Why there is need of after sex contraceptives?? Does all Indian couple who do not want pregnancy now use highly effective reversible contraceptives? About 16 % of couple doesn’t use such methods though don’t like to have pregnancy now. In India millions of couple don’t use regular effective reversible contraceptives like IUCDs, or hormone containg contraceptives like Pills, Injectables or Vaginal rings or Implants. Such coupe is faced to the consequences of untimed and unplanned pregnancies. Most of such unwanted pregnancies are terminated in unhygienic conditions culminating into much damage to reproductive organs of female partner. Sometimes such induced miscarriage can lead to fatal events. To avoid such unplanned pregnancy regular use of dependable reversible contraceptives use is highly recommended like oral pills, injectables or vaginal rings, minipills or subdermal implants (IMPLANON). Fortunately IUCDs also do offer maximum contraceptive efficacy as because there is seldom error in method use unlike pills (forgotten pills) or drop out from three monthly injectable.

Brand Names & Composition of Different after sex Pills (Emergency contraceptive Pills which are commonly prescribed in India)

Classification of Emergency Pills:  When menstruation will commence after taking such after sex pills thereby giving relief to the couple:

5.Brand Names & Composition of Different Pills used  as EC (commonly prescribed brands):-

First Type of Emergency Pills: High Dose Progesterone tablets: Single hormonal  tablets

1)  Composition:  This type of pills contains a synthetic progesterone hormone (levonorgestrel) and this is the most popular type of EC worldwide. In fact most women who take pill (combined oral contraceptive) are familiar with the term progesterone hormone as because progesterone hormone is commonly used in most of the pill along with small amount of oestrogen hormone. But levonorgestrel used in EC is at much higher dose than the pills and there is no oestrogen in emergency pills.

2)   Brand Names and Packaging in Trade: In the market such emergency pills are packed in two types. Most brands dispense two pills per pack and each pill of such pack contains 0.75mg of progesterone hormone (the approx cost is Rs. 80-100/- per pack).

In India there is another type of pack available in trade where each pack contains one pill weighing 1.5 mg of progesterone( Brand I-Pill-cost Rs 100/- per pack of 1 ablet).

 Brand Names:

 A) Trade preparations containing 1.5mg of progesterone hormone per tablet :( single tablet pack e.g. ‘I’-Pill (Cipla)-Cost is approx. Rs. 100/- per pack.

 B) Preparations containing two tablets in a pack, each tablet in such pack contains 0.75mg progesterone hormone:  Brand names are Unwanted-72(cost about Rs.80/- per pack), Ecee-2, Pill-72, Preventol, Norlevo, Nopreg, E-Pill (Govt. of India). In overseas such EC pills are available in the brand names of Plan B, Levonelle-2, and Norlevo.  These are popular brands in UK.

3) Dose: There are two types of dose schedule.  A)  Single dose regime:-The most convenient regimen is a single dose consisting of 1.5mg levonongestrel taken as soon as possible after unprotected intercourse. In the market such tablets are available as I-Pill. B)  Split dose regime:  Alternatively, one dose of 0.75mg levonongestrel tablet can be taken as soon as possible after unprotected intercourse followed by the another such tablet taken 12 hours later (split dose).

 Efficacy of both the doses are same but many scientists advocate in favor of using single tablet. They claim that this ‘single dose treatment’ will avoid taxation on busy house wife and skipping or delay in taking the second dose will be zero. However if a woman purchases a pack containing two tablet then she can take two tablets together from such pack. The efficacy will be same as first type of pack.

4) Window of opportunity (Therapeutic window): This type of EC is effective up to 72 hours of unprotected sex. Readers will be surprised to know that efficacy of this drug declines fast as time elapses. For instance, this type of emergency pill will be able to prevent pregnancy in 98% occasions if the drug is consumed within 12 hours of unprotected sex.

No delay in initiating the life saving after sex contraceptives: More is the delay  less will be the efficacy. Conversely, the efficacy falls down to only 50-60% if the drug is taken late say at any time between 72 hours to within 120 hours of unprotected intercourse. It is also reminded that two per cent of women can fall into prey of pregnancy even if she take the drug soon after unprotected sex. Therefore it is mandatory to perform home monitoring of urine for pregnancy test in menstruation does not ensue within three weeks of consumption of such emergency pills.

5) Mode of Action: This type of drug work primarily as preventing ovulation. It also alters endometrium (womb) making uterus unsuitable for implantation. But it does not disrupt an implanted pregnancy and thus it is not an abortificient.

7. When menstruation will commence and the couple will be relieved? Onset of menstruation:  After ingesting such EC Pills 87% of women will have their next menstrual period at the expected time or within 7 days of the expected time whereas 13% had a delay exceeding 7 days.

 There may be heavier menstruation in 11-14% women and irregular bleeding (spotting) for couple of days may occur in 10-30% cases. This may be annoying to a lady who is employed outside home or whose job demands frequent travel.

 Therefore one should always use a dependable contraceptive which keep the couple worries free (because this method has minimum 2% failure rate) and irregular bleeding in some women which can compromise her daily routine including social and religious works. A delay in menstruation for more than 7 days is of clinical concern; the possibility of pregnancy should be considered.

8. Side effects of Pills:-The followings are the common side effects of emergency progesterone containg pills.

Common Side effects: There are virtually no side effects with this type of emergency pills. In fact High dose progesterone tab (ECee-2, Pill 72). I.e. the levonorgestrel only regimen is preferred because it is more effective and is associated with a lower incidence of side effects. Author has prescribed about three hundred women in last four years who has taken this type of pill and less than three per cent women complained of side effects and that too were mild discomfort which are most women believe as acceptable side effects. However different international studies have revealed following side effects (maximum figure have been cited).

Nausea 12% to 23% Abdominal pain 14% to 18% Fatigue 8% to 17% Headache 11% to 17% Dizziness 4% to 11% Breast tenderness 3% to 11% Vomiting 1% to 6% Diarrhea 1% to 5%

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  9. Efficacy of emergency contraceptive pills in averting pregnancy: Levonongestrel pills are more effective the sooner they are taken after unprotected intercourse preferably on the same night. In fact such tablets are most effective if taken within 3 days (72 hours).

However, if there is more delay in taking such tablet i.e. beyond 72 hours after unprotected coitus there will be still considerable contraceptive effect up to 5 days (120 hrs.) after unprotected intercourse.

 As stated earlier the efficacy may be reduced if pills are taken 72 hours after coitus and efficacy will be reduced to fifty to sixty percent instead of 98% if taken within few hours of unprotected sex.

9) Contraindications of emergency contraceptive pills:

There are no known contraindications to taking such type of pill. Women having jaundice should not take this pill. But women who are suffering from diabetes, high blood pressure or stroke can consume such EC if situation so demands.

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10)  Recommended Follow up after ingestion of emergency pills: Progesterone Pills designed for emergency contraception (Levonorgestrel) is an innocuous and safe drug. Therefore, no follow up is needed if the client has been duly explained about what to do in case menstruation does not ensue within three weeks of last dose of EC pills.

 But a conscientious healthcare provider may visit her residence or talk to her over phone enquiring whether the couple has accepted a regular contraceptive after the onset of menstruation. Continuous motivation is warranted for adoption of regular effective contraception in most Indian couple.

 12) Health risks. There are no health risks if a woman consumes such emergency pills four to six times per year. But frequent swallowing of such hormonal tablets may cause gross menstrual abnormalities which will be unacceptable to the woman concerned.

3) Teratogenecity: It does not cause any birth defect in case pregnancy cannot be prevented in spite of taking such EC. In such an event if she opts to continue the pregnancy she should be reassured that high dose progesterone ingested will not cause birth defect. Such statement is also true for the pill (combined oral contraceptives)

Mifepristone (RU 486) Tablets:

i)               Brand Names : Mifegest, Mifeprin

ii)           Composition: Mifepristone is most commonly used for inducing medical abortion. But it can also be successfully used as postcoital contraceptive but it is more costly than high dose progesterone tablets. Only recently it has been approved as emergency contraceptive in some selected countries and I am afraid many Indian couple is not aware of such uncommon use of mifepristone.

iii)       Dose:  A single dose of mifepristone 50 mg. taken within 5 days of unprotected intercourse is highly effective for emergency contraception. As a matter of fact as low 20mg or even 10mg will be effective. But in India mifepristone tablets weighing only 200mg is available. Mifepristone has three advantages over first group of EC i.e. high dose progesterone (levonorgestrel).

iv)        Mechanism of Action as contraceptive:     These are a) low incidence of side-effects b) more effective than progesterone pills c) It will act as EC if taken within five days of sex. Many scientists now claim that it will claim that mifepristone   may exert some action as EC if taken even beyond five days but within seven days of unprotected sex. However mifepristone is more costly than high dose progesterone tablets and 9-18% of women experience a delay in resumption of menstruation more than five days in comparison to first group of postcoital contraceptive pills. This may sometime cause concern. Women taking mifepristone should therefore be counseled appropriately regarding this delay in onset of menstruation. A major constraint for the use of mifepristone is its cost.  Till further informations become available author advocates use of such pill only when decision to take EC tablets is taken after elapse of three days of sex . At that juncture first group of pills will be less effective. But in the unfortunate event pregnancy cannot be prevented (drug failure) after ingesting mifepristone then it will be wise to go for abortion. But first group of pills are absolutely safe (no bad effect on embryo) and thus if drug failure occur one can continue pregnancy. Such failure though uncommon can occur under following circumstances I) delay or omission of second dose of tablets ii) one tablet has been vomited out and she forgets to take another such additional tablet. In fact if she vomits within one hour of ingestion then she has to purchase another pack to have another pill Iii) If such drug is taken late i.e. between 72 to 120 hours of unprotected sex

v)            Side effects: There is no remarkable side effect.

VI) Window of opportunity:  Out of three types of emergency pills (POEC, Mifepristone and COC) this is the most effective in pregnancy prevention. But there is little to choose if EC pills are consumed within 24 hours of sex and author believes that POEC ( first group of EC pills)  will be a better choice as the cost is much less and the drug is innocuous. But after passage of 24 hours efficacy of first group of EC pills (single hormone progesterone tablets) falls steadily as time passes but mifepristone will continue to exert its contraceptive effect certainly up to 72 hours of sex. Most scientists have observed that it is very effective in pregnancy prevention even consumed during the time frame of 72 to 120 hours of unprotected sex.

VII) Contraindications: WHO ARE UNSUITABLE FOR HIGH DOSE PROGESTERONE Pills? There is no contraindication but one should consult doctor if there is gross liver, kidney disease or she suffering from adrenal (suprarenal) gland diseases.