Effect of post-coital contraceptive methods on the endometrium and the menstrual cycle

Pharmacist Critique Was Ill-Informed

Pharmacists’ ability to exercise “professional right of conscience” in dispensing emergency contraception, as well as the professionalism of pharmacists, has fallen under attack recently by the media, by state governments, and even by other healthcare professionals in published commentaries. This editorial discusses the controversy surrounding emergency contraceptives, the right of pharmacists to refuse to fill prescriptions that they consider morally objectionable, and the responsibility of pharmacists to provide medications in a timely and professional manner. The professionalism of pharmacy is also examined in light of the expanded scope of practice in which pharmacists increasingly find themselves practicing.

Association between knowledge about levonorgestrel emergency contraception and the risk of ectopic pregnancy following levonorgestrel emergency contraception failure: a comparative survey

Objective

To study the association between knowledge about levonorgestrel emergency contraception (LNG‐EC) and the risk of ectopic pregnancy (EP) following LNG‐EC failure.

Methods

This study included 600 women who had visited the hospital with LNG‐EC failure. Of these, 300 with EP and 300 with intrauterine pregnancy (IUP) were recruited to the EP group and IUP group respectively. The participants were interviewed face‐to‐face using a standardized questionnaire.

Main Outcome Measures

Pearson's chi‐square tests and t‐test were used to compare the sociodemographic characteristics, reproductive and gynecological history, surgical history, previous contraceptive experience, and answers to 10 questions concerning the knowledge about LNG‐EC.

Results

Those who gave incorrect answers to the question regarding the basic mechanism and specific method of levonorgestrel emergency contraceptive pills (LNG‐ECPs) were at a higher risk of EP after LNG‐EC failure. Women who did not strictly follow instructions or advice from healthcare professionals were more likely to subsequently experience EP (p < 10⁻⁴). Women with LNG‐EC failure reported friends/peers, TV, and Internet as the main sources of information. No difference was observed with regard to the sources of knowledge on LNG‐EC (p = 0.07).

Conclusions

The results illustrate the importance of strictly following the doctor's guidance or drug instructions when using LNG‐ECPs. The media should be used to disseminate information about responsible EC, and pharmacy staff should receive regular educational training sessions in this regard. © 2016 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.

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.

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.

Opinions of West Texas pharmacists about emergency contraception

BACKGROUND

The pharmacist's role in dispensing emergency contraception (EC) has become controversial due to the intersection of personal and professional ethics. Therefore, to examine the issue of EC availability, we surveyed a sample of West Texas pharmacists. West Texas is a religiously and politically conservative region where no methods of EC have been made available.

OBJECTIVE

to survey a sample of pharmacists in West Texas about their experience, beliefs, and knowledge of EC both before and after a presentation of the current literature about EC.

METHODS

We asked a convenience sample of 75 pharmacists about their experience, beliefs, and knowledge of EC both before and after a presentation of the current literature about EC.

RESULTS

Sixty-four (85%) pharmacists agreed to complete the study questionnaire. None carries EC in his/her pharmacy, and scientific understanding of EC was generally poor. Fourteen percent stated EC conflicts with their religious views, 17% considered it a method of abortion, 11% would not be willing to fill an EC prescription written by a doctor. 58% would be willing to offer EC over the counter. The presentation encouraged more to offer it over the counter, but in general did not significantly change their beliefs.

CONCLUSION

Our sample of West Texas pharmacists demonstrated very little experience with, a general lack of knowledge about, and some personal and religious objections to EC.

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.

Emergency contraception

Despite significant declines over the past 2 decades, the United States continues to have teen birth rates that are significantly higher than other industrialized nations. Use of emergency contraception can reduce the risk of pregnancy if used up to 120 hours after unprotected intercourse or contraceptive failure and is most effective if used in the first 24 hours. Indications for the use of emergency contraception include sexual assault, unprotected intercourse, condom breakage or slippage, and missed or late doses of hormonal contraceptives, including the oral contraceptive pill, contraceptive patch, contraceptive ring (ie, improper placement or loss/expulsion), and injectable contraception. Adolescents younger than 17 years must obtain a prescription from a physician to access emergency contraception in most states. In all states, both males and females 17 years or older can obtain emergency contraception without a prescription. Adolescents are more likely to use emergency contraception if it has been prescribed in advance of need. The aim of this updated policy statement is to (1) educate pediatricians and other physicians on available emergency contraceptive methods; (2) provide current data on safety, efficacy, and use of emergency contraception in teenagers; and (3) encourage routine counseling and advance emergency-contraception prescription as 1 part of a public health strategy to reduce teen pregnancy. This policy focuses on pharmacologic methods of emergency contraception used within 120 hours of unprotected or underprotected coitus for the prevention of unintended pregnancy. Emergency contraceptive medications include products labeled and dedicated for use as emergency contraception by the US Food and Drug Administration (levonorgestrel and ulipristal) and the "off-label" use of combination oral contraceptives.

Emergency contraception - knowledge and attitudes in a group of Australian university students

OBJECTIVE

To explore first year Australian university students' knowledge and attitudes about emergency contraception and their understanding of the risk for pregnancy.

METHOD

A self-report questionnaire was completed by a convenience sample of 627 first year on-campus students from both health and non-health disciplines.

RESULTS

Knowledge about emergency contraception (EC) was generally poor including misunderstanding that it can only be used the 'morning after', as well as where it may be accessed. Its potential use was, however, more highly accepted as a preventative measure after unprotected sexual intercourse than abortion in the event of unplanned pregnancy. Women had better knowledge than men, and on a number of measures there were significant differences between these groups.

CONCLUSIONS

Poor knowledge about the timing, accessibility, action and side effects of EC may act as a barrier to its use in the event of unprotected sexual intercourse. Although EC has been available in Australia as a Schedule 3 medication since 2004, its availability from pharmacies is not well known, nor is access from other primary health care providers.

IMPLICATIONS

The lack of knowledge about EC may lead to its underutilisation and underlines the need for future educational strategies about EC as well as the need for health professionals who provide contraceptive services to discuss EC with clients. Health promotion campaigns which are both general as well as gender-specific may improve overall community knowledge about this method of contraception.

Reasons for requesting emergency contraception: A survey of 506 Italian women

OBJECTIVE

To evaluate the reason for requesting emergency contraception (EC), previous use of contraceptive methods and provision route in a Family Planning Clinic in Italy.

METHODS

Women requesting EC were interviewed, through a questionnaire containing questions on demographic characteristics, about their reasons for requesting EC, their prior contraceptive use, their reasons for not using an effective contraceptive method (or possible reasons for its failure) and specifically about the so-called 'provision route' (i.e. whether and where they had previously requested EC receiving a negative response).

RESULTS

Almost 70% of all women requesting EC were aged between 18 and 25 years. Some 80% of all women were in a stable relationship with their partner, with fewer than 20% having had an occasional intercourse. The vast majority of women (83%) reported prior use of a modern contraceptive method, i.e. 64% with a condom, 27% for combined oral contraceptives and 1.1% for the intrauterine device (IUD). In addition, 15% of the women had used more than one method (oral pills and condoms). Concerning the reasons for requesting EC, condom breakage or slipping was the most frequently cited (64%), followed by totally unprotected intercourse (28%), failed withdrawal (5%) and forgetting one or more pill (only 1.1%).

CONCLUSIONS

More than one-third of the women interviewed had previously used an emergency contraceptive modality; although no one did so more than four times. Therefore, it can be inferred that-at least in the present series-EC had not been used as a routine contraceptive method. Finally, it seems clear that in Italy, even in large cities, information about the availability, proper usage and mechanism of action is lacking. This seems due to information being spread by word of mouth between peers and friends, with more formal communication channels lagging behind.

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%).

Attitudes and beliefs about emergency contraception among patients at academic family medicine clinics

PURPOSE

The possible mechanisms of action of emergency contraception (EC) include preventing ovulation, fertilization, or implantation of an embryo. Differences in the use of terminology between medical personnel and the general public could be misleading to patients who would use EC. This cross-sectional survey evaluated women's beliefs regarding pregnancy and EC's possible mechanisms of actions.

METHODS

An anonymous questionnaire was developed and pilot tested for an appropriate reading level and ease of analysis. It collected information on demographics and beliefs about pregnancy and EC. During an 8-week period, the questionnaire was given to a convenience sample of female patients aged 18 to 50 years visiting 2 academic family medicine clinics in the southeastern United States. Descriptive statistics and logistic regression models were used for analysis.

RESULTS

A total of 178 women completed questionnaires. Nearly one-half (47%) of respondents believed that pregnancy begins with fertilization; however, less than one-third (30%) believed that life begins with fertilization. Thirty-eight percent of respondents stated that they would use EC only if they believed it worked before fertilization or implantation. Generally similar proportions thought that EC works before fertilization (24%) and before implantation (36%), or were unsure about when it works (34%). Younger age was associated with higher odds of believing that EC works before fertilization; none of the other demographic factors studied conferred either higher or lower odds.

CONCLUSIONS

Many women are uninformed about the possible mechanisms of action of EC, and we found no reliable predictors for those who were better informed. This study raises questions regarding women's understanding of EC and demonstrates the need to better educate them about its possible mechanisms of action.

In vivo assessment of the human sperm acrosome reaction and the expression of glycodelin-A in human endometrium after levonorgestrel-emergency contraceptive pill administration

BACKGROUND

The objectives were firstly to assess acrosome reaction (AR) status of spermatozoa following uterine flushing, secondly to measure levonorgestrel (LNG) levels in serum and in uterine flushing fluid and finally to measure endometrial glycodelin-A expression after administration of LNG as a form of emergency contraception (EC).

METHODS

Forty-eight experiments were conducted on 15 regularly menstruating women. Four groups were formed based on different intercourse to treatment interval and treatment to recovery of spermatozoa and the biopsies.

RESULTS

Twenty-four and forty-eight hours after treatment, there were 14.5 +/- 3.9 x 10(6) and 17.3 +/- 6.8 x 10(6) sperm recovered from the uterus, respectively. There were no differences between the AR rate and the endometrial glycodelin-A staining intensity in an LNG or placebo treated cycles. The LNG in uterine flushing medium represented 1.38% of the values observed in serum 24 h after the LNG intake.

CONCLUSIONS

Twenty-four and forty-eight hours after administration of EC, neither the proportion of AR sperm, nor the glycodelin-A level was influenced by 1.5 mg of LNG. LNG did not impair the cervical mucus either because viable spermatozoa were found in the genital tract 36-60 h after coitus and 24-48 h after LNG intake. The mechanism of action of LNG as EC remains unknown.

Contraception today

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution-the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and-thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control. At the turn of the millennium, all over the world, more than 600 million married women are using contraception, with nearly 500 million in developing countries. Among married women, contraceptive use rose in all but two developing countries surveyed more than once since 1990. Among unmarried, sexually active women, it grew in 21 of 25 countries recently surveyed. Hormonal contraception, the best known method, first made available as a daily pill, can today be administered through seven different routes: intramuscularly, intranasally, intrauterus, intravaginally, orally, subcutaneously, and transdermally. In the field of oral contraception, new strategies include further dose reduction, the synthesis of new active molecules, and new administration schedules. A new minipill (progestin-only preparation) containing desogestrel has been recently marketed in a number of countries and is capable of consistently inhibiting ovulation in most women. New contraceptive rings to be inserted in the vagina offer a novel approach by providing a sustained release of steroids and low failure rates. The transdermal route for delivering contraceptive steroids is now established via a contraceptive patch, a spray, or a gel. The intramuscular route has also seen new products with the marketing of improved monthly injectable preparations containing an estrogen and a progestin. After the first device capable of delivering progesterone directly into the uterus was withdrawn, a new system releasing locally 20 microg evonorgestrel is today marketed in a majority of countries with excellent contraceptive and therapeutic performance. Finally, several subcutaneously implanted systems have been developed: contraceptive "rods," where the polymeric matrix is mixed with the steroid and "capsules" made of a hollow polymer tube filled with free steroid crystals. New advances have also been made in nonhormonal intrauterine contraception with the development of "frameless" devices. The HIV/AIDS pandemic forced policy makers to look for ways to protect young people from sexually transmitted diseases as well as from untimely pregnancies. This led to the development of the so-called dual protection method, involving the use of a physical barrier (condom) as well as that of a second, highly effective contraceptive method. More complex is the situation with antifertility vaccines, still at a preliminary stage of development and unlikely to be in widespread use for years to come. Last, but not least, work is in progress to provide effective emergency contraception after an unprotected intercourse. Very promising in this area is the use of selective progesterone receptor modulators (antiprogestins).

Effects of oral contraceptives administered at defined stages of ovarian follicular development

OBJECTIVE

To elucidate the effects of initiating oral contraceptives (OC) at defined stages of ovarian follicle development.

DESIGN

Prospective longitudinal study.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Forty-five healthy women between the ages of 18 and 35 years, randomized to initiate OC when a follicle diameter of 10, 14, or 18 mm was first detected.

INTERVENTION(S)

The OC administration at defined stages of dominant follicle development.

MAIN OUTCOME MEASURE(S)

Fates of all dominant follicles and serum concentrations of E(2)-17beta, LH, and P before and after initiating OC.

RESULT(S)

No ovulations (0/16) were observed when OC use was initiated at a follicle diameter of 10 mm, 4/14 (29%) follicles ovulated when OC were initiated at 14 mm, and 14/15 (93%) ovulated when OC were initiated at 18 mm. When ovulation did not occur, follicles regressed or became anovulatory cysts. Peak LH and E(2) levels were lowest in the 10-mm group, moderate in the 14-mm group, and greatest in the 18-mm group. Peak endocrine levels in all treatment groups were lower than the historic reference group.

CONCLUSION(S)

Follicular development, ovulation, and endocrine concentrations were not suppressed effectively when OC were initiated at late stages of dominant follicle development.

Emergency contraception

Teen birth rates in the United States have declined during the last decade but remain much higher than rates in other developed countries. Reduction of unintended pregnancy during adolescence and the associated negative consequences of early pregnancy and early childbearing remain public health concerns. Emergency contraception has the potential to significantly reduce teen-pregnancy rates. This policy statement provides pediatricians with a review of emergency contraception, including a definition of emergency contraception, formulations and potential adverse effects, efficacy and mechanisms of action, typical use, and safety issues, including contraindications. This review includes teens' and young adults' reported knowledge and attitudes about hormonal emergency contraception and issues of access and availability. The American Academy of Pediatrics, as well as other professional organizations, supports over-the-counter availability of emergency contraception. In previous publications, the American Academy of Pediatrics has addressed the issues of adolescent pregnancy and other methods of contraception.

Late follicular phase administration of levonorgestrel as an emergency contraceptive changes the secretory pattern of glycodelin in serum and endometrium during the luteal phase of the menstrual cycle

This study examined serum glycodelin concentrations and endometrial expression during the luteal phase following oral administration of levonorgestrel (LNG) at different stages of the ovarian cycle. Thirty women were recruited and allocated into three groups. All groups were studied during two consecutive cycles, a control cycle and the treatment cycle. In the treatment cycle, each woman received two doses of 0.75 mg LNG taken 12 h apart on days 3-4 before the luteinizing hormone (LH) surge (Group 1), at the time of LH rise (Group 2) and 48 h after the rise in LH was detected (Group 3). Serum progesterone (P) and glycodelin were measured daily during the luteal phase, and an endometrial biopsy was taken at day LH +9 for immunohistochemical glycodelin-A staining. In Group 1, serum P levels were significantly lower, serum glycodelin levels rose earlier and endometrial glycodelin-A expression was weaker than in Groups 2 and 3, in which no differences were found between control and treatment cycles. Levonorgestrel taken for emergency contraception (EC) prior to the LH surge alters the luteal phase secretory pattern of glycodelin in serum and endometrium. Based on the potent gamete adhesion inhibitory activity of glycodelin-A, the results may account for the action of LNG in EC in those women who take LNG before the LH surge.

Changes in young women's awareness, attitudes, and perceived barriers to using emergency contraception

BACKGROUND

In a 1996 survey, most young women ages 13-20 years from an urban, hospital-based clinic and a drug treatment center had inadequate awareness of emergency contraception (EC), and perceived several barriers to its use. Since that time, the FDA has approved two products for EC, media coverage has increased, and physicians have provided more counseling about EC.

PURPOSE

The purpose of this study is to compare the awareness, attitudes, and perceived barriers to using EC among a sample of young women from 1996 with a different sample of women from 2002.

METHODS

We recruited 139 young women (mean age 16.7 +/- 1.8 yrs) from the same adolescent clinic and drug treatment center as the 1996 sample. They had similar demographic characteristics, with the majority (63%) being African-American or multi-ethnic; 85% had ever been sexually active. They were interviewed using a questionnaire about their sexual and contraceptive history as well as their knowledge of and experience with EC. They then watched a 4(1/2) minute video and received a 5-minute didactic review of EC. Following the educational intervention, participants' knowledge, attitudes, and perceived barriers to using EC were assessed. The questionnaire used to guide the interviews was nearly identical to that used in 1996.

RESULTS

Between 1996 and 2002, the percentage of participants reporting that they had ever heard of EC grew (44% vs. 73%, P < 0.001), as well as the percentage reporting that they had ever used EC (4% vs. 13%, P = 0.02). Of those participants who had ever heard of EC, fewer 1996 participants knew where to obtain it compared to 2002 participants (78% vs. 95%, P = 0.002) and fewer 1996 participants knew the correct time limits for use (20% vs. 51%, P < 0.001). The above data were collected prior to a didactic review session about EC. After receiving information about EC, the percentage of participants reporting a positive attitude toward EC grew between 1996 and 2002 (72% vs. 96%, P < 0.001). Young women also had fewer concerns about safety and side effects in 2002. The 1996 participants were more likely to report barriers to using EC compared to the 2002 participants. In 1996, EC side effects and impact on fertility were the most commonly perceived barriers to EC use. However, in 2002 the frequency of all reported barriers decreased and cost had become the number one perceived barrier.

CONCLUSION

Since 1996, young women at an urban hospital-based adolescent clinic and drug treatment center increased their awareness, use, and positive attitudes towards EC, as well as decreased their perceived barriers to using EC. Educational interventions that focus on improving knowledge among younger adolescents, specifically about correct time limits and identifying ways to find affordable EC, will address the most common knowledge deficits and perceived barriers to EC use among adolescents.

The role of emergency contraception

Emergency contraception is an underused therapeutic option for women in the event of unprotected sexual intercourse. Available postcoital contraceptives include emergency contraceptive pills (ECPs) both with and without estrogen, and copper-bearing intrauterine devices. Each method has its individual efficacy, safety, and side effect profile. Most patients will experience prevention of pregnancy, providing they follow the treatment regimen carefully. There are concerns that women who use ECPs may become lax with their regular birth control methods; however, reported evidence indicates that making ECPs more readily available would ultimately reduce the incidence of unintended pregnancies. In addition, it is typically conscientious contraceptive users who are most likely to seek emergency treatment. Patient education is paramount in the reduction of unintended pregnancies and there are numerous medical resources available to women to assist them in this endeavor. Finally, ECPs are associated with financial and psychologic advantages that benefit both the individual patient and society at large.

Emergency contraception and morality: reflections of health care workers and clients

In this study, we explore the retrospective reports of 21 US Planned Parenthood clients about their use of emergency contraception pills (ECPs) and the views of ten Planned Parenthood health care workers at two clinics about providing ECPs. We elucidate the sociological phenomena that frame emergency contraception usage: cultural ideology about contraception, sexuality, unintended pregnancy, and abortion. We focus on the ways in which interactions between health care workers and clients both mediate and reinforce such cultural ideology. Our research indicates that the distinctions between fertilization and pregnancy, between contraception and abortion, between responsible and irresponsible procreative behavior, are not hard and fast boundaries upon which everyone agrees. We illuminate the dividing lines and continuities our participants invoked, affirmed, and questioned when contemplating the continuum from potential fertility to realized (and unwanted) pregnancy.

Emergency contraception--clinical and ethical aspects

Emergency contraception (EC) consists of either 1.5 mg of levonorgestrel (LNG) in one or two doses, or a combination of LNG with ethinylestradiol, administered for up to 5 days after unprotected intercourse. Clinical studies indicate that LNG alone is more effective and has less side effects. Its effectiveness decreases the longer after coitus it is taken. EC is indicated when there is non-compliance or accidents with the use of regular methods of contraception, or when women have had voluntary or imposed unprotected intercourse. The ethics of providing EC has been questioned by some, arguing that it acts by preventing implantation. Scientific evidence does not support this concept, but shows that EC acts mostly before fertilization. Placing obstacles to the access of EC is unethical as it transgresses the ethical principles of autonomy, non-maleficence beneficence and justice. Far from inducing abortions, EC reduces unwanted pregnancies and prevents abortion.

Emergency contraception: models to increase accessibility

Much of the recent focus on emergency contraception (EC) has been on the need to increase the availability of EC without a prescription. Barriers to the wider accessibility of EC include the need to use the medication within a 72-hour window, cost, and knowledge about its availability. Concerns about the non-prescription accessibility of EC include missing the opportunity to see a physician, possible reduced use of barrier contraceptives and the resulting increase in sexually transmitted infections, and overuse of EC and underuse of regular contraception. As the wider availability of EC is a reality, and pressure to further increase its access is growing, it is timely that issues surrounding accessibility of EC be discussed. This paper explores the issues around making EC more accessible and the various models of obtaining EC, namely, prescription medication, pharmacist-physician collaboration, pharmacist-dispensed medication, schedule II (behind the counter) medication, or on-the-shelf medication. The ideal model will be the one that provides improved accessibility for adolescents, other low-income women, and indeed for all women. Increased accessibility of EC should also lead to cost savings for the health-care system because of fewer unwanted pregnancies.

Effectiveness of the Yuzpe regimen of emergency contraception by cycle day of intercourse: implications for mechanism of action

OBJECTIVE

The purpose of this study was to provide evidence about the mechanism of action of the Yuzpe method of emergency contraception by examining effectiveness by cycle day of intercourse relative to ovulation.

METHODS

Through a literature search, we identified eight studies that present the number of women treated and outcome of treatment by cycle day of unprotected intercourse relative to expected day of ovulation. Using five sets of external estimates of conception probabilities by cycle day of intercourse among women not using contraception, we assessed and compared the effectiveness of the Yuzpe regimen by whether intercourse occurred on or before the second day before ovulation or afterward, and whether intercourse occurred on or before the first day before ovulation or afterward.

RESULTS

In 36 of the 45 pairs of estimates of effectiveness, based on eight separate studies and the eight studies combined and five different sets of conception probabilities by cycle day, effectiveness was higher-and in most cases substantially higher-when intercourse occurred on or before the second day before ovulation (day -2) than when it occurred later. When data were stratified by whether intercourse occurred on or before the day before ovulation (day -1), effectiveness was greater when intercourse occurred early in 43 of 45 pairs.

CONCLUSIONS

These results suggest that one hypothesized mechanism of action of the Yuzpe method, inhibiting implantation of a fertilized egg, is unlikely to be the primary mechanism of action.

Emergency contraception

The last decade has seen a huge interest in emergency contraception (EC) because of the potential it has to reduce abortion rates. A variety of hormonal methods is available although mifepristone-arguably the best method-is only licensed in China. The intrauterine device is highly effective but its use is limited because of the technical skill required for successful insertion. The mechanism of action of both the Yuzpe regimen of EC and of levonorgestrel is poorly understood and for all methods there are serious methodological difficulties involved with calculating efficacy. Nevertheless the risks and side-effects of EC are negligible and the practicalities of prescribing it are extremely simple. Research and programmatic efforts should concentrate on improving availability if EC is to fulfil its promise as a public health intervention to reduce unwanted pregnancy.

Postfertilization effect of hormonal emergency contraception

OBJECTIVE

To assess the possibility of a postfertilization effect in regard to the most common types of hormonal emergency contraception (EC) used in the US and to explore the ethical impact of this possibility.

DATA SOURCES AND STUDY SELECTION

A MEDLINE search (1966-November 2001) was done to identify all pertinent English-language journal articles. A review of reference sections of the major review articles was performed to identify additional articles. Search terms included emergency contraception, postcoital contraception, postfertilization effect, Yuzpe regimen, levonorgestrel, mechanism of action, Plan B.

DATA SYNTHESIS

The 2 most common types of hormonal EC used in the US are the Yuzpe regimen (high-dose ethinyl estradiol with high-dose levonorgestrel) and Plan B (high-dose levonorgestrel alone). Although both methods sometimes stop ovulation, they may also act by reducing the probability of implantation, due to their adverse effect on the endometrium (a postfertilization effect). The available evidence for a postfertilization effect is moderately strong, whether hormonal EC is used in the preovulatory, ovulatory, or postovulatory phase of the menstrual cycle.

CONCLUSIONS

Based on the present theoretical and empirical evidence, both the Yuzpe regimen and Plan B likely act at times by causing a postfertilization effect, regardless of when in the menstrual cycle they are used. These findings have potential implications in such areas as informed consent, emergency department protocols, and conscience clauses.

Effects of the Yuzpe regimen, given during the follicular phase, on ovarian function

This study was conducted to assess to what extent the Yuzpe regimen, or half the dose, given in the follicular phase, prevents ovulation during the ensuing 5 days. Sixty women were divided into six groups. All groups received placebo in one cycle and drug in another, in a randomized order. Groups differed by the dose and size of the leading follicle at the time of treatment (12-14, 15-17, or 18-20 mm). Ovulation was absent during the ensuing 5 days in 13 of 20 participants (65%) and in 8 of 20 participants (40%) who received the full and the half dose, respectively, when follicles were 12-17 mm. No ovulation occurred, within the critical period, in 7 of 39 placebo cycles (18%). When follicles were 18-20 mm, treatment did not prevent ovulation. In most drug-treated cycles, plasma gonadotropin and sex steroid levels were significantly depressed within the 5-day period, even when follicular rupture occurred within that period. In conclusion, the Yuzpe regimen can suppress or postpone ovulation to an extent that exceeds the fertile life of spermatozoa. Lack of ovulation within the critical period and dysfunction of the ovulatory process probably account for the contraceptive effect of this method in most cases. The present data do not warrant the use of half the dose of the Yuzpe regimen.

Hormonal emergency contraception

In the 1960s, high-dose estrogen was identified as a highly effective emergency contraceptive but was associated with a high frequency of nausea and vomiting. The combination of low-dose estrogen and a progestin (the Yuzpe regimen) is highly effective and much better tolerated. Recently, a progestin-only regimen containing levonorgestrel was found to be more effective than the Yuzpe regimen and caused significantly less nausea and vomiting. Danazol, an antigonadotropin, is well tolerated but has questionable efficacy Mifepristone has several pharmacologic actions that make it highly effective with an adverse-effect profile similar to that of the Yuzpe regimen. Progress has been made in the last 3 years toward increasing the number of emergency contraceptives that are accessible to women in the United States, and several highly effective options are available. The most effective and well-tolerated regimen available is levonorgestrel. However, the barriers to access and low patient and provider awareness limit the impact of emergency contraception on the rate of unintended pregnancies.

On the mechanisms of action of short-term levonorgestrel administration in emergency contraception

The effects of short-term administration of levonorgestrel (LNG) at different stages of the ovarian cycle on the pituitary-ovarian axis, corpus luteum function, and endometrium were investigated. Forty-five surgically sterilized women were studied during two menstrual cycles. In the second cycle, each women received two doses of 0.75 mg LNG taken 12 h apart on day 10 of the cycle (Group A), at the time of serum luteinizing hormone (LH) surge (Group B), 48 h after positive detection of urinary LH (Group C), or late follicular phase (Group D). In both cycles, transvaginal ultrasound and serum LH were performed from the detection of urinary LH until ovulation. Serum estradiol (E2) and progesterone (P(4)) were measured during the complete luteal phase. In addition, an endometrial biopsy was taken at day LH + 9. Eighty percent of participants in Group A were anovulatory, the remaining (three participants) presented significant shortness of the luteal phase with notably lower luteal P4 serum concentrations. In Groups B and C, no significant differences on either cycle length or luteal P4 and E2 serum concentrations were observed between the untreated and treated cycles. Participants in Group D had normal cycle length but significantly lower luteal P4 serum concentrations. Endometrial histology was normal in all ovulatory-treated cycles. It is suggested that interference of LNG with the mechanisms initiating the LH preovulatory surge depends on the stage of follicle development. Thus, anovulation results from disrupting the normal development and/or the hormonal activity of the growing follicle only when LNG is given preovulatory. In addition, peri- and post-ovulatory administration of LNG did not impair corpus luteum function or endometrial morphology.

The effects of peri-ovulatory administration of levonorgestrel on the menstrual cycle☆

Levonorgestrel (LNG) 0.75 mg administered 12 h apart within 72 h of unprotected coitus, is an established method of emergency contraception (EC). The mechanism of action of LNG used in this manner is unknown. We administered LNG 0.75 mg twice immediately before ovulation, to test the hypothesis that LNG acts as an emergency contraceptive by abolishing the pre-ovulatory lutenizing hormone (LH) surge and thereby delaying ovulation. Twelve women took LNG on or before the day of the first significant rise in urinary LH in 12 cycles. In four women, the LH peak and the onset of next menses were significantly delayed (delay of 16.8 days (SD +/- 8.7) from the day of mean LH peak in placebo cycles). One woman did not ovulate at all, despite a normal LH peak and cycle length. In the remaining eight women, LNG did not affect ovulation or the cycle length, but the length of the luteal phase and the total luteal phase LH concentrations were significantly reduced. We suggest that LNG acts as an emergency contraceptive by other mechanisms as well as delaying the LH surge and interfering with ovulation.

Oral contraceptive pills: considerations for the adolescent patient

Combined oral contraceptive pills (OCPs) are the most commonly prescribed method of birth control for adolescents. This article presents an overview of OCP pharmacology and summarizes the different types of OCPs. The initial patient evaluation and subsequent care are described, with a focus on management plans specific to adolescents. Emergency contraception, an alternative use of OCPs, is described as well. A thorough knowledge of OCPs and an appreciation of adolescent-specific management plans will enhance nurse practitioners' skills in preventing pregnancy in their adolescent patients.

Repeated use of hormonal emergency contraception by younger women in the UK

A cohort of women aged 14-29 in 1993 was identified from the General Practice Research Database and followed up for a period of 4 years. Patient files were searched for evidence of use of emergency contraception and regular contraception. Of the 95 007 women, 15 105 (16%) had received emergency contraception during the study period (an average of 5% per annum). There was a small year on year increase in uptake of emergency contraception between 1994 and 1997. Only 4% of emergency contraception users received emergency contraception more than twice in any year. More than 70% of those who had no previous record of use of regular contraception had used regular contraception within 1 year of using emergency contraception. Teenagers were more likely than other age groups to use emergency contraception, to be repeat users of emergency contraception and to fail to start regular contraception after first use of emergency contraception until later in the study period. These results disprove the notion of widespread repeated use of emergency contraception. They show that provision of an emergency contraception service does not result in failure to initiate regular contraception or abandonment of regular contraception; rather they show many women using regular contraception for the first time after use of emergency contraception.

Emergency contraception: a review of the programmatic and social science literature

Many biomedical aspects of emergency contraception have been investigated and documented for >30 years now. A large number of social science questions, however, remain to be answered. In this article, we review the rapidly growing but geographically lopsided literature on this topic. Using computer database searches supplemented by reference reviews and professional correspondence with those active in the field, we gathered literature on the social science and service delivery aspects of emergency contraception published in English up through December 1998, as well as a few unpublished papers from the same time and slightly later, representing regions where published material is practically nonexistent. Methodologically acceptable papers are summarized in our tables and text, and form the basis for suggested improvements in existing emergency contraceptive services. The review also offers ideas for designing new emergency contraception services where they do not yet exist. We conclude by proposing an agenda for further social science research in this area.

Ovulatory potential of preovulatory sized follicles during oral contraceptive treatment

The ovulatory potential of preovulatory follicles was studied in five women taking monophasic gestodene pills containing 20 micrograms of ethinyl estradiol. After one normal pill cycle, follicles were allowed to grow to 16 mm in diameter by deliberate extension of the pill-free period. Once the size of the leading follicle reached 16 mm, the women resumed oral contraceptives for the following 21 days to investigate whether ovulation can be inhibited by late onset of the pill. In addition, 100 micrograms of gonadotropin releasing hormone analog was given intravenously on the third pill day to induce ovulation. Follicular growth and activity were monitored by ultrasonography and by serum concentrations of ethinyl estradiol, progesterone, luteinizing hormone, and follicle stimulating hormone from the last pill day of the first cycle until the end of the second pill intake of 21 days. An increase in luteinizing hormone secretion started before intravenous administration of a gonadotropin releasing hormone analog in all women, eventually leading to ovulation in four of five women. One woman developed an unruptured follicle. Thus, the ovulatory potential of a 16-mm functional follicle cannot be inhibited by reintroduction of pills containing 20 micrograms ethinyl estradiol and 75 micrograms of gestodene.

The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices

Modern hormonal contraceptives and intrauterine contraceptive devices have multiple biologic effects. Some of them may be the primary mechanism of contraceptive action, whereas others are secondary. For combined oral contraceptives and progestin-only methods, the main mechanisms are ovulation inhibition and changes in the cervical mucus that inhibit sperm penetration. The hormonal methods, particularly the low-dose progestin-only products and emergency contraceptive pills, have effects on the endometrium that, theoretically, could affect implantation. However, no scientific evidence indicates that prevention of implantation actually results from the use of these methods. Once pregnancy begins, none of these methods has an abortifacient action. The precise mechanism of intrauterine contraceptive devices is unclear. Current evidence indicates they exert their primary effect before fertilization, reducing the opportunity of sperm to fertilize an ovum.

Safety and effectiveness of hormonal postcoital contraception: a prospective study

OBJECTIVE

The aim of this study was to evaluate the demographic characteristics of the population attending our hospital requesting postcoital contraception and to determine the effectiveness of the method and its side-effects.

METHODS

A total of 503 women asking for postcoital contraception were included in a prospective open trial. After filling in a questionnaire dealing with demographic and contraceptive data, we prescribed an ethinylestradiol-levonorgestrel combination (100 micrograms/500 mg for two doses 12 h apart).

RESULTS

Only 487 women were available for analysis of demographic data. A further 77 were excluded because they presented irregular menstrual cycles and 55 cases were lost for follow-up. Mean age was 22.6 +/- 5.25 years and 35.9% of cases came to the center within the first 5 h after unprotected intercourse. Only 18.8% had previously asked for postcoital contraception. Breakage of condom was the most common reason for request (81.9%). Two pregnancies occurred in the remaining 355 women. According to Dixon's method 15.5 pregnancies should be expected being the overall efficacy of 87.14%. There were no serious adverse effects. Nausea and vomiting (16.33%) were the most prevalent and 59% of the users menstruated at the expected time whilst menses were delayed in 6% of the cases.

CONCLUSION

The combination of ethinylestradiol and levonorgestrel in low doses is an effective and safe method of postcoital contraception.