10 common questions on emergency contraception
By Robert A. Hatcher, MD, MPH
Chairman, Senior Author, Contraceptive Technology
Professor of Gynecology and Obstetrics
Emory University School of Medicine, Atlanta
1. Is it sometimes appropriate to prescribe emergency contraceptive pills (ECPs) over the phone to a woman whom you have never seen?
Yes. A woman can obtain combined pills over the counter in much of the world. Pharmacists are being cleared to provide ECPs in the United States. Therefore you as a physician or nurse practitioner can, under certain circumstances, prescribe ECPs to a woman you have not seen previously. The only medical reason that prevents a patient from taking ECPs is present severe migraine headaches with neurologic impairment. This can be asked about over the phone.
2. Would you provide ECPs (combined OCs) to a woman with a more common reason for avoiding combined pills as an ongoing contraceptive?
• Smoker over 35? Yes.
• Diabetic with vascular disease? Yes.
• History of severe migraine? Yes.
• History of venous thromboembolism? Yes.
• Benign or malignant liver tumor? Yes.
• At moment having migraine with neurologic impairment such as blurred or lost vision, seeing flashing lights or zigzag lines, trouble speaking or moving? No.
3. What would you recommend for a woman who seeks ECPs slightly more than 72 hours after unprotected intercourse or who cannot remember when intercourse occurred?
Provide the ECPs if she wants them, or consider insertion of a Copper T 380. The same could be true if a woman had one or several acts of unprotected intercourse within the past 72 hours and also acts of intercourse more than 72 hours previously. Although not available in the United States, RU-486 would be another post-coital emergency option. Remember the wisdom of my long-time friend and administrative assistant, Maxine Keel: "Blessed are the flexible, for they shall not be bent out of shape."
4. Which would you prescribe for a woman wanting ECPs: Ovral 2+2 or Lo-Ovral 4+4?
Lo-Ovral 4+4 (or any pharmacologically equivalent pill) is definitely preferable to Ovral 2+2 because some pharmacists do not stock Ovral, and while Lo-Ovral will cost $15 to $30, Ovral may cost $25 to $55 for one cycle. Pharmacists will charge your patient for an entire pack. Contact the pharmacist a woman will go to if you choose to prescribe Ovral. Make sure he or she (a) has Ovral and (b) it does not cost too much. In one drug store in Atlanta, the cost of Lo-Ovral 4+4 is $24.99, and the cost of Ovral 2+2 is $42.99. At one drug store in New York City, the cost of Lo-Ovral is $26, and the cost of Ovral is $45.
When asked about Ovral, one pharmacist replied, "Are you sure you mean Ovral?" This indicates a level of uncertainty that could cause anxiety for a woman who had been given a prescription for Ovral as a post-coital contraceptive.
• If you want to continue using the combined pills you prescribed as an ECP on an ongoing basis (that is, as her contraceptive in the future), you probably will want to use a low-dose pill, not a 50 mcg pill. Corollary: Exactly how might you write your prescription for ECPs? Two ways:
• Phenergan 25 mg, 4 tablets. Take one this evening between 6 and 7 p.m. Repeat in 12 hours.
• Lo-Ovral (21-pill pack). Take 4 tablets 1¼2 hour after anti-nausea medication. Repeat in 12 hours. If nausea is severe from the first or second dose of Lo-Ovral, an extra tablet of Phenergan may be taken.
5. How can we help women make the transition from the use of combined pills as ECPs to their regular method of birth control?
Most common approach: 4 tabs followed by 4 tabs 12 hours later. Then instruct client to start a new package of pills the Sunday after her menstrual period begins. Advantages:
• Waiting period before additional OCs used.
• She may want to return to a completely different brand of pills.
• Fewer pills taken if she is already pregnant or becoming pregnant.
Disadvantages:
• Withdrawal bleed may occur early, at expected time, or late.
• Patient has to wait to continue pill use.
"Seamless care" could be accomplished as follows: Patient should take 4 tabs; followed by 4 tabs in 12 hours; followed by one tablet daily for the next 13 days (using backup contraception for the first 7 of the 13 days); then stop pills for 7 days. In this case, encourage your client to use a backup contraceptive for seven days. Advantages:
• 13 pills are not wasted.
• Use of OCs begins with pill used as an ECP.
• Withdrawal bleed likely when last pill taken.
Disadvantages:
• No extra pills left over if a second episode of unprotected sex occurs.
• More pills taken if she already is pregnant.
6. If a woman vomits 10 minutes, one hour, two hours, or three hours after taking a dose of ECPs, what should be done?
Nothing needs to be done if the vomiting was caused by the ECPs (probably). Vomiting occurs in 12% to 22% of women who take ECPs. According to the Washington-based American College of Obstetricians and Gynecologists Practice Guide-lines 1996:1 "There is no evidence that vomiting within three hours of ingesting the dose is associated with an increased failure rate; however, none of the studies2,3,4,5 were designed to specifically measure this effect. There is no evidence on which to base a recommendation for repeating the dose if emesis occurs. However, it seems reasonable to infer that if gastrointestinal symptoms are estrogen mediated secondary to an effect on the central nervous system, absorption of the dose should have occurred by the time of emesis." (A copy of the practice pattern is included in a comprehensive ECP provider kit. See resource, p. 12.)
7. Are you concerned that women will "abuse" this option?
No. One wouldn’t want it to happen because other contraceptives are more effective, and the side effects and expense of ECPs are undesirable. But in real sexual relationships, it may happen because people tend to make the same mistakes repeatedly (just as we all do in other areas of our lives). What concerns me is the clinician or college health service that refuses to provide ECPs for a woman who needs it several times.
8. How can you avoid the perception that you are encouraging careless contraception by widely publicizing emergency contraception?
Deal with this issue seriously. It is a risk you take. This concern is definitely a perception hindering health care providers in reproductive health from enthusiastically endorsing emergency contraception. Stress three messages:
• Mistakes do happen.
• Emergency contraception does work.
• Ongoing contraception works better and must be emphasized when we tell women about ECPs.
9. When should failure to have a menstrual bleed be of concern?
An average of 98% of women bleed by 21 days after ECP use. If you plan to schedule a follow-up visit, it should be about 21 days after she has taken ECPs. If no bleeding occurs by 21 days, strongly consider pregnancy.
10. What should a woman be told about the risk to her fetus if her ECPs fail?
No studies have assessed the teratogenic effects associated specifically with ECPs, and there are no biochemical reasons to expect an increased risk for birth defects. Combined oral contraceptives have been studied extensively. The risk of having a baby with birth defects does not seem to increase in pill users who became pregnant,6 although one recent study found an increased risk of urinary tract defects if pills were taken during pregnancy.7
Remember that close to 20 million women use pills annually. If 5% became pregnant (typical user pregnancy rate), then one million women use pills during a pregnancy. Corollary: What is our advice for women who miss one period after taking pills perfectly? Our advice for the patient is to take another cycle of 21 low-dose pills and return to the clinic if another period is missed. Our modus operandi currently is to prescribe an additional 21 pills for a woman who could become pregnant.
References
1. American College of Obstetricians and Gynecologists. Emergency Oral Contraception. ACOG Practice Patterns. Number 3. Washington, DC: The American College of Obstetricians and Gynecologists, December 1996.
2. Bagshaw SN, Edwards D, Tucker AK. Ethinyl oestradiol and D-norgestrel is an effective emergency postcoital contraceptive: a report of its use in 1,200 patients in a family planning clinic. Aust N Z J Obstet Gynaecol 1988; 28:137-140.
3. Percival-Smith RK, Abercrombie B. Postcoital contraception with dl-norgestrel/ethinyl estradiol combination: Six years experience in a student medical clinic. Contraception 1987; 36:287-293.
4. Rowlands S, Guillebaud J, Bounds W, et al. Side effects of danazol compared with an ethinyl-oestradiol/norgestrel combination when used for postcoital contraception. Contraception 1983; 27:39-49.
5. Van Santen MR, Haspels AA. Interception II. Postcoital low-dose estrogens and norgestrel combinations in 633 women. Contraception 1985; 31:275-293.
6. Bracken MB. Oral contraception and congenital malformations in offspring: a review and meta-analysis of the prospective studies. Obstet Gynecol 1990; 76(3 Pt 2):552-557.
7. Li DK, Daling JR, Mueller BA, et al. Oral contraceptive use after conception in relation to the risk of congenital urinary tract anomalies. Teratology 1995; 51:30-36.
Colposcopy Education
The following is a non-inclusive listing of colposcopy education programs and materials:
o American Society for Colposcopy and Cervical Pathology, 18-20 W. Washington St., Hagerstown, MD 21740. Phone: (800) 787-7227. This mailing address is effective Jan. 1, 1998. No phone or fax was available at press time. For updated information on 1998 postgraduate courses, the biennial meeting and symposium, and educational materials, readers may check the group’s Web page: http://oac1. oac.tju.edu/ASCCP.
p Basic Colposcopy Education Program. Mary Rubin, RNC, PhD, CRNP, Education Program Associates, One West Campbell Ave., Campbell, CA 95008. Phone: (408) 374-3720. (Fax) 408-374-7385. E-mail: [email protected].
o Basic Colposcopy for Advanced Practice Clinicians. Women’s Health Care Nurse Practitioner Program. Cynthia Allen, University of Texas Southwestern Medical Center at Dallas, 2330 Butler, Suite 103, Dallas, TX 75235-9081. Phone: (214) 905-2131. Fax: (214) 905-4432. E-mail: calle2@mednet. swmed.edu.
o Colposcopy for Advanced Practice. Susan Ashford, MN, RNC, FNP, Emory University School of Medicine, Regional Training Center, 100 Edgewood Ave. NE, Atlanta, GA 30303. Phone: (404) 523-1996. Fax: (404) 521-0271.
o Post Graduate Advanced Practice Colposcopy Education Program. Dorothy R. McMaster, MSN, CRNP, 260 South Broad St., Suite 1000, Philadelphia, PA 19102. Phone: (215) 985-2612. Fax: (215) 546-3989. E-mail: [email protected].
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