?
- Tatiana Izotova (26 September 2006)
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Association or Causation?
- Maria Gough RGN, BSc (Hons) (26 September 2006)
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Emergency contraception; a paradoxical effect?
- James W. Gerrard (26 September 2006)
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Charu Chanana, Registrar AIIMS, New Delhi,India-110029
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EMERGENCY CONTRACEPTION- BOTH SIDES OF THE COIN Dr Charu Chanana Emergency contraception is the need of the day. However Emergency contraception is not without its disadvantages. It may indirectly lead to promiscuity and an increased incidence of sexually transmitted diseases including HIV-AIDS. With Emergency contraception a number of unplanned, unexpected pregnancies can be got rid off. This results in a decline in the number of abortions that women undergo. In developing and under-developed nations abortions are many a times carried out by untrained personnel under unhygienic conditions without the use of any aseptic precautions as a consequence of which till date conditions like septic abortions and its complications namely septic shock, acute renal failure & DIC, uterine and subsequent gut perforations and severe hemorrhage resulting in anemia are encountered. Thus knowledge of emergency contraception can really help in reducing the maternal morbidity and mortality besides reducing the psychological trauma of undergoing an abortion that women undergoing abortions often face. I feel that emergency contraception should be available over the counter but at the same time people should be educated that emergency contraception is only a emergency measure to be used in cases of unprotected exposures or condom breakage and not as a replacement of routine contraceptive methods. Also people should be told that emergency contraception does not protect against sexually transmitted diseases Competing interests: None declared |
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Iain C Reeves, Consultant in GU Medicine Royal Sussex County Hospital, BN2 5BE
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Anna Glasier neglects to mention that the price of over-the-counter emergency contraception is an effective barrier to its use, discriminating in particular against women on lower incomes. To suggest that the "fuss" over political ideology and religious belief interfering in rational decisions over the licensing of medications is of interest to only one or two individuals is extraordinary. Few people interested in reducing termination of pregnancy rates would argue against greater investment in the provision of effective and convenient contraception. Competing interests: None declared |
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Richard Ma, GP and Family Planning Doctor The Village Practice, London N7 7JJ
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Professor Anna Glasier is right to highlight that emergency hormonal contraception is not the solution to reducing unplanned pregnancy and abortion rates. There is no question of increased availability of emergency hormonal contraception to women; in some areas, young women can obtain this free of charge from community pharmacists. However, if we are serious about reducing the rates of unplanned pregnancy and abortion in women of all ages, we need to ensure women can obtain regular contraception easily and in a timely manner. With the current deficits in the NHS, contraceptive services are experiencing a relative disinvestment, forcing many clinics to close or limit the number of clients that they see. Health professionals and the media should also be responsible about how they discuss and report emergency hormonal contraception, as some women interpret “the morning after pill” quite literally. They may have the opportunity to get emergency contraception in 48 hours but don’t because they think that it is literally for “the morning after”. Competing interests: None declared |
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John S Ashcroft, general Practitioner Old Station Surgery,Heanor Rd, Breaston,Derbyshire DE78 ES
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Dear Sirs Anna Glasier points out the research that increasing the availability of emergency contraception, and indeed even increasing its use, doesnt appear to result in decrease in unplanned pregnancy and concludes that the contraception use before and during sex is more important. I suggest that the "quality" of that contraception is even more important still. Condoms and oral contraceptive pills "can work", but "do they work" in the teenage population? Evidence suggests they do not and that other methods such as injectibles, and implants are much more effective. Though such long acting reversible contraceptives (LARCs) were supported by NICE (1), the Teenage Pregnancy Unit fails to fully embrace the importance of this. Implants are the most effective method of contraception we have, and the one usually most suitable for use in the teenage group. However training for GPs (by far the largest providers of contraceptive services), is very patchy and has to be undertaken in their own time and at their own expense. A GP having done that will then find there is still no national reimbursement under the NHS for GPs to counsel, fit or remove them. A womens need for emergency contraception should raise the question "What didn't work", and an exploration of "what will work". Moving emergency contraception out of the the surgery and clinic, into the pharmacy as has happened since 2002 (2), hasn't made that question easier to ask. 1 NICE clinical guidance on LARC, published October 2005 2 C Marston et al BMJ 2005;331:271 (30 July), Competing interests: None declared |
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Somasundari Gopalakrishnan, Honarary Research Fellow Department of Public Health, University of Birmingham, Birmingham. B15 2TT
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In this interesting article, the author has questioned the value of emergency contraception (EC) in the prevention of abortion rates. Epidemiological studies analysing the causes of abortion has shown that failure of contraceptives is the commonest reason for requesting abortions (1). Unprotected sex (as in an accidental situation) contributes only a minor proportion and hence the expected reduction in abortion rate from EC may not be high. Statistics has shown that in UK, use of EC has grown from 1% in 1984 to 12% in 2002(2). We cannot deny that the money spent on educating the population about the accessibility and the awareness of EC is justified. How do we account for the increase in number of abortions from 11 per 1000 women aged 15-44 in 1984 to 17.8 per 1000 in 2004? This may be due to a combination of factors including contraceptive failures, reluctance of career oriented women to start family, binge drinking, rise in female population in university education and earlier onset of sexual activity in teenage population (3). One cannot blame failure of EC alone for rise in abortion rates. DOH has said that morning after pill was its last resort to encourage safe sex. It is needless to say here that prevention is better than cure. In an ideal world, regular use of contraception should be promoted to avoid unnecessary abortions. However, the availability of EC is vital for the vulnerable population especially to victims of rape. We cannot disregard this by figures, which quote year on increase in abortion rates. References: 1.Gordon AF, Owen P. Emergency contraception: change in knowledge of women attending for termination of pregnancy from 1984 to 1996. Br J Fam Plann. 1999; 24: 121-122. 2. Trussell J, Stewart F. The effectiveness of postcoital contraception. Fam Plann Perspect 192;24: 262-4. 3. The national survey of sexual attitudes and lifestyles: Teenage pregnancy. http://www.brookes.ac.uk/schools/social/population-and- household-change/4_wellings.html! (Accessed 17th September 2006) Competing interests: None declared |
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Trevor G Stammers, Senior Tutor in general practice St George's Hospital Medical School
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The fall in the abortion rate in the US could be due to delay in sexual debut amongst unmarried teenage girls (1)—another ideological battleground not mentioned by Glasier, so if you are looking for another intervention that will reduce abortion rates,perhaps you should concentrate most on encouraging young people to delay intercourse until they are in committed, long-term relationships.(2)(3) 1. Mohn JK Tingle LR Finger R An analysis of the causes of the decline in non-marital birth and pregnancy rates for teens from 1991-1995 Adoles and Fam Health 2003 3 39-47. www.afhjournal.org 2. Genuis SJ, Genuis SK Commentary: adolescent behaviour should be priority BMJ 2004 328 894 3. Cabezon C, Vigil P, Rojas I et al Adolescent pregnancy prevention: an abstinence-centered randomized control intervention in a Chilean public school J Adolesc Health 2005 36 64-9 Competing interests: Trevor Stammers is the author of 'Saving Sex' and a webdoctor for www.loveforlife.org.uk |
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Eurica Califorrniaa, Director Micro ICU Project, Haleiwa, HI 96712
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"[I]f you don't want to get pregnant anything is better than nothing," says Anna Glasier. (1) I wonder, would that be cause to promote the withdrawal method? Or worse, something inferior? Suppose, as I will argue, that the morning-after pill really is inferior to the withdrawal method. Would it then be reasonable to suspect that this might explain a proportionate increase in abortions based on increased infatuation with the method? A 2004 resolution of the American Medical Association made the unfortunate mistake of equating two different hormonal regimens of the morning-after pill using the American brand name for one of the regimens as a generic name for both, stating, "The Plan B pill is a post-coital contraception method which transiently provides a high dose of (1) combined estrogen and progestin or (2) progestin-only..." The resolution strongly opposed leadership that would prevent over-the-counter access to either regimen for girls and women of all ages. (2) Ironically, within a couple of months the combined regimen, marketed as Preven, was voluntarily withdrawn from the U.S. market. Apparently, physicians did not appreciate that the combined regimen is twice as ineffective on an annual basis of perfect use when compared to the progestin-only regimen. (3) With added irony, the withdrawal of Preven from the prescription use market received little attention, including from the American Medical Association, in stark contrast to the attention given to delays caused by the U.S. Food and Drug Administration concerning over-the-counter use of Plan B. The withdrawal was swept under the rug, and even the company website, www.preven.com, has now disappeared. Yet what of the progestin-only regimen? In the United States, the prescription label for Plan B does not help us to answer this question. For, in an amazing sleight-of-hand, the label leaves doctors with nothing to compare it to! Specifically, the label presents annual use rates for traditional methods, but only the single use rate for perfect use of Plan B is included, not the annual use rate. (4) To the unsuspecting, a single use rate of 89% may sound like a grand ("better than nothing") number. But little does one know that the relationship between single use and annual rates is exponential. (5-6) For example, the 75% single use rate for Preven, when compared to the 89% rate for Plan B, implies a two-fold increase in annual rates (38 pregnancies per 100 women, versus 19). (3) So how could well-informed physicians have equated the two? The plot thickens when we learn that the annual rate of pregnancy expectation for perfect use of Plan B, though available, was not included in the prescription label for comparison with traditional methods. It turns out that on an annual basis of pregnancy expectation, women can expect as many pregnancies from perfect use of Plan B (19 per 100 women in the first year of use) as they would from typical use of the withdrawal method! Notably, the same researcher, Princeton University professor James Trussell, had a hand in the publication of both of these statistics, and it was his work that the U.S. Food and Drug Administration had relied upon in making its decisions. (3, 6) So why is this comparison absent from the prescription label? And why are experts still deceived by the ineffectiveness? How many young girls and women have to suffer an increase in unplanned pregnancies before authorities pull from the market something that creates fantasies and expectations about a method that is less effective than typical use of the withdrawal method? amb@juridic.org References: 1. Glasier A.Emergency contraception. BMJ 2006; 333: 560-561 2. American Medical Association House of Delegates. Resolution 443 (A -04) Re: FDA Rejection of Over-The-Counter Status for Emergency Contraception Pills. June 12, 2004. http://www.ama- assn.org/meetings/public/annual04/443a04.rtf 3. NOT-2-LATE.com. The Emergency Contraception Website. "How effective is emergency contraception." http://ec.princeton.edu/questions/eceffect.html 4. Prescribing Information. Plan B (Levonorgestrel) tablets, 0.75 mg. Revised February 2004. Barr Laboratories. Pomona, NY. http://www.go2planb.com/PDF/PlanBPI.pdf 5. Califorrniaa E. Juridic Embassy, Micro ICU Project. Comment to U.S. Food & Drug Administration, Dec. 15, 2004. Comment C 2044 in Vol. 300 of Docket No. 2001P-0075, “Switch Status of Emergency Contraceptives from Rx to OTC”. Docket entered Dec. 22, 2004. http://www.fda.gov/ohrms/dockets/dockets/01p0075/01p-0075-c002044-01- vol300.pdf 6. Califorrniaa E. Juridic Embassy, Micro ICU Project. Comment to U.S. Food & Drug Administration, Sept. 8, 2005. Comment C 5 in Vol. 1 of Docket No. 2005N-0345, “Drug Approvals: Circumstances under which an active ingredient may be simultaneously marketed in both a prescription drug product and an over-the-counter drug product”. Docket entered Sept. 13, 2005. http://www.fda.gov/ohrms/dockets/dockets/05n0345/05n-0345- c000005-01-vol1.pdf 7. Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Stewart F, Cates W, Stewart GK, Guest F, Kowal D. Contraceptive Technology; Seventeenth Revised Edition. New York, NY: Irvington Publishers, 1998 Competing interests: None declared |
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Tatiana Izotova, F2 Aintree Hospital, Longmoor Lane, Liverpool, L9 7Al
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Is emergency contraception “worth the fuss”? I suspect it is for the 75 million women with unintended pregnancies across the developing world (1). Glasier’s suggestion that morning after pills usage is not supported by evidence is not substantiated (2). The current evidence undoubtedly supports their use. In 1996 Trussell et al reviewed the results of ten clinical trials of women treated with Yuzpe emergency contraceptive pill (ECP) regimen. They showed that the weighted average of the effectiveness rates was 74.0% (3). More so, Glasier herself reported in 1997 that 75-85% of pregnancies were prevented when using Estrogen and progesterone morning after pills (4). In 1998 The World Health Organisation Task Force on Postovulatory Methods of Fertility Regulation conducted a randomised double blind controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception and found that the crude pregnancy rate was 1.1% with the levonorgestrel-only regimen (5). Following this, Trussell et al re-analysed the existing data and found that Yuzpe regimen reduced the risk of pregnancy by 74.1 percent, with a 95 percent confidence interval of 62.9–79.2 percent. It was even argued that the true effectiveness is likely to be greater because treatment failures may include women who already were pregnant or became pregnant after being treated (6). Jones then conducted a review which suggested that in the USA more than 50,000 abortions were averted by use of emergency contraceptive pills in 2000 (7). The World Health Organisation then conducted another randomised, double blind trial in 15 family planning clinics in 10 countries, comparing three emergency contraception methods and found that the pregnancy rate lied between 1.5%-1.8%, this compares to 8% in women who do not use any form of contraception method. In other words emergency contraception seems to reduce the pregnancy rate by at least 75% (8). The International Planned Parenthood Federation (IPPF), after the October 2003 meeting, emphasized that family planning associations should strive to promote and provide emergency contraception in their countries (9). In conclusion I would argue that inferring a causal relationship between rising abortion rates in the UK and failure of emergency contraception is a huge jump. Rising or reduction of abortion rates looks at the failure or success of the family planning system and not emergency contraception. Why not put the blame on the usage of condoms, intra- uterine devices (IUDs), oral contraceptives and injectable contraception? It has to be remembered that morning after pills are forms of “EMERGENCY CONTRACEPTION”, they are meant to be used ONLY IN EMERGENCIES when other forms of contraception methods fail, in other words when the family planning system fails. 1) Beitz, J. and Hutchings, J. Emergency contraception: a vital component of reproductive health programs. Western Journal of Medicine 176:152–154 (2002). 2) Glasier A, Emergency contraception, BMJ 2006;333:560-561, doi:10.1136/bmj.38960.672998.80 [Extract] [Full text] [PDF] 3) Trussell, J. et al. The effectiveness of the Yuzpe regimen of emergency contraception. Family Planning Perspectives 28(2) (1996). 4) Glasier A. Emergency postcoital contraception. N Engl J Med 1997;337:1058-64. 5) Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Task Force on Postovulatory Methods of Fertility Regulation. Lancet 1998;352:428-33 6) Trussell, J. et al. Updated estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception 59:147–151 (1999). 7) Jones, R.K. et al. Contraceptive use among U.S. women having abortions in 2000–2001. Perspectives on Sexual and Reproductive Health 34(6):294–303 (November/December 2002). Available www.guttmacher.org/pubs/journals/3429402.pdf. 8) von Hertzen H, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a World Health Organization (WHO) multicentre randomized trial. The Lancet. 2002; 360 (9348): 1803-1810. 9) International Planned Parenthood Federation (IPPF). IMAP statement on emergency contraception. IPPF Medical Bulletin. 2004;38(4):1–3. Available at: www.ippf.org/medical/bulletin/pdf/Vol38No1March2004en.pdf. Competing interests: None declared |
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Maria Gough RGN, BSc (Hons), Advanced Nurse Practitioner Harlow WIC , 1a Wych Elm, Harlow CM 20 1QP
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As a Senior Nurse Practitioner in a Walk in Centre I have provided (over the past 5 years) a great deal of (free) Levenelle 1500. I do not argue that the demand for both EHC & TOPs is increasing but I doubt that the 'failure' of the former is causing the latter. One feels many patients are being 'economical' with the truth: sexual intercourse was longer ago than reported; there was more than one episode of sexual intercourse in this menstrual cycle; rather than a 'split' condom - there was no condom at all (otherwise there are serious problems with the manufacturing of condoms). Patients know which particular hoops they have to go through in order to access Levenelle 1500 - but since the patient must take the EHC pill in front of us - the one thing we can be sure of is that they are swallowing it. This current trend is, of course 'self-limiting': the more sexual intercourse, the more STI's and the less likelihood of ANY pregnancies - problem solved. Competing interests: Regular provider of EHC |
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James W. Gerrard, GP Windmill Health Centre, Mill Green View, Leeds LS14 5JS
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Glasier asks whether emergency contraception is worth all the fuss (1). As she says, for the individual woman after an episode of unprotected sex, it may be, since it will prevent pregnancy "some of the time". But herein lies the problem. Most of the time emergency contraception is taken unnecessarily: pregnancy would not have resulted anyway. So at these times it acts as no more than a placebo. When her period occurs, the woman may be left with an inflated idea of the treatment's success. Repeated across a population it is not hard to imagine this developing into a folk-belief of legendary effectiveness out of proportion to the truth. This matters because, as a consequence, if risk taking behaviour increases, both for the population as a whole and the individual over time, unwanted pregnancies will be more likely. This might go some way to explaining the simultaneous increases in emergency contraception use and abortion rates, as well as the quoted increase in women requesting abortion who have used emergency contraception in the past. If this is right then Glasier's advice to encourage contraception before or during sex, not after it, was never more important. (1). Glasier A. Emergency contraception.BMJ 2006;333:560-1 Competing interests: I am a pro-life GP wondering how best to reduce abortion rates. I prescribe emergency contraception. |
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