Emergency contraception - Guest Editorial

As physicians with a special interest in women's health, we have a duty to advise our patients about their full range of contraceptive options, including emergency contraception.

Emergency contraception (EC) is safe and effective and should be a routine part of your contraceptive counseling. Timely use of these products could prevent more than 1 million abortions and as many as 2 million unintended childbirths in the United States each year.

Yet, according to a 1997 study conducted by the Henry J. Kaiser Family Foundation, only 9%-11% of the physicians surveyed made emergency contraception an integral part of their advice to patients. The same study revealed that 11% of the women asked had a basic understanding of the methods employed in EC but only 1% had actually used it. Many of the women who had heard about EC believed it was not safe and would have been reassured had their doctors discussed it with them. In fact, more than 40% of the women surveyed said they would have been more likely to use EC if it was on a doctor's recommendation, or if they had it at home when they needed it (J. Am. Med. Womens Assoc. 53[5 Suppl. 2]:242-46, 1998).

Another study has shown that only 1% of American women had ever used emergency contraception, while 2%-3% of women of childbearing

Many doctors worry that women who know about EC might be less likely to use their regular methods of contraception, especially if they are given a supply of the EC pills in advance. Yet the evidence suggests that women who are appropriately educated about EC and supplied with pills do indeed use them, but not at the expense of their usual contraceptives.

Since January 2002, pharmacists in California have been authorized, with special training, to dispense emergency contraceptive pills without a prescription. This program has been successful in some large urban areas, but elsewhere many pharmacists are not certified to participate. Many insurance plans do not cover the fees for the pharmacist counseling that is a required part of the program. Physicians should not assume that our patients can obtain emergency contraception without our help.

Two types of EC pills are available. The newer product, on the market since 1999, is 0.75 mg levonorgestrel (Plan B) taken as soon as possible after unprotected intercourse, followed by another dose 12 hours later. Another option, available since 1998, is a combination of 50 [micro]g ethinyl estradiol and 0.25 mg levonorgestrel (Preven), two pills per dose, with the first dose similarly taken as soon as possible and the second 12 hours later.

In a randomized controlled trial of 1,998 women, Plan B was associated with a pregnancy rate of 1%, compared with 3% for Preven. The rates of nausea and vomiting with Plan B were 23% and 6%, respectively, compared with 51% and 19% for Preven (Lancet 352[9126]:428-33, 1998). I now consider Plan B the method of choice.

Both products are most effective when taken within 24 hours of unprotected intercourse, but they retain some efficacy for up to 5 days, There is no evidence that either drug increases the risk of venous thromboembolism, and there is little risk of teratogenicity if a pregnancy has already been established. You should warn patients who use Preven that they might experience up to a 7-day delay in menses, and that this does not mean they're pregnant.

Mifepristone, marketed as Mifeprex, has been shown to be even more effective than Preven as an emergency contraceptive in doses as low as 10 mg, although the Food and Drug Administration hasn't approved it for this indication. Intrauterine devices inserted within 5 days of unprotected intercourse prevent more than 99% of expected pregnancies, making them the only method that can do double duty, both for emergency and long-term contraception.

Emergency contraception provides an outstanding and thus far very underutilized opportunity to empower our patients to prevent undesired pregnancies.