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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
response to all three questions/concerns
EC in Russia
EMRGENCY CONTRACEPTION
1) effects on sexual behavior 2) question about postfertilization concerns
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Alison Karasz, Bronx, New York, USA Assistant Professor, Albert Einstein College of Medicine, Marji Gold
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The Raine et al. (1) study found a trend towards less consistent contraceptive use in adolescents afforded advance prescription. However, these results are not consistent with most research. As described in a recent review by Sue et al, six recent studies have found that increased access to EC does not increase unprotected intercourse or decrease the use of regular contraceptive methods. (2,3,4,5,6) The writer asks about our finding that only two women objected to the potential abortifacient effects of EC. He makes the valid point that if women didn’t know about EC to start with, their opinion might have been influenced by the description given by the interviewer. We went back and examined the script used by interviewers. The script includes three points: that EC is not the same as mifepristone (RU486), that EC may suppress ovulation and/or prevent ovulation, and that EC’s mechanism is still not yet fully understood. Women were allowed to ask questions, but our review of our transcripts suggests that they didn’t. It is possible that further discussion might have clarified participants’ views on this point. The writer’s other point, that studies have not found a decrease in pregnancy rates in women with access to EC, reflects a consistent finding in the literature and is obviously an important issue. We think that more research is needed to understand why increasing the availability of EC has not been shown to decrease unintended pregnancy. Ultimately it will be important to develop interventions that increase the effective use of EC. In the interim, assuring access is an important first step. ________________________________________________________ Raine T, Harper C, Leon K and Darney P (2000) Emergency contraception: advanced provision in a young, high-risk clinic population. Obstet Gynecol 96, 1–7. Sue S.T. Lo1,4, Susan Y.S. Fan1, P.C. Ho2 and Anna F. Glasier3.(2004). Effect of advanced provision of emergency contraception on women's contraceptive behaviour: a randomized controlled trial. Human Reproduction 2004 19(10):2404-2410. Glasier AF and Baird DT (1998). The effects of self-administering emergency contraception. N Engl J Med 339, 1–4. Lovvorn A, Nerquaye-Tetteh J, Glover EK, Amankwah-Poku A, Haya M and Raymond E (2000) Provision of emergency contraceptive pills to spermicide users in Ghana. Contraception 61, 287–293. Ellertson C, Ambardekar S, Hedley A, Coyaji K, Trussell J and Blanchard K (2001) Emergency contraception: randomized comparison of advanced provision and information only. Obstet Gynecol 98, 570–575 Jackson RA, Schwarz EB, Freedman L and Darney P (2003) Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol 102, 8–16. Glasier AF, Fairhurst K, Wyke S, Ziebland S, Seaman P, Walker J and Lakha F (2004) Advanced provision of emergency contraception has not reduced abortion rates. Contraception 69, 361–366 Competing interests: None declared |
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Nataliya Sherbakova, Voronezh, Russia pharmacist
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I have just become acquainted with the article “ The Visit Before the Morning After: Barriers to Prescribing Emergency Contraception”. I would like to share my experience with this problem as a pharmacist from Russia. Women in Russia do not have to suffer the stress and embarrassment of calling their doctor to ask for the pill, since anyone can drop in to the pharmacy and buy an EC pill. A lot of women who might need EC are completely aware of its accessibility in the pharmacy. The common source of their knowledge is not only their gynecologist, but also friends or colleagues. Most pharmacists explain how to properly take the pill. There is a growing problem of irresponsible sex. In my practice I have cases when a woman has already taken a pill this month, but had unprotected sex again. A pharmacist will know all the details of the case to judge whether she is allowed to take another one this month or not, depending on the phase of the cycle when the pill was taken. However, the effect of 750 mg of levonorgestrel influences the hypothalamic-pituitary system, affecting the regularity of the cycle for two months or more. Side effects often include vomiting and severe headache. That’s why when visiting their doctor or pharmacist, women become more compliant with the advice for regular contraception with low-hormone tablets. Competing interests: None declared |
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Riptinder Singh, Fiji Islands Gynecologist, Fiji School of Medicine
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Making EC available through advance prescription increases EC use after unprotected sex but does not increase frequency of unprotected intercourse. Its like having the tampoon handy in the bag for unexpected use, so a prior prescription of EC should be there. Competing interests: None declared |
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Joseph B. Stanford, United States Associate Professor, Dept of Family and Preventive Medicine, University of Utah
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A comment and a question with regard to this study. First, Karasz et al’s findings are similar to those of a qualitative study by Bissell, et al, which found that both prescribing pharmacists and users were generally positive about hormonal emergency contraception (EC), but had concerns about its potential impact on sexual behavior, in terms of possible decreased use of prospective contraception and increased sexual risk taking. (1) Perhaps we should pay attention to these concerns of physicians, pharmacists, and users with further qualitative and quantitative research on the long-term outcomes of EC provision, rather than simply dismissing all such concerns as irrational moral qualms. Not all research is reassuring with regard to sexual behavior and population impact. One study found a trend to less consistent use of more reliable contraception in adolescents given advanced access to EC.(2) To date, studies have not found a decrease in pregnancy rates in populations given widespread access to EC. (3) (4) Second, I have a question for the authors. The authors note that “only 2 women objected to EC because of potential abortifacient effects.” What information was given to women during the educational component of the interview about the mechanism of action of EC? Was the issue sufficiently discussed to allow all women to be aware of it? Even strong advocates of increased access to EC have agreed that evidence for postfertilization effects of EC (5) is sufficient to warrant routinely informing women of the potential for postfertilization effects. (6) Joseph B. Stanford, MD Associate Professor, Family and Preventive Medicine University of Utah 375 Chipeta Way, Suite A Salt Lake City, UT 84108 801-587-3331 fax 801-587-3352 Jstanford@dfpm.utah.edu 1. Bissell P, Anderson C. Supplying emergency contraception via community pharmacies in the UK: reflections on the experiences of users and providers. Soc Sci Med 2003;57(12):2367-78. 2. Raine T, Harper C, Leon K, Darney P. Emergency contraception: advance provision in a young, high-risk clinic population. Obstet Gynecol 2000;96(1): 1-7. 3. Glasier A, Fairhurst K, Wyke S, et al. Advanced provision of emergency contraception does not reduce abortion rates. Contraception 2004;69(5):361 -6. 4. Falk G, Falk L, Hanson U, Milsom I. Young women requesting emergency contraception are, despite contraceptive counseling, a high risk group for new unintended pregnancies. Contraception 2001;64(1):23-7. 5. Kahlenborn C, Stanford JB, Larimore WL. Postfertilization effect of hormonal emergency contraception. Annals Pharmacotherapy 2002;36(3): 465–70. 6. Drazen JM, Greene MF, Wood AJ. The FDA, politics, and plan B [Author reply]. N Engl J Med 2004;350(23):2413-14. Competing interests: None declared |
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