To Be or Not To Be..., Pregnant, that is

NOW WOMEN HAVE A CHOICE when there has been a contraceptive failure. Surprisingly, over half of pregnancies in this country are unintended, and of those, fully half represent contraceptive mishap. In these instances in prior years, women would just have to be fearful and wait for nature to take its course.

Now they have a choice: emergency contraception. Emergency contraception, often referred to as "the morning after pill," Plan B, or ECP, is widely available, highly effective, very safe and simply under-utilized. Only 3 to 4 percent of women who are candidates for its use are aware of its availability.

It is important for all physicians caring for fertile women to inform patients of emergency contraception. For maximal effectiveness, every woman should be offered an "advance prescription" for this product at her yearly health screening evaluation. Providing this prescription to minors does not require parental consent and is not prohibited by any law.

Although ECP is now available in California for women of all ages without a prescription, it is sometimes difficult to find a pharmacy which has it in stock, and which has a pharmacist specially trained to dispense it as such.

Without a prescription this product can cost as much as $50. A patient with an advance prescription can have it filled at a wider range of pharmacies and just pay her usual insurance co-pay for the product.

To find a local pharmacy that provides this product, a patient can enter her zip code into a data base at www.not-2-late.com or at www.ec-help.org, or can call 1-800-NOT-2-LATE.

Emergency contraception works best if taken within the first 24 hours after unprotected intercourse, so getting the product in a timely fashion is critical to its successful use. It reduces the chance of pregnancy by up to 95 percent, with only 1 percent of women becoming pregnant (instead of the expected 8 percent without ECP use). It can be taken up to five days after such an event (though at 60 hours, the effectiveness drops to 60 percent). It consists of a two-dose regimen of oral contraceptive. The first is taken immediately, the second dose 12 hours later.

ECP can be dispensed as the dedicated product, "Plan B," which is a prepackaged set of two pills, each containing 0.75 mg of levonorgestrel. It is more effective and has fewer side effects than the alternative - a standard combination birth control pill taken at a more concentrated interval. (Go to www.not-2-late.com for comprehensive details of options.)

Emergency contraception works primarily by preventing ovulation. It also alters the uterine environment to inhibit a sperm from getting to the egg if ovulation has already occurred. This change in the endometrial environment would also inhibit a fertilized egg from implanting - if the pills are taken after conception has occurred.

This latter mechanism of action, thought to occur rarely, makes those who define life as beginning at conception label this product an abortifacient. Medical science defines pregnancy as beginning at implantation. Once implanted, this product does not disrupt an ongoing pregnancy.

All women can take ECP - even those who cannot take birth control pills. There are no contraindications to its use, and no serious side effects have been reported. Emergency contraception would not disrupt an existing pregnancy and no untoward effect on the fetus would be expected.

It is extremely unusual for women to use this product as a form of regular contraception (mainly due to its expense and aggravation). Its availability has not been shown to alter the sexual behavior or regular contraceptive use of our youth or their partners.

Susceptible patients must be advised that use of emergency contraception does not protect against sexually transmitted diseases, and is not as effective at preventing pregnancy as is regular use of contraception.

One out of every two women aged 15 to 44 in the US has experienced at least one unintended pregnancy. The cost to society in terms of medical care dollars and the psychological costs to women with unplanned pregnancies is considerable. Making emergency contraception more widely available is very important to help women reduce their risk of unintended pregnancy and the consequent need for abortion

"To be or not to be…" pregnant: Let's provide our patients affordable, attainable options when unexpectedly faced with such a question.

ruth.haskins@ucdmc.ucdavis.edu