Post-coital administration of levonorgestrel does not interfere with post-fertilization events in the new-world monkey Cebus apella

The Levonorgestrel-Releasing Intrauterine Device as Emergency Contraception: Re-examining the Data

Emergency contraception methods that also deliver ongoing contraception provide the most effective options for individuals hoping to prevent pregnancy after unprotected intercourse. Although the copper intrauterine device (IUD) provides the most effective option for emergency contraception because the device prevents pregnancy when placed before implantation and offers long-acting contraception, uptake by patients has been limited. Recently, the Society of Family Planning issued new guidance recommending the levonorgestrel IUD (LNG-IUD) as an emergency contraception option along with the copper IUD. Here, we review evidence related to this recommendation and conclude that the available data do not support use of the LNG-IUD for emergency contraception. We discuss the mechanisms of action of emergency contraception methods and how these concepts interface with the current political and social landscape of contraception and abortion care. We describe limitations of the existing evidence supporting use of the LNG-IUD as emergency contraception and highlight the critical research needed to establish the device as a highly effective method of emergency contraception.

Continuous Use of Combined Hormonal Contraceptive and the Effect on Blood Coagulation Factors in Female Capuchin Monkeys (Sapajus libidinosus)

This study aimed at evaluating the availability of the primate Sapajus libidinosus as an animal model for research assessing the physiological effects of the continuous use of combined hormonal contraceptives. In order to do this, six reproductively active female S. libidinosus from the Primate Research Center of the University of Brasília were selected to take part in this experiment. Every 21 days or so, each female received a single dose of combined hormonal contraceptive (algestone acetophenide and 17-enanthate estradiol) in a total of five doses throughout the experiment. The physiological parameters were accessed by means of 13 blood samples from each female, whereas three were gathered during the baseline and 10 samples were collected during the treatment phase. The results showed that the contraceptive use provoked changes in hematological coagulation factors such as an increase in the amount of platelets (p = 0.039) and a reduction in both prothrombin (p < 0.001) and thromboplastin coagulation time (p < 0.001). These results are similar to what has been observed in human patients; thus, it is concluded that S. libidinosus can be successfully used in studies about the physiological impact of hormonal contraceptives.

Muftis in the Matrix

English- and Arabic-language cyberfatwas on emergency contraception (EC) illuminate current debates around sexuality in the global Muslim community. In websites with fatwas about EC, there are significant differences in the way that English- and Arabic-language fatwa websites discuss this reproductive health technology. During the study period of 2016–17, English-language sites were more likely to rule that EC was not religiously acceptable, whereas no Arabic-language online fatwas declared the technology forbidden to Muslims. In contrast, Arabic questions to online fatwa sites were more concerned about whether EC would facilitate illicit sex and the health risks of contraceptives. Only English-language sites discussed the morality of pharmacists providing EC. These websites and fatwas reveal different visions of Muslims’ relationships with technology, science, and scientific experts. They also suggest the influence of non-Islamic religious constituencies on Muslim interpretations of reproductive health technologies.

Effects of low doses of mifepristone on human embryo implantation process in a three-dimensional human endometrial in vitro co-culture system

OBJECTIVES

We wanted to explore the effects of two different low doses (0.5μM and 0.05μM) of mifepristone, exposed during the receptive period, on the human embryo implantation process, using a well-established three-dimensional in vitro cell culture model, specifically developed to study this process.

METHODS

An in vitro three-dimensional cell culture model was constructed using human endometrial cells isolated from the endometrium of proven fertile women, collected on cycle day LH+4. After 5 days of culture, supernumerary human embryos were added and cultured for another 5 days with mifepristone 0.5μM (n=8) or 0.05μM (n=10) or vehicle as control (n=10). The cultures were checked for embryo attachment and terminated. We studied the expression of 16 reported endometrial receptivity markers in the endometrial constructs using real-time polymerase chain reaction.

RESULTS

None of the embryos in 0.5μM of mifepristone attached to the endometrial constructs (p=.004), whereas 4 out of 10 in 0.05μM (p=.3698) and 7 out of 10 embryos in the control group attached to the cultures. We found that most of the studied receptivity markers were significantly altered with mifepristone exposure in a similar direction in both treatment groups. Only IL6 was significantly differentially expressed between the treatment groups (p=.017).

CONCLUSION

We report for the first time that exposure to a low concentration (0.5μM) of mifepristone during the receptive period successfully inhibits human embryo implantation process in vitro. Further, we observed a dose-dependent effect of mifepristone on endometrial receptivity at the functional level.

IMPLICATION

This study contributes new knowledge that low dose of mifepristone during the short period of receptive phase can inhibit endometrial receptivity, which further promotes mifepristone as a contraceptive agent. This could give women a treatment choice to avoid unwanted pregnancy with high efficacy and minimal side effects.

Practice Bulletin No. 152: Emergency Contraception

Emergency contraception, also known as postcoital contraception, is therapy used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. Common indications for emergency contraception include contraceptive failure (eg, condom breakage or missed doses of oral contraceptives) and failure to use any form of contraception (). Although oral emergency contraception was first described in the medical literature in the 1960s, the U.S. Food and Drug Administration (FDA) approved the first dedicated product for emergency contraception in 1998. Since then, several new products have been introduced. Methods of emergency contraception include oral administration of combined estrogen-progestin, progestin only, or selective progesterone receptor modulators and insertion of a copper intrauterine device (IUD). Many women are unaware of the existence of emergency contraception, misunderstand its use and safety, or do not use it when a need arises (). The purpose of this Practice Bulletin is to review the evidence for the efficacy and safety of available methods of emergency contraception and to increase awareness of these methods among obstetrician-gynecologists and other gynecologic providers.

Physicians' information to patients and prescription of the emergency contraceptive pill according to their personal experience of using the method and perception of its mechanism of action

OBJECTIVES

The aim of the study was to evaluate the association between physicians' understanding of the mechanism of action of the emergency contraceptive pill (ECP), their personal use of it, and their practice in informing their patients about the method and in prescribing it.

METHODS

The study was carried out in a sample of 3337 obstetrician-gynaecologists who responded to a mailed questionnaire. Bivariate analysis was used to test the association between physicians' personal use of the ECP, their understanding of its mechanism of action, and their practice in informing their patients about the method and in prescribing it. Multiple Poisson regression analysis was carried out to identify variables independently associated with the two dependent variables.

RESULTS

Multiple regression analysis showed that the percentage of physicians who had informed their patients about the ECP was significantly lower among those who had needed it themselves but had not used it and among those living in the northeast of Brazil. A significantly higher percentage of female than male physicians had provided information on the ECP. The percentage of physicians who had prescribed the ECP was significantly lower among those who had needed it themselves but had not used it and among those who believed that it caused a mini-abortion. The proportion of physicians who had ever-prescribed the ECP was greater among those who worked exclusively in private practice and among those who worked in a state capital.

CONCLUSIONS

The misconception that emergency contraception could cause a mini-abortion was associated with its denial to potential users, while physicians' personal experience of needing to use it favoured the likelihood of their informing potential users about it and prescribing it.

Emergency contraceptive pill safety profile. Comparison of the results of a follow-up study to those coming from spontaneous reporting

BACKGROUND

The emergency contraceptive pill (ECP) containing levonorgestrel is dispensed without a prescription in Spain since 2009. An easy access could diminish unwanted pregnancies; however, there is a risk of misuse and, in any case, of developing some adverse events. The aim of the present study is to further learn the adverse effects of this ECP.

METHODS

An ad hoc follow-up study was carried out in three community pharmacies in a city of Central Spain; the sample was composed of those women asking for the ECP; they were interviewed by telephone after at least a month since the last menses. We completed the safety profile obtained with that coming from spontaneous reporting in Spain.

RESULTS

Out of 139 women surveyed, 113 developed any adverse event--two considered as severe; the most frequently reported events were menstrual disturbances, which accounted for 21% of all events. Through spontaneous reporting, 36 cases of whatever adverse events related to levonorgestrel as ECP were identified. Twenty-five cases were considered as severe. Both types of reaction and severity were significantly different in the follow-up study and in the spontaneous reporting. Some of the reactions identified, such as miscarriage, febrile neutropenia, and porphyria, are not included in the Summary of Product Characteristics.

CONCLUSIONS

Levonorgestrel as an ECP is mostly safe. Attention should be paid to some severe events and particularly to those risk factors for them to appear. Combining spontaneous reporting with an ad hoc follow-up study, the whole safety profile of a given medication can be obtained.

Plan B and the German Catholic bishops

Germany's Catholic bishops recently ruled that levonorgestrel emergency contraception (EC) was acceptable for prevention of pregnancy in the case of rape. The ruling represents a significant change in Catholic doctrine that has been opposed to most forms of birth control. In their ruling the bishops cited a lack of evidence that levonorgestrel EC acts as an abortifacient. This case serves as a reminder of the need for bioethics to be based on current scientific literature as well as articles of faith and morals.

Emergency contraception

There have been numerous attempts to control fertility after unprotected sexual intercourse (UPSI). From very bizarre methods like the vaginal application of Coca Cola to the more serious attempts using calcium antagonists influencing fertility parameters in sperm to hormonal methods or intrauterine devices. So far, hormonal methods preventing or delaying ovulation have proved to be the most popular starting with the combination of ethinyl estradiol and levonorgestrel (LNG), known as the Yuzpe regimen. The first dose had to be taken within 72 hours of UPSI, a second one 12 hours later. Later on, LNG alone, at first in a regimen similar to the Yuzpe method (2 × 0.75 mg 12 hours apart) showed to be more successful, eventually resulting in the development of a 1.5 mg LNG pill that combined good efficacy with a high ease of use. Several efficacious and easy to use methods for emergency contraception (EC) are available on the market today with the most widely spread being LNG in a single dose of 1.5 mg (given as one tablet of 1.5 mg or 2 tablets of 0.75 mg each) for administration up to 3 days (according to WHO up to 5 days) after UPSI. Its limitations are the non-optimal efficacy which is decreasing the later the drug is taken and the fact that it is only approved for up to 72 hours after UPSI. This regimen has no effect on the endometrium, corpus luteum function and implantation, is not abortive and don't harm the fetus if accidentally taken in early pregnancy. It has no impact on the rate of ectopic pregnancies. It has become the standard method used up to this day in most countries. Since the mid 1970s copper IUDs have been used for EC, which show a high efficacy. Their disadvantages lie in the fact that EC is considered an off label use for most IUDs (not for the GynFix copper IUD in the European Union) and that they might not be acceptable for every patient. Furthermore IUD-insertion is an invasive procedure and it is required trained providers and sterilized facilities. Mifepristone in the dosages of 10 or 25 mg is used with good results as an emergency contraceptive in China for up to 120 hours after UPSI, but has never received any significant consideration in Western countries. While high doses of mifepristone has an effect on endometrial receptivity and will inhibit ovulation if given in the follicular phase and prevent implantation if given in the early luteal phase, low doses such as 10 mg has no impact on the endometrium. Mifepristone does not increase the rate of ectopic pregnancies. The most recent development is the approval of the selective progesterone receptor modulator ulipristal acetate (UPA) in the dosage of 30 mg for EC up to 5 days after UPSI, combining the safe and easy application of the single dose LNG pill with an even higher efficacy. It has shown to be more efficacious than LNG and can be used for up to 120 hours after UPSI; the difference in efficacy is highest for 0-24 hours, followed by 0-72 hours following UPSI. No VTE has been reported following UPA-administration or any progesterone receptor modulator. No effect on endometrium, corpus luteum function and implantation has been observed with doses used for EC. Independent of the substance it should be noted that, if there is a choice, the intake of an oral emergency contraceptive pill should happen as soon as possible after the risk situation. A pre-existing pregnancy must be excluded. Possible contraindications and drug interactions must be considered according to the individual special product informations.

Emerging options for emergency contraception

Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference.

Effect of single post-ovulatory administration of levonorgestrel on gene expression profile during the receptive period of the human endometrium

The hypothesis that levonorgestrel (LNG) used as an emergency contraceptive interferes with endometrial receptivity remains unproven. We compared the endometrial gene expression profile during the receptive period after administering a single dose of LNG 1.5 mg or placebo on day 1 of the luteal phase. An endometrial biopsy was done on day LH+7 or LH+8 and samples were taken from seven volunteers, each one contributing with one cycle treated with placebo and another with LNG. The expression of 20 383 genes was determined using cDNA microarrays. Real-time RT-PCR was used 1) to confirm the differences found in DNA microarray analysis and 2) to determine the effect of LNG on transcript levels of C3, C4BPα, COX2, MAOA, S100A4, and SERPINB9, known to be upregulated during receptivity, and on cPLA2α, JAK1, JNK1, CTSL1, and GSTP1, known to respond to mifepristone. Additional endometrial biopsies were done during the pre-receptive (LH+3) and receptive (LH+7) period and samples were taken from eight untreated volunteers in order to determine the changes associated with acquisition of receptivity of 14 genes. Mean levels of PAEP, TGM2, CLU, IGF2, and IL6ST mRNAs increased after administering LNG while those of HGD, SAT1, EVA1, LOC90133, ANXA1, SLC25A29, CYB5A, CRIP1, and SLC39A14 decreased. Except for the level of ANXA1 transcript, all changes remained within the range observed in untreated controls, and none of the transcripts responding to mifepristone changed in response to LNG. Post-ovulatory administration of LNG caused minimal changes in gene expression profiling during the receptive period. Neither the magnitude nor the nature or direction of the changes endorses the hypothesis that LNG interferes with endometrial receptivity.

How do levonorgestrel-only emergency contraceptive pills prevent pregnancy? Some considerations

Controversial opinions exist about the possible mechanisms throughout emergency contraception prevents pregnancy. Recently, the International Federation of Gynaecology and Obstetrics and the International Consortium for Emergency Contraception released a Joint Statement declaring that 'inhibition or delay of ovulation should be their primary and possibly only mechanism of action'. They still added that 'Review of the evidence suggests that LNG-ECPs cannot prevent implantation'. Concerning levonorgestrel-only emergency contraceptive pills effects on ovulation, the Statement based on seven reference papers which considered a total of only 142 patients, divided into still different subgroups. Basing on their same references we got quite different conclusions.

Emergency contraception: potential role of ulipristal acetate

Unintended pregnancy is a global reproductive health problem. Emergency contraception (EC) provides women with a safe means of preventing unwanted pregnancies after having unprotected intercourse. While 1.5 mg of levonorgestrel (LNG) as a single dose or in 2 doses with 12 hours apart is the currently gold standard EC regimen, a single dose of 30 mg ulipristal acetate (UPA) has recently been proposed for EC use up to 120 hours of unprotected intercourse with similar side effect profiles as LNG. The main mechanism of action of both LNG and UPA for EC is delaying or inhibiting ovulation. However, the 'window of effect' for LNG EC seems to be rather narrow, beginning after selection of the dominant follicular and ending when luteinizing hormone peak begins to rise, whereas UPA appears to have a direct inhibitory effect on follicular rupture which allows it to be also effective even when administered shortly before ovulation, a time period when use of LNG is no longer effective. These experimental findings are in line with results from a series of clinical trials conducted recently which demonstrate that UPA seems to have higher EC efficacy compared to LNG. This review summarizes some of the data available on UPA used after unprotected intercourse with the purpose to provide evidence that UPA, a new type of second-generation progesterone receptor modulator, represents a new evolutionary step in EC treatment.

Suppression of ovulation by a synthetic progestin in the capuchin monkey

BACKGROUND

From the limited research in New World monkeys it is not clear whether they are as sensitive to the antiovulatory effects of synthetic progestins as noted in human beings. We examined whether levonorgestrel prevented ovulation in the capuchin monkey.

METHODS

Cebus apella monkeys were treated orally with two doses of 2 mg of levonorgestrel, 8-9 hours apart, in four periovulatory stages assessed by laparoscopy.

RESULTS

Levonorgestrel-induced luteinization of the follicle prevented oocyte release up to 8 hours before ovulation. Unhealthy oocytes were recovered from 46% of unruptured follicles. Luteal progesterone was reduced by 55%, 35%, and 25% according to when levonorgestrel was given -2, -1, and 0 day from estradiol peak respectively.

CONCLUSION

The capuchin monkey, a neotropical primate in which progesterone circulates at levels much higher than in Old World primates and human beings, is sensitive to the antiovulatory effects of synthetic progestins.

Emergency contraception: a review

Emergency contraception (EC), also known as 'the morning after pill', or post-coital contraception, is a modality of preventing the establishment of a pregnancy after unprotected intercourse. Both a hormonal and an intrauterine form are available. Modern hormonal EC, with low side effects, was first proposed by Yuzpe in 1974. More recently, a new regimen, consisting of levonorgestrel administered alone, was introduced and found in clinical trials to be more effective (if taken as early as possible), and associated with less side effects than the Yuzpe regimen, which it has gradually replaced. The WHO developed another regimen based on the use of the selective progesterone receptor modulator (antiprogestin) mifepristone and conducted trials with different dosages. Intrauterine EC was first proposed by Lippes in 1976. It has the advantage of being applicable for almost a week and the disadvantage of a greater complexity. In addition, this modality is solely interceptive, acting by preventing implantation. Pregnancy rates reported following EC using an intrauterine device with more than 300 mm2 of copper are consistently low (0.1-0.2%).

Progesterone, but not luteal estrogen, is required for the establishment of pregnancy in the new world monkey Cebus apella

The aim of this study was to examine the requirement of luteal progesterone or luteal estrogen for the establishment of pregnancy in the Cebus monkey and to test in a primate species the synergism between RU 486 and letrozole (LTZ) found in rodents for inhibiting implantation. Exposure of target tissues to either hormone was suppressed during the mid-luteal phase of mating cycles by subcutaneous administration of the antiprogestin (RU 486), the aromatase inhibitor LTZ or the antiestrogen (ICI 182780) on days 4-7 of the luteal phase. Administration of 0.1 or 0.5 mg/kg of LTZ on days 5-7 of the luteal phase caused a profound drop in the levels of E(2) in all animals, whereas administration of ICI 182780 0.2 mg/kg on days 4-6 of the luteal phase had the opposite effect. The pregnancy rate in vehicle treated cycles of the same females was (58.3%). Treatment with RU 486, 0.8 mg/kg/day on days 5-7 of the luteal phase-induced endometrial bleeding in 3/5 mated females none of which became pregnant, whereas pregnancy was confirmed in one of the two animals that did not bled. Treatment with RU 486, 0.4 mg/kg/day alone or with LTZ on days 5-7 or ICI 182780 alone, on days 4-6 of the luteal phase failed to induce bleeding, allowing the establishment of pregnancy in 50.0-66.6% of the animals in these groups. We conclude that in Cebus monkeys, progesterone but not luteal estradiol is required for the establishment of pregnancy and that RU 486 and LTZ do not exhibit in this species the synergism found in rodents.

Emergency contraception knowledge after a community education campaign

BACKGROUND

This study evaluates the effectiveness of a community education campaign in the Boston community of Jamaica Plain conducted by the Massachusetts Emergency Contraception (EC) Network aimed at improving public knowledge of EC.

STUDY DESIGN

Pre- and postintervention surveys of reproductive-age women were conducted to evaluate the effectiveness of the community education campaign. Knowledge of EC was compared before and after the intervention using surveys of community-based samples of women.

RESULTS

One hundred eighty-eight and 290 women participated in the preintervention and postintervention surveys, respectively. Following the intervention, women were significantly more likely to have heard of EC (91% vs. 82%, p=.007), know the mechanism of action of EC (49% vs. 39%, p=.04), have discussed EC with a health care provider (38% vs. 25%, p=.003) and have received an advance prescription for EC (22% vs. 12%, p=.004), as well as were more likely to use EC in the future if needed (79% vs. 63%, p=.0002).

CONCLUSION

This grassroots-based community education campaign on EC was effective in improving EC knowledge in this Boston community.

Emergency contraception under attack in Latin America: response of the medical establishment and civil society

The concept that it is possible to prevent a pregnancy after coitus is not new, but has gained prominence over the last 10-15 years. It provides a second chance to women who do not want to get pregnant and who, voluntarily or not, have had unprotected intercourse. Emergency contraception has been under strong attack by the Catholic church and anti-choice organisations in Latin America, who claim that the interference with implantation of the fertilised ovum is equivalent to an early abortion. The accumulation of evidence, however, is that the mechanism of action of emergency contraception is to prevent ovulation and that it does not interfere with implantation. This has been ignored by the anti-choice movement. The pattern of opposition to emergency contraception has been the same all over the Latin America region. The medical establishment and civil society, including the International Consortium for Emergency Contraception, have played a key role in defending access to emergency contraception throughout the region. A positive consequence of the public opposition of the Catholic church is that the concept and the method have become better known, and emergency contraception has become widely used. The cases of Peru, Brazil and Chile are described as examples.

Factors associated with safe sex among public school students in Minas Gerais, Brazil

A cross-sectional study was conducted to evaluate factors associated with safe sex among sexually active public school students in Minas Gerais State, Brazil. The study focused on correlations between the variables gender, age, schooling, current grade, ethnicity, religion, importance attributed to religion, mothers' education, prior exposure to any sex education, promotion of juvenile protagonism, and participation by health professionals in school activities and consistent condom use with casual or stable partners and with use of other modern contraceptive methods. Bivariate and multivariate logistic regression analyses were used. Male gender and participation by health professionals in school activities were positively associated with all indicators of safe sex, and maternal schooling of more than eight years was positively associated with consistent condom use with casual and stable partners. Secondary (versus elementary) schooling and age (older) were inversely associated with consistent condom use with casual and stable partners, respectively. Ascribing greater importance to religion and Evangelical religion were negatively associated with use of modern contraceptives in the last sexual intercourse.

Expanding access to emergency contraception

Emergency contraception (EC) is safe and has the potential to prevent unwanted pregnancies. However, use remains low in most settings, due to a range of barriers to access. This paper reviews key issues related to EC and describes recommendations reached during the Women's Health Alliance pre-Congress workshop, held in advance of the FIGO 2006 World Congress. The working group concluded that national societies of obstetrics and gynecology can play an important role in increasing access to this unique contraceptive method.

Levonorgestrel-Only Dosing Strategies for Emergency Contraception

The United States Food and Drug Administration-approved progestin-only dosing strategy for emergency contraception is levonorgestrel 0.75 mg taken as soon as possible within 72 hours of unprotected intercourse, with a second 0.75-mg dose taken 12 hours later. However, different dosing strategies have been studied and promoted by various organizations. The American College of Obstetricians and Gynecologists recommends a single dose of levonorgestrel 1.5 mg for emergency contraception as one option. As another option, they recommend two doses of levonorgestrel 0.75 mg may be effective when taken 12-24 hours apart. We performed a search of MEDLINE and International Pharmaceutical Abstracts from 1967-2006 to evaluate and describe the existing pharmacokinetic and patient outcome data regarding administration of levonorgestrel as a 1.5-mg single dose or two 0.75-mg doses taken 12 or 24 hours apart. Additional studies were identified from the bibliographies of the selected literature. Several pertinent articles were identified. All of the studies demonstrated that emergency contraception effectively prevented pregnancy. In addition, evidence supports the safety and efficacy of a single dose of levonorgestrel 1.5 mg for emergency contraception. Furthermore, when two doses of levonorgestrel 0.75 mg are administered, the second dose can confidently be taken 12-24 hours after the first without compromising efficacy. Understanding the evidence that supports the different emergency contraception dosing strategies is critical for clinicians, and especially pharmacists, who have interactive roles in dispensing emergency contraception.

Effectiveness of levonorgestrel emergency contraception given before or after ovulation--a pilot study

BACKGROUND

Although widely used, the mechanisms of action of the levonorgestrel emergency contraceptive pill (LNG ECP) are still unclear. There are increasing data to indicate that LNG is particularly effective as an ECP by interrupting follicular development and ovulation. An important outstanding question is whether it has any effect on fertilization or implantation.

METHOD

Ninety-nine women participated; they were recruited at the time they presented with a request for emergency contraception. All women took LNG 1.5 mg in a single dose during the clinic consultation. A blood sample was taken immediately prior to ingestion of the ECP for estimation of serum LH, estradiol and progesterone levels to calculate the day of ovulation. The specimens were analyzed in a single batch. Based on these endocrine data, we estimated the timing of ovulation to be within a +/-24-h period with an accuracy of around 80%. Women were followed up 4-6 weeks later to ascertain pregnancy status. The effectiveness of ECP when taken before and after ovulation was determined.

RESULTS

Three women became pregnant despite taking the ECP (pregnancy rate, 3.0%). All three women who became pregnant had unprotected intercourse between Days -1 and 0 and took the ECP on Day +2, based on endocrine data. Day 0 was taken as ovulation day. Among 17 women who had intercourse in the fertile period of the cycle and took the ECP after ovulation occurred (on Days +1 to +2), we could have expected three or four pregnancies; three were observed. Among 34 women who had intercourse on Days -5 to -2 of the fertile period and took ECP before or on the day of ovulation, four pregnancies could have been expected, but none were observed. We found major discrepancies between women's self-report of stage of the cycle and the dating calculation based on endocrine data.

CONCLUSION

These data are supportive of the concept that the LNG ECP has little or no effect on postovulation events but is highly effective when taken before ovulation.

Knowledge, Attitudes, and Use of Emergency Contraception Among Rural Western North Carolina Women

BACKGROUND

To determine the knowledge, attitudes and self-reported usage of emergency contraception (EC) in rural western North Carolina women.

METHODS

Using a cross-sectional survey, with a convenience sample, participants self-administered the survey in waiting rooms of eight medical clinics in three counties in western North Carolina. Participants included 401 English-speaking women of childbearing age (18-44 years old) presenting for routine medical care during a three-month period in 2004.

RESULTS

Of the 70.5% who responded, almost all (97%) were sexually active and most (92%) perceived an unintended pregnancy to be a problem. A majority of the participants (72%) were aware of EC, but only 7.5% of women reported usage in the last year. More than 80% of the surveyed women were uncertain if EC was the same as the abortion pill, RU-486. While only 16% of respondents indicated they had discussed EC with a doctor or another health professional, most women (89%) reported that doctors or other health professionals would be their first choice for accurate information about EC pills.

CONCLUSIONS

Among western North Carolina women of childbearing age, EC is rarely used, perhaps because of confusion about its mechanism of action. Furthermore, EC is infrequently discussed with doctors. Since women indicate that health care providers would be their preferred choice for accurate information about EC, improved patient education by physicians about EC would be a first step in increasing knowledge among patients.

Emergency contraception - a human rights issue

Emergency contraception is the only resource that women can use to avoid becoming pregnant after having sexual intercourse without contraceptive protection. It could be a powerful means to prevent unwanted pregnancies and their devastating consequences for women's health, social wellbeing and life project, and for the unwanted child, if all people had ample access to good quality information, education and services for sexual and reproductive health. In spite of the preventive medicine value of emergency contraception, conservative sectors oppose its availability, appealing to moral values that are not universally shared in pluralistic societies. Excluding the only contraceptive that can be used after intercourse because some consider the mechanism of action to be unacceptable would mean restricting the right of choice of others, and imposing one particular belief or set of values on all members of the community, thus violating the freedom of conscience. Authorities have a moral obligation to protect human rights.

Cost savings from use of emergency contraceptive pills in Australia

BACKGROUND

Emergency contraception, which prevents pregnancy after unprotected sexual intercourse, has the potential to reduce significantly the incidence of unintended pregnancy and the consequent need for abortion and to reduce medical care costs.

AIM

To determine the savings generated by use of Postinor-2, the levonorgestrel regimen of emergency hormonal contraception, in Australia.

METHODS

We modelled the cost savings when women obtain Postinor-2 directly from a pharmacist where cost savings are measured as the cost of pregnancies averted by use of Postinor-2 per dollar spent on Postinor-2.

RESULTS

Each dollar spent on a single treatment with Postinor-2 saves A$2.27-A$3.81 in direct medical care expenditures on unintended pregnancy depending on assumptions about savings from costs avoided by preventing mistimed births. Postinor-2 is cost-saving even under the least favourable assumption that mistimed births when prevented today occur 2 years later. Results are robust even to large changes in model input parameters.

CONCLUSION

Emergency contraception is cost saving. More extensive use of emergency contraception could save considerable medical and social costs by reducing unintended pregnancies, which are expensive.

Selective progesterone receptor modulators and progesterone antagonists: mechanisms of action and clinical applications

Since the discovery of the antiprogestin mifepristone, hundreds of similar compounds have been synthesized, which can be grouped in a large family of progesterone receptor ligands. This family includes pure agonists such as progesterone itself or progestins and, at the other end of the biological spectrum, pure progesterone receptor antagonists (PA). Selective progesterone receptor modulators (SPRM) have mixed agonist-antagonist properties, and occupy an intermediate position of the spectrum. These compounds have numerous applications in female health care. Mifepristone is used to terminate pregnancy, and as such is commercially available in many countries. The negative abortion-related image of mifepristone has clearly limited the involvement of the major pharmaceutical companies in the development of PA and SPRM. Many PA and SPRM display direct antiproliferative effects in the endometrium, although with variable actions which seem product- and dose-dependent. This property justifies their use in the treatment of myomas and endometriosis. PA also suppress late follicular development, block the LH surge and retard endometrial maturation, which renders them potential estrogen-free contraceptive drugs. SPRM such as asoprisnil are not as effective in blocking the LH surge and appear to target the endometrium directly and produce amenorrhoea. Interestingly, clinical data show that treatment with these compounds is not associated with hypo-estrogenism and bone loss. The potential clinical applications of these compounds cover a broad field and are very promising in major public health areas. These include emergency contraception, long-term estrogen-free contraception (administered alone, or in association with a progestin-only pill to improve bleeding patterns), myomas (where they induce a marked reduction in tumour volume and produce amenorrhoea) and endometriosis. Further developments might also include hormone replacement therapy in post-menopausal women, as well as the treatment of hormone-dependent tumours.

Pituitary–ovarian function following the standard levonorgestrel emergency contraceptive dose or a single 0.75-mg dose given on the days preceding ovulation

We assessed to what extent the standard dose of levonorgestrel (LNG), used for emergency contraception, or a single dose (half dose), given in the follicular phase, affects the ovulatory process during the ensuing 5-day period. Fifty-eight women were divided into three groups according to timing of treatment. Each woman contributed with three treatment cycles separated by resting cycles. All received placebo in one cycle, and standard or single dose in two other cycles, in a randomized order. The diameter of the dominant follicle determined the time of treatment. Each woman had the same diameter assigned for all her treatments. Diameters were grouped into 33 categories: 12-14, 15-17 or 18-20 mm. Follicular rupture failed to occur during the 5-day period in 44%, 50% and 36% of cycles with the standard, half dose and placebo, respectively. Ovulatory dysfunction, characterized by follicular rupture associated with absent, blunted or mistimed gonadotropin surge, occurred in 35%, 36% and 5% of standard, single dose or placebo cycles, respectively. In conclusion, LNG can disrupt the ovulatory process in 93% of cycles treated when the diameter of the dominant follicle is between 12 and 17 mm. It is highly probable that this mode of action fully accounts for the contraceptive efficacy as well as the failure rate of this method. The present data suggest that half the dose may be as effective as the standard dose.