Hope vs. reality – Access to EC pills doesn’t work

Emergency contraception (EC) should be widely available and easily accessible to all women, according to a just-released committee opinion issued by the American College of Obstetricians and Gynecologists (ACOG).1

Age restrictions, cost, insurance coverage, and misconceptions about EC are all unnecessary barriers that continue keeping women from using emergency contraception to prevent unwanted pregnancies in the first few days after unprotected sex, sexual assault, or contraceptive failure, the opinion states.

Although the Food and Drug Administration (FDA) approved the first dedicated product for emergency contraception in 1998, numerous barriers to access to emergency contraception remain. ACOG continues advocating for the FDA to remove the over-the-counter age restriction for the levonorgestrel emergency contraceptive pill (Plan B One Step, Teva Women’s Health, Woodcliff Lake, NJ; Next Choice and Next Choice One Step, Watson Pharmaceuticals, Parsippany, NJ; levonorgestrel 0.75 mg tablets, Perrigo, Allegan, MI) because there is no scientific or medical reason for it. Clinicians are advised to write advance prescriptions for EC for adolescents under age 17 to prevent delayed access, the ACOG opinion asserts.

In addition, private and public insurers are encouraged to cover all forms of EC and to publicize this coverage to their members, the opinion states. Any physician or pharmacist who objects to prescribing or dispensing EC should offer referrals to women who request the contraceptive, it notes.1

The IUD is best

While the ACOG opinion notes that oral EC is more common, the copper intrauterine device (IUD) is the most effective form of emergency contraception. This point is driven home by the research presented at the recent Contraceptive Technology: Quest for Excellence conference by James Trussell, PhD, professor of economics and public affairs and faculty associate at the Office of Population Research at Princeton (NJ) University.2

Fifteen studies have examined the impact of increased access to emergency contraceptive pills on pregnancy and abortion rates,3 and only one has shown any benefit4, says Trussell.

While there might be flaws in the studies, Trussell notes their consistency is compelling. The evidence does suggest that provision of EC pills does not increase risk taking. Also, insufficient use of EC pills is definitely a problem, he says.

“Stress efficacy for individuals,” says Trussell. “Everyone deserves a second chance to prevent an unintended pregnancy.”

More than 12,000 post-coital insertions of copper-bearing intrauterine devices have been performed since the practice was introduced in 1976; with only 12 failures, this approach has a pregnancy rate of 0.1%.5

Because they are safe for most women, highly effective and cost-effective when left in place as ongoing contraception, whenever clinically feasible, IUDs should be included in the range of emergency contraception options offered to patients presenting after unprotected intercourse, states Trussell and co-authors of a just-published systematic review of 35 years’ experience with the device.6

Check ulipristal acetate

Uptake of the emergency contraceptive drug ulipristal acetate, (Watson Pharmaceuticals) has been slow since it has been introduced in the United States in 2010, says Trussell.

Use of the prescription-only drug might swing upward, predicts Trussell. A meta-analysis of two randomized studies indicates ulipristal acetate is superior to levonorgestrel when used as an emergency contraceptive.7 In another study, research indicates that ulipristal acetate can significantly delay follicular rupture when given immediately before ovulation.8 The evidence suggests the drug could possibly prevent pregnancy when administered in the advanced follicular phase, even if luteal hormone levels already have begun to rise. This distinction is important, for it is a time when levonorgestrel EC is no longer effective in inhibiting ovulation, researchers note.8

Clinicians might wish to keep body mass index (BMI) in mind when discussing any emergency contraceptive pill, says Trussell. Recent data indicates that levonorgestrel pills showed a rapid decrease of efficacy with increasing BMI, reaching the point where it appeared no different from pregnancy rates expected among women not using EC at a BMI of 26 kg/m2 compared with 35 kg/m2 for women using ulipristal acetate.7

References

  1. Access to emergency contraception. Obstet Gynecol 2012; 120(5):1,250-1,253.
  2. Trussell J. High hopes, harsh reality: an update on emergency contraception. Presented at the Contraceptive Technology: Quest for Excellence conference. Atlanta; November 2012.
  3. Polis CB, Schaffer K, Blanchard K, et al. Advance provision of emergency contraception for pregnancy prevention: a meta-analysis. Obstet Gynecol 2007; 110(6):1,379-1,388.
  4. Shaaban OM, Hassen SG, Nour SA, et al. Emergency contraceptive pills as a backup for lactational amenorrhea method (LAM) of contraception: a randomized controlled trial. Contraception 2012; Doi:10.1016/j.contraception.2012.07.013.
  5. Trussell J, Schwarz EB. Emergency contraception. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
  6. Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012; 27(7):1,994-2,000.
  7. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet 2010; 375(9714):555-562.
  8. Brache V, Cochon L, Jesam C, et al. Immediate pre-ovulatory administration of 30 mg ulipristal acetate significantly delays follicular rupture. Hum Reprod 2010; 25(9):2,256-2,263.