• Emergency Contraception: a second chance

    by Renee Cotter, MD
    on Nov 9th, 2015

It happens. Sometimes there’s an accident: a condom breaks or you forget to take the pill. Or other times you may just get caught up in the moment. Whatever the reason, emergency contraception (EC)-- also known as “the morning after pill” -- is a safe and effective method of birth control taken after unprotected sex and one form is available over the counter to any age. Unintended pregnancies are still a large problem in the United States as half of all pregnancies are not planned, resulting in a whopping 3.2 million unintended pregnancies. If you’ve had one of those “oopsie” moments, you do not just need to cross your fingers and hope for the best outcome.

 

Emergency contraceptives (ECs) are available to all women, regardless of age, status, race, etc., and should be used if ever there has been an accident that increases your risk for pregnancy. Unfortunately, many misunderstand EC, are unaware of its existence, or are worried about potential harmful effects. Even more, those who are aware only believe that EC exists as a pill, unaware that the Copper IUD is actually an extremely effective way to prevent pregnancy both as an emergency and extending into the long term for contraception. This week we aim to inform about ECs, types, uses, safety, and get rid of any misconceptions surrounding this form of birth control.

 

About Emergency Contraception (The Morning After Pill)

EC is a form of birth control taken after inadequately protected or unprotected intercourse. Reasons for using ECs include breakage of a condom, forgetting to take a birth control, or not using a condom or other method of birth control at all. The word “emergency” somehow makes this form of birth control seem more dangerous than other forms and implies that women should caution its use. On the contrary, EC is very safe. It has never resulted in a death or serious complication in the history of its use. So, the word emergency should rather be taken to mean “last plan of defence” rather than “oh no, danger!”. In fact, in the 1970s, some women use it as their primary form of birth control if they were not sexually active frequently. To them, taking one pill after sex was better than taking one pill every day for birth control. Today, ECs can be used up to 5 full days after the incident and soon, they may be approved for use up to 10 days after (though it is most effective as close to the sexual encounter as possible).

EC has been around for nearly 50 years, however the first “official” EC was approved by the FDA in 1998.

There are four different types of EC:


How Do They Work?

All four methods are slightly different in the way they work and also work differently depending on which day of your cycle you are in and which day of your cycle the sexual activity occurred. All methods should be taken as soon as possible after the accident to be most effective, however all methods can still be administered 3 days after intercourse and some for up to 5 or even 10 days. Furthermore, if a women wishes to begin an oral contraceptive pill after EC, she may begin using it immediately. The Copper IUD may simply be left in place for continual contraception.

Progestin only and Progestin-Estrogen Pills

If you are in the first half of your cycle, the best forms of EC to use are the Progestin only or combined Progestin-Estrogen pills. These both work by delaying or preventing ovulation, thus, preventing sperm from being able to fertilize an egg. If no egg is released, or it is released after the sperm has already died, the sperm cannot fertilize. Progestin only and Progestin-Estrogen pills affect the developing egg itself, preventing it from being able to be fertilized; however, this is only possible if it is used during the first half of the cycle. These pills must be used in the first half of the cycle, before a hormone, called Luteinizing Hormone (LH), surges. It is this surge in LH that causes an egg to be released from your ovary. Some studies have shown that the pills are still effective even after the LH surge, however experts are unsure how and why. If the egg has already been fertilized, the EC will not be effective. In addition to this, the morning after pill poses no risk or harm to the developing embryo if it is unknowingly taken once pregnancy has already occurred.

Selective Progestin Receptor Modulator (SPRM)

This method of EC, containing 30 mg ulipristal acetate, can be used even after LH has begun to rise. It works by both delaying ovulation and preventing the rupture of a follicle. SPRMs are still best used if used in the first half of your menstrual cycle, but have the potential to still delay ovulation after LH has begun to rise, but at a lower efficacy. This class of drug is also used at later stages for abortions, however in the early stages, shortly after sexual activity, it may be used to prevent pregnancy. 

Copper IUD

The copper IUD is the most effective form of EC and can be administered at any time of the menstrual cycle. It works by affecting the function and quality of the sperm. There is still some that is unknown about how the copper IUD is so effective, but studies suggest that it may also affect the lining of the uterus and the egg itself. By affecting the lining of the uterus, copper IUDs may prevent an already fertilized egg from sticking itself to the inside of the uterus. It is still unsure how the copper IUD effects the egg. Currently, it is possible that the copper IUD may be used up to 5 days after the sexual encounter, however research is currently being conducted to see if this may possibly be extended to 10 days. Because other forms of EC may be less effective for heavy women, a Copper IUD is the best option. ​

An added benefit of the Copper IUD is that after insertion as an EC, it may be left in as a normal and highly effective form of contraception. It is highly effective at preventing pregnancy and may be left in place for up to 10 years. If a woman decides that she wishes to become pregnant, the IUD may be removed, instantly returning a woman to her natural fertility. For these reasons and all those above, I consider the Copper IUD to be the best form of EC.

One problem with the Copper IUD is that it does need to be authorized by insurance to reduce the cost of the IUD, a lengthier process that inhibits EC. The pharmaceutical company’s price for the IUD without insurance authorization is high at about $780, so this is an option that must have cost taken into consideration. While considering the cost of the IUD, it is important to also consider that this is also a form of long term birth control, usable for up to 10 years after insertion and may be worth it for you depending on your financial situation. ​​


Safety

As mentioned above, ECs are very safe. There has never been a reported death or serious side effect from the use of an EC. Women have only ever reported minor side effects in relation to an EC. Furthermore, EC pills are safe to use even if pregnancy has already occurred and all ECs, including the IUD, have no effect on future fertility.  ​

Side Effects

Side effects of ECs are minimal and are generally manageable. These side effects will also resolve on their own without any further treatment.
Side effects include:

  • Headache (19%)
  • Nausea (12%)
  • Breast tenderness
  • Irregular bleeding: 16% report spotting within one week of use. Menstruation may also come earlier than expected by up to 7 days.
  • Other: fatigue, dizziness, abdominal tenderness.
  • For the Copper IUD: If left in, side effects of the IUD include heavier menstruation and increased menstrual cramps.

Birth Control and NOT Abortion

It should be stressed that EC is a form of birth control and not abortion. Once a fertilized egg has been implanted into the uterus and an embryo begins to develop, EC cannot terminate a pregnancy. Women should feel safe knowing that an embryo cannot be harmed by EC and should also be aware that if an egg has already been fertilized and implanted, no form of EC can abort the pregnancy.

Effect on Pregnancy

Because more research is now available, EC has been deemed safe against existing pregnancies. Fears used to exist surrounding potential negative effects of EC on an existing pregnancy, however it is now known that there are little to no negative effects. Contrary to popular belief, EC does not increase the risk for ectopic pregnancy. Some associated studies also indicate that there is no increased risk of birth defects related to hormonal contraception use during pregnancy.

Repeated Use

Though it is not recommended that women use ECs as their primary form of birth control, it is safe for use more than once in the same menstrual cycle. No current information yet exists for the continued, long-term use of EC pills, so it is warned against. Continual use of EC would expose a women to higher hormone levels than an oral birth control pill, so if you desire long term protection from pregnancy, it is recommended to choose another form of contraception such as an IUD or a birth control pill.


How To Get Them & Effectiveness

Progestin Only: Over the counter. Available as either a single tablet or two tablets. The single tablet form is available to anyone without age restriction. The two tablet form is only available to those 17 and older with a valid ID.

Progestin-Estrogen: Prescription. Available in different Progestin-Estrogen ratios.

SPRM: Prescription

Copper IUD: Office visit and insertion by a physician or nurse practitioner

A Note on Body Weight

Body weight affects the ability of all ECs except for the Copper IUD. Women who have a BMI over 25 are at an increased risk for a failed EC. To calculate your BMI, visit this website. If you do have a BMI over 25, it may be best to seek out the Copper IUD (cost considered), though if the quickest option is the Progestin only pill. If you are unable to get a Copper IUD, it is still best to at least try the over the counter method to prevent pregnancy.

Treatment Delay

Whether you’re unsure if you need an EC, don’t know where to get one, or are fearful of ECs, there are several reasons that might delay your treatment. Unfortunately, the longer the time between sexual activity and treatment with EC, the lower its effectiveness in preventing pregnancy.


Conclusion

Emergency Contraceptives are safe to use and vastly underutilized by many women around the world. Waiting and wishing for the best seems silly when there is an easy way to have peace of mind. This peace of mind comes with no serious risk to you or a pregnancy if it is too late to prevent. Only minor side effects occur such as headache, nausea, irregular period, and breast tenderness, all of which resolve on their own. EC is available to any woman or girl of any age, over the counter. A newer form of EC is the Copper IUD. The benefit of this is that it may be left in for long term birth control for up to 10 years! Lastly, EC is not the same as abortion. EC does not have the ability to harm an already formed pregnancy and studies suggest zero increased risk of birth defects. EC is only a form of birth control, a method to prevent pregnancy from occurring. It is my hope that women will begin to embrace this last chance available to them and help prevent the rise of unintended pregnancies.



References
​Unintended Pregnancy Protection. CDC. 2015.
ACOG. Emergency Contraception. ACOG Practice Bulletin number 152. 2015.
WHO. Emergency Contraception. WHO Fact Sheet N244. 2012
Trussell, J., Raymond, E.G., & Cleland, K. Emergency Contraception: a last chance to prevent unintended pregnancy. Princeton University. 2015.

Author Renee Cotter, MD

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Renee Cotter, MD
7320 Woodlake Ave
Suit 160
West Hills, CA 91307