WHY IS THE MORNING AFTER PILL CALLED THE MORNING AFTER PILL?
DISCLAIMER: This article is intended to help readers understand the role of emergency contraceptive pills in pregnancy prevention, but not to encourage or discourage the use of this medication.
Did you know that morning-after-pills can still be effective for pregnancy prevention if given within 5 days after unprotected intercourse? This, despite a name that seems to imply the pills work only the morning after. Which is why calling this medication, the morning-after-pills is technically incorrect, and really only a colloquial term. In a pharmacy setting, they are actually known as emergency contraceptive pills, or ECPs for short, because these types of medications can actually be effective if taken within 120 hours.
The confusion is probably a result of the proliferation of medical information on the internet, whereby many of these sources still propagate myths about emergency contraceptive pills. Such portals of information may not be reviewed by health care professionals, and the fallacies contained in turn are shared among peers. This may also be compounded by a reader’s sense of embarrassment to ask physicians or pharmacists about how ECPs work.
Therefore, the purpose of this paper is to summarize information about ECPs from reliable sources which pharmacists use. The information is presented in laymen language to help readers understand the material. By the end of the article, readers will be able to know the role of ECPs, find out how they can get ECPs in British Columbia, and anticipate the pharmacist’s one-on-one consultation with them or their partners.
To do this, I’ll present a fictional case scenario to illustrate some frequently asked questions about ECPs, and also guide readers on how to obtain ECPs in a retail setting:
KP is a 16-year-old who just been dating a guy in Vancouver the past month. They had unprotected sex 3 days ago. KP is worried about getting pregnant and wants to know how to prevent it. She has the following concerns:
Can an emergency contraceptive pill be used even though she is not taking it the morning after unprotected sex?
A clinical study published by von Hertzen et al in 2002 showed that ECPs are effective if taken within 120 hours of unprotected intercourse, so it is possible for KP to take the pill at the time indicated (72 hours). However, in the same study, pregnancy rates were slightly higher among women who started treatment more than 72 hours after unprotected intercourse, although authors surmised that the difference was not significant. Therefore, KP would need to be beware that the earlier the first dose is taken, the more effective the therapy will be. She also needs to understand ECPs are never 100% effective.
How do ECPs work?
ECPs contain hormones that act to prevent pregnancy. They work by inhibiting ovulation, fertilization of an egg, and/or implantation of a fertilized egg in the uterus. They function in a similar manner to the regular daily birth control pills, which also prevent pregnancy through hormone activity.
Since KP is only 16 years old. Does she need parental consents in order to get ECPs?
In British Columbia, children under 19 years old are protected under the Infants Acts and this allows them to get medications, including ECPs, without parental consent. However, KP must understand the nature and consequence of taking ECPs, via information provided by the medical practitioner involved.
What if the unprotected intercourse happened more than 5 days ago?
A special copper device called a Nova-T can be inserted in her uterus up to 7 days after unprotected intercourse. This intra-uterine device functions by preventing the implantation of a fertilized ovum, and having a direct toxic effect on the sperm, before fertilization of the ovum. However, a physician must confirm KP has no medical condition that bars her from using it (e.g. allergies) and also be responsible for inserting the device for her (this can be painful!). This device can also cause side effects such as vaginal bleeding and uterine cramping.
KP wants to go to her family physician’s clinic for a prescription of ECPs. It is midnight now and the clinic is closed. She knows there is a 24-hour pharmacy in her neighborhood. She has the following questions:
She learns that Health Canada has recently changed the drug schedule for ECPs and hears that customers can now buy ECPs in retail pharmacies without prescription. So, she asks whether she can get any pharmacists to sell her ECPs?
It is true that ECPs are now non-prescription medications under federal legislation. However, in BC, the provincial legislation overrides the federal law that still labels ECPs as prescription items. Despite that, pharmacists can complete the ECP training program organized by the British Columbia Pharmacy Association and obtain prescribing authority on ECPs. Therefore, KP should ask the pharmacists on duty if any one of them is certified to prescribe ECPs.
So, if it is OK to get ECPs in from pharmacists, what is the point of getting ECPs from physicians?
KP needs to be aware that the certified pharmacists will go through a more thorough interview with her, if she does not have a prescription from a physician. It is because a physician would already be required to thoroughly assess if ECPs were suitable for the client before prescribing them. If a person goes directly to the pharmacist, this assessment now becomes the responsibility of the pharmacist. Approximately $25, in addition of the drug cost and dispensing fee, will be charged for this service.
In contrast, if KP has a prescription from a physician, she can have the ECPs dispensed by any pharmacist. She does not need to pay the $25 counseling fee, and will have a less thorough interview with the pharmacist.
How does KP know which pharmacy has a certified pharmacist to prescribe ECPs?
She can go to the website www.not-2-late.com, which lists pharmacies with ECP-certified pharmacists in BC. However, it is not mandatory for pharmacies to register in the website. KP may find other certified pharmacists whose workplaces are not listed.
KP decides to get ECPs in the pharmacy, which has an ECP-certified pharmacist. What happens during the one-on-one consultation with the pharmacist?
First, the pharmacist brings KP to a private and quiet area for an interview and counseling. Next, they go through the “Informed consent for emergency contraception form,” which is also available here. The pharmacist will ask KP when is the first day of her most recent menstrual period, to make sure KP keeps track of her cycle. This way, if her period does not start within 3 weeks, KP should also see her physician or do a home pregnancy test, since pregnancy would have probably occurred. Secondly, the pharmacist will record the date and time of the unprotected intercourse to determine if an effective treatment can be given within the 120 hours timeframe. Next, the pharmacist will question if the exposure is due to a failure of other birth control methods, and offer other effective methods if necessary. Then, the pharmacist will explain how ECPs work. The pharmacist will also inform KP that ECPs, not being 100 percent effective, are for emergency use only. This is to encourage the use of regular birth control methods, such as taking daily birth control pills, which are more effective. After that, the pharmacist will tell KP ways to monitor possible side effects of ECPs – these include nausea and vomiting, fatigue, dizziness, breast tenderness and early or late menstrual period. For example, KP can take an over-the-counter anti-nauseant to relieve nausea and vomiting; she can make arrangements so that she can rest until the fatigue, dizziness, and breast tenderness goes away; and she would have the knowledge to expect her period to possibly be a few days early or late.
After that, the pharmacist will remind KP that ECPs offer no protection from sexually transmitted disease (STD) and will determine if she needs to be referred for STD assessment. In addition, KP needs to know that this prescription will be entered on her PharmaNet medication profile, which is connected to all retail pharmacies’ computers in BC. Next time, when she has a prescription medication dispensed in any pharmacy in the province, its pharmacy staffs will access her profile and know she has taken ECPs. Her physicians also have the rights to know what KP has taken and can ask pharmacists to look up her PharmaNet medication profile.
Is a physical examination needed?
No.
Should KY be referred for sexually transmitted disease assessment?
Women fitting any one of the following criteria need to be referred for diagnosis and assessment of STD:
1) The woman had sex with a new partner in the past month;
2) Her partner had sex with someone else in the past month;
3) Her partner has a sexually transmitted disease; or
4) The woman has had 2 or more partners in the last 6 months
Since KP met this partner in the past month, she fits the first criteria and needs to be referred.
Under what other circumstances are referrals needed?
The Children, Family and Community Act states “it is an obligation to report if pharmacists become aware that a child has been physically harmed, sexually abused or sexually exploited.” KP does not seem to be abused or harmed and thereby should not need to be reported. However, if KP inquires about regular birth control methods, she should be referred to a physician for assessment.
What happens after the counseling?
After the counseling, both KP and the pharmacist sign the informed consent form, which stays in the pharmacy. Then, the pharmacist dispenses the ECPs, but does not have to witness KP taking the doses. The pharmacist also gives the “How to use emergency contraceptive pills patient information” handout for KP to take home. This handout, which can be downloaded here, provides comprehensive information on how to take the pills, what side effects to expect, and what they should do to prevent pregnancy in the future.
KP notices in the bottom of the informed consent form under the “pharmacy use only” section, there are two options of ECPs provided. What are the differences between them?
Plan B and Ovral are the two options of ECPs that currently can be offered. Plan B, containing the hormone progestin, prevents pregnancy with a success rate of 89%. On the other hand, Ovral has the hormone estrogen in addition to progestin, but prevents pregnancy with a success rate of only 75%. Plan B has a more convenient dosing schedule: women take only 2 tablets at once. In contrast, they need to take 2 Ovral tablets once, and then 2 more in 12 hours. Moreover, Ovral causes relatively more nausea and vomiting than Plan B, so an anti-nauseant must be given 1 hour prior to each dose of Ovral. Since Plan B has a higher pregnancy reduction rate, more convenient dosing and fewer side effects, it is more popular among women. However, Plan B is more expensive and is not covered for people on social assistance. In addition, it is important to note that Ovral can also used as a regular daily birth control pill and thereby has more than 4 tablets in one package.
KP wonders whether the pharmacist can disclose her use of ECPs if her parents request about it?
All pharmacy staffs are obligated to keep clients’ information confidential unless the clients give consent to release it. So, even her parents cannot assess her medical information. However, if KP has a family medical plan that covers her ECPs, her family members can check her use of medications through the medical plan agency.
KP decides to take Plan B. She gets the medication dispensed and then takes it at home. Half an hour later, she phones the pharmacy and says that she threw up after taking the pills. What should she do now?
If she vomits within an hour after taking an ECP, she should contact her physician or come back to the pharmacy for another dose. It is likely that she has not absorbed the medication.
KP says that one of her girlfriends took Plan B many years ago. Instead of taking 2 pills together, her girlfriend separated them into 2 doses 12 hours apart. KP wonders if she took Plan B the right way. She suspects that her vomiting is due to overdose.
In the past, women were told to take 1 Plan B pill immediately, and then another pill after 12 hours. However, the clinical study by von Hertzen et al in 2002 showed that 2 pills could be taken at once without an increase in side effects. Since then, Plan B users have been told to take 2 pills at once for convenience sake. KP took Plan B the right away and did not overdose herself.
In summary, ECPs can be taken within 120 hours of unprotected intercourse, but they are not 100% effective in pregnancy prevention. They work by inhibiting ovulation, fertilization of an egg, or implantation of a fertilized egg in the uterus. However, ECPs can only be obtained from a physician or a pharmacist who is certified to prescribe ECPs. If a woman wants to get her ECPs in a pharmacy, without a prescription, she has to go through one-on-one counseling with the certified pharmacist. After the counseling, one of the two ECPs may be offered: Plan B or Ovral. Plan B has a higher pregnancy reduction rate, more convenient dosing and fewer side effects. However, Plan B is more expensive and is not covered for people on social assistance.
Hopefully, this fictional case scenario has helped to answer some frequently asked questions about emergency contraceptive pills. However, if there is still doubt, do not hesitate to contact your local pharmacist and physician for information. You can also visit the website www.not-2-late.com or dial the 24-hour BC Nurseline at 604-215-4700 (within Greater Vancouver) or 1-866-215-4700 (elsewhere within BC). Remember: the earlier the first dose is taken, the more effective the therapy will be.
References
British Columbia Pharmacy Association ECP Provider Binder.
College of Pharmacists of British Columbia. Important ECP Updates. Nov –Dec 03.
The Emergency Contraception Website. www.not-2-late.com. (Assessed Nov 8, 06).
Repchinsky, Carol. Patient Self-Care 1st ed., p. 661-665
Von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bartfai G, Ng E, Gemzell-Danielsson K, Oyunbileg A, Wu S, Cheng W, Ludicke F, Pretnar-Darovec A, Kirkman R, Mittal S, Khomassuridze A, Apter D, Peregoudov A; WHO Research Group on Post-ovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002 Dec 7;360(9348):1803-10.