EMERGENCY CONTRACEPTIVES.
(Synonyms: Morning after Pill, Postcoital Contraceptives, Secondary
Contraceptives, Last Chance Contraceptives, After-Sex Contraceptives, Second
Class Contraceptives, Back-up Contraceptives)
INDEX
(Overview- p 1. , Classification- p
6 , Indications-p.6, Brand Names-p12, Efficacy of different methods-p18 , Onset
of menstruation- p16, Detailed Information on high dose of progesterone pills-p.15.
Contraindications- p-19, Ongoing Contraception p-20,)
1.
Overview:
Most
contraceptives are appropriate before intercourse. Of late, several methods are
available which can be used within
a short time after unprotected intercourse to
avoid unwanted pregnancy. Often
called “morning after pills,” they are better named
as secondary or emergency contraceptives. These names remove the idea that the
user must wait until the morning after unprotected intercourse to initiate treatment
or that she will be too late if she cannot take the pills or get fitted with an
IUD (Intra Uterine Device) until the afternoon or night after intercourse.
These
contraceptives are usually in the form of tablets or some plastic devices put inside the womb.
Such
emergency contraceptive pills again may be
composed of 1) high dose progesterone tablets,
2) mifepristone tablet of 100m mg. 3)
Ullipristal tablet weighing 30 mg. or 4)
mixture of estrogen & progesterone tablets
in high dose . Of these four classes of pills used for postcoital prevention of pregnancy,
the last quoted pills are seldom used now-a-days as because such pills cause
much vomiting. Instead of emergency ingestion of tablets containg
levonorgestrel type of progesterone (brand names are unwanted-72, Pill-72, I-Pill), Ullipristal (Ella One- 30 mg. one tablet).
However, if one dislikes taking pill or is interested in long term prevention of
pregnancy then she can opt for
IUD which may be put inside the uterus by a doctor or trained nurse.
These
type of tablets (as described above) or copper wire containg intrauterine
devices (described later) which are used for postcoital prevention of pregnancy are
collectively called ECP (i.e. Emergency Contraceptive Procedures or more
commonly EC (Emergency Contraceptives). Throughout the text, the
acronym EC has been used which mean all types of emergency contraceptives.
2. Classification
of EC: Drugs or devices used as post-coital contraceptives: Emergency Contraceptives are basically are
either drugs to be taken by month or some plastic device to be fitted inside
the womb by a Health Care Provider. Earlier such tablets were used be
abbreviated as POEC-Per Oral Emergency
Contraceptives)
A)
DRUGS
to prevent pregnancy after unprotected coitus:
i)
High dose progesterone tablets:
These are often called ‘dedicated
ECP’. This hormonal tablets containing only progesterone hormone levonongestrel (LNG) may either weigh
0.75mg or 1.5mg per tablet. Worldwide such levonorgestrel containg pills is the most popular and accepted form
of EC.
ii) Mifepristone
or French abortion pill (RU-486): This type of tablet was primarily designed to induce medical
abortion. It is used to be called as French Abortion
Pill as this chemical agent was first discovered in France. It
is now known that mifepristone is very effective as emergency contraceptive
pill and in many countries it has been also approved as EC.
In fact
mifepristone (abortion pill) is becoming fast popular though it is costlier than first group of
EEC drugs and causes more side effects. Further initiation of
menstruation is usually delayed by couple of days after ingestion mifepristone
in comparison to levonorgestrel progesterone. But many scientists are now
claiming that as an EC mifepristone is superior to levonorgestrel pills so far
as efficacy is concerned. In our country such type of costly EC (mifepristone)
is seldom used. The trade names are Mifegest, Mifeprin. Only 50 mg tablet will
suffice but WHO recommends that such pills weighing only 10 mg. will suffice.
iii)
Combined oestrogen and progesterone tablets (like
Ovral-G or Duoluton-L etc): Such
high dose oestrogen containing pills however are less effective and only used
when first group of drug (levonorgestrel) i.e. dedicated EC is not available in
the local market. Not only its efficacy as EC is less but high dose oestrogen
containg combined pills causes many side
effects because one has to swallow good amount of oestrogen which induces
nausea and vomiting in most women.
B)
Devices to be put inside the womb: Copper
intrauterine device: These are plastic devices with outer
coating of copper wire. Such device, when fitted inside the womb releases copper
ions which exert contraceptive efficacy. It is primarily designed for long term contraception and
once inserted some brands depending on the copper content will continue to offer
contraception for a period of fourteen years!
Though IUC (intra Uterine Contraceptive
Devices) are very effective as EC but unfortunately such intra
uterine devices are seldom chosen by the client
(contraceptive acceptor) as emergency contraception (EC). But many researchers
believe that this device is possibly the most effective as EC.
Not
only copper containg devices, but Levonongestrel hormone containing intra
uterine devices is also available .Once considered as
ineffective as EC is now used occasionally as EC. In
trade such devices are known as Mirena, Skyla-Bayer co. or Emily. The last
two types of devices are manufactured at India. Such devices does exert some
activity as EC in addition to ongoing contraception for five years. But its efficacy
as ECP is by far less.
3. When
one should use emergency contraception? Indications of ECP:
Unlike
animals, there is no definite mating season in humans. Humans can have sexual activity
in almost all seasons and needless to mention sexual act is seldom preplanned.
Sexual act can be of several types: - e.g.1) consensual sex 2) commercial sex in
lieu of money or gift or favour in service or noncommercial sex 3) Sex with regular
or nonregular partner 4) Recreational / Sex for procreation sex 5) Sex within marital
bindings or sex without marriage.
Unprotected sexual exposure may occur in
the following circumstances necessitating use of emergency contraception:-
a)
Failure to use a contraceptive:
i.
Sexual activity was unplanned and
accidental. This often happens in adolescent age group or in illicit sex. In most of such cases either
the sex was forced (nonconsensual sex) or she did not
expect to have sex and she was not using any regular contraception.
Admittedly, most unplanned sex occurs in marital sex.
ii.
Miscalculation of safe period which she
realized this after the sex act.
iii.
Failed coitus interrupts (failure to
withdraw male organ at the time appropriate).
b)There
is a contraceptive accident or misuse including:
i.
Condom break, dislodgement or improper
withdrawal resulting in semen leakage.
ii.
Diaphragm or cervical cap slips out of
place during vigorous sex.
iii.
Contraceptive pill are forgotten on two
or more consecutive days or there is delay in starting a pack by more than 2
days and she became aware of this soon after sex act.
iv.
Intra-uterine device is expelled or
misplaced which she realized within 72 hours of sex. Occasionally an intra
uterine device may fall off the womb without the knowledge of the acceptor.
v.
More than two weeks late for progestin
only contraceptive injection(Quarterly shots) and more that 3 days late for
combined estrogen progestin injection (Inj. Lunelle)
vi.
Failure
of spermicidal tablet (Today sponge)
to melt in vagina before intercourse i.e. too early recourse to sex act.
Spermicidal tablets usually take couple of minute’s time to melt down after it
is being inserted inside the birth canal. Many such tablets produce foam inside the upper birth
canal and thus act both as chemical contraception as well as barrier
contraception. Therefore one should allow sufficient time to melt down the
spermicidal tablets before commencing penetrative sex.
c)
Recent use of a possible teratogenic drug or a
woman who develop chicken pox (varicella) within few days of unprotected
sex. Inadvertent use of live vaccine and
then if somebody engages in sex without due protection that also become an indication
for use of EC. .
Additionally one
can use postcoital pill in two following special
situations if woman concerned so desires:
i)
Use of pills immediately before engaging in sex act if she is not under cover of
regular contraceptives:
Traditionally
emergency contraceptives are used within 72 hours after an unprotected sex if
couple intends to avoid unplanned pregnancy.
But if such pills are available at her home she can take such pills just prior
to sex act instead of postcoitally i.e. early recourse to emergency contraceptives.
In such situations emergency pills may be aptly termed as pre-coital pills. ECs taken immediately before intercourse are as effective as ECs
taken immediately afterwards. However, if a woman has an opportunity to plan to use a contraceptive method before
intercourse, a method other than ECs, such as condom or another barrier method is recommended.
ii)
Use
of Emergency pills in so called safe period:
One question often asked by the couple is that should ECP be used if sex occurs
during safe period. The science is that fertilization results from intercourse
only during a five to seven day interval around the time of ovulation.
Theoretically, ECs are not needed if unprotected intercourse occurs at other
times of the cycle because chances of pregnancy even without ECs are nearly
zero.
However, in
practice ECPs generally should be
provided any time unprotected sex occurs and if the client is
concerned that she is at risk for pregnancy. Honestly speaking it is often
difficult to determine for certain whether a specific act of intercourse
occurred on a fertile or infertile day. In situations when the unprotected act
is extremely unlikely to result in pregnancy, the client’s anxiety level will
determine the use of ECP.
Thus
after going through long list of indications of EC, the author believes that
readers are convinced about the widespread scope of this all
important method.
Is emergency contraceptive drugs are essential drug ?
In
fact World Health Organization has included Emergency contraceptive
drugs/Devices in the list of essential drugs. As mentioned earlier there are four varieties of pills and two types of devices
(to be put inside the womb) which are used as postcoital contraceptive.
Brand
names, Doses, Mechanism of Action, Efficacy, Side effects and health
risks of each of five emergency contraceptives methods are discussed in detail
assuring that all the five methods are safe, easily available .Author firmly
believes after going through details of each methods couple will have no doubt
about the relevance and safety of such emergency pills/devices and these
detailed informations will help the couple to remove any misconception about
such essential drug.(contd.)
