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Are ECs really contraceptives - that is, do they prevent conception, as supporters insist? Are they ineffective if a woman is already pregnant, as they also claim? Or do they always or usually cause abortions, as some pro-life groups say? And if so, why would legislators who usually oppose abortion support ECs, and even vote to make them available without a prescription?
Are emergency contraceptives as easy, safe, and effective as the advertising suggests?
Before addressing such questions, it might be helpful to illustrate the opposing perspectives on emergency contraceptives. One view is held by reproductive "professionals" who promote them as a silver bullet solution to unintended pregnancy; some women who have been on the receiving end of this bullet have a different perspective.
The American College of Obstetricians and Gynecologists (ACOG) has long advocated legal abortion, even partial-birth abortion. So it was no surprise that in late April, newly-elected ACOG president Thomas F. Purdon, MD, issued a "call to action" to ob-gyns, asking them to offer "an advance prescription" of ECs to women during routine office visits. No need to wait until the FDA permits over-the-counter sale, he explained: "We need to pursue all avenues to increase women's awareness of emergency contraception and their ability to get it within 72 hours" (ACOG News Release, 4/30/01). He calls ECs "a last chance method of oral contraception, which helps prevent abortion," and he hopes that one day they will be "as common in most women's homes as a first aid kit."
Planned Parenthood boasts of being the largest supplier of ECs and says they could "prevent 1.7 million unintended pregnancies and 800,000 abortions each year." It also says that women who have used ECs "report high levels of satisfaction." But that's clearly not true of all women. Postings on a "morning after pill" on-line support message board (After Abortion) contradict the rosy picture of EC use as easy or uncomplicated.
"L" describes "feeling agonizing remorse." She wrote to her doctor several times, asking him to explain why he never told her it could cause an abortion and to tell him what she had been going through since learning, five years later, that she might have aborted her child. He never replied. She also felt angry with her mother, who had taken her to the doctor for morning-after pills but later refused to "pressure" the doctor to explain why he hadn't warned her that the pills might cause an abortion. On October 25, 2000, "L" posted this message: What I can say with absolute certainty is that FOR ME the morning-after pill was a totally negative experience which left me with lots of self-blame, unanswered questions, mistrust in doctors and even loss of much of the trust I had in my own mother.
"D" wrote on February 8, 2001: I just want to say ... [BLEERRRRRGGGGGGHHHHHHH!!!] I'm sick. I'm sore. I'm a complete emotional wreck. I'm scared. I'm now terrified about the prospect of having to have sex again. I've got a pounding headache. I have spots in front of my eyes. I have 2 children under 5 that need looking after today.
Several women commiserate with "D," mentioning their own experiences - being sick for three days or thinking they'd never stop throwing up.
"Anonymous" wrote on March 8, 2001: I feel so many things, all so conflicting, and I have so much fear and self-loathing, I need help. My counselor today said he thinks I may be suffering from pas [post-abortion syndrome], and I don't want to deal with this with him because I want it to go away. He says I don't have to have had a surgical abortion to feel like I caused that baby to die by my taking those pills. I am so scared and confused. ...
This is supposed to be good for women? And it's going to prevent abortions?
What are "Emergency Contraceptives"? The idea of "emergency contraceptives" arose decades ago as a high dose of ordinary oral contraceptive pills. The idea was that women could use these hours or days after "unprotected intercourse" or after their usual contraceptive had failed to avert a pregnancy. The ACOG Practice Bulletin (No. 25, March 2001) lists the following methods of emergency contraception: "combination or progestin-only oral contraceptives, danazol, synthetic estrogens and conjugated estrogens, antiprogestins and the insertion of an intrauterine device [IUD]."
Combination oral contraceptives (COCs) typically contain a low daily dose of a synthetic estrogen (ethinyl estradiol) and a low dose of progestin (norgestrel or levonorgestrel). When used as a back up for missed or failed contraception, two doses of COCs, consisting of 2, 4 or 5 pills each, are taken 12 hours apart, beginning within 72 hours of intercourse. This method, known as the "Yuzpe Regimen," was introduced in 1974 and is the most commonly used. In 1998 the FDA approved the first product specifically marketed for emergency contraception, the "Preven" Emergency Contraceptive Kit. It contains 4 pills for the Yuzpe regimen, a pregnancy test, and instructions.
Progestin-only oral contraceptives (e.g., Ovrette) contain a low dose of norgestrel. For use as emergency contraception, one must take 20 Ovrette pills, followed by another 20 pills twelve hours later. In 1999, the FDA approved "Plan B," an emergency contraception kit with two high-dose pills of levonorgestrel each, equal to about one-third of the amount one would take in a month. The copper-releasing intrauterine device (IUD) can be used as "emergency contraception" if inserted within five to seven days after intercourse. With such use, "the IUD interferes primarily with the process of implantation" thus ending the life of the week-old embryo. (Rosenfield, A., "Emergency Contraception: A Modality Whose Time Has Come," Journal of the American Medical Women's Association, vol.53, no.5, Sept. 1998, p. 212)
How Emergency Contraceptives Work
This discussion will focus only on the two most widely used methods of emergency contraception - COCs (Preven or "ordinary" COCs used according to the Yuzpe regimen) and Plan B. First, it might be helpful to review the normal fluctuations of a woman's reproductive hormones each month.
At the beginning of a woman's menstrual flow, the pituitary gland produces a higher level of follicle stimulating hormone (FSH). The ovary responds by ripening a follicle from which a maturing egg will be released. The covering of the egg then produces estrogen which prompts the lining of the uterus to proliferate. The rising estrogen level sets off a sudden release of luteinizing hormone (LH) from the pituitary gland. The LH "surge" causes the now mature egg to be released from the ovarian follicle. This is ovulation. After ovulation, the lining of the follicle begins to produce the hormone progesterone. Normally the follicle's cells live for eleven to sixteen days, producing progesterone and small amounts of estrogen. The progesterone causes the uterine lining to thicken and produce a nutritious liquid so that if the egg were fertilized, the week-old embryo can implant in it.
If conception does not occur, then eleven to sixteen days after ovulation, levels of progesterone and estrogen drop and the next menstrual period begins.
The human egg lives only for about 24 hours after its release. Sperm can live for three days, and possibly even five days during the fertile phase. A woman's "fertile phase" may therefore last at most from about six calendar days prior to ovulation to the calendar day following ovulation.
The main mechanisms of ECs are suppressing ovulation (by delaying or suppressing FSH and LH), altering cervical mucus which slows sperm transport, slowing transport of egg or embryo through the fallopian tube, and changes to the uterine lining which make it thin and atrophied, inhibiting implantation of the embryo. Researchers describe three possible post-fertilization effects of hormonal contraceptives: the slower transport of the embryo through the fallopian tube could prevent the embryo from reaching the uterus to implant (resulting in embryo loss or tubal pregnancy); changes in the uterine lining which prevent implantation; changes in the uterine lining which are "not sufficient to prevent implantation but unfavorable for maintenance of the pregnancy" (Larimore, W. and Stanford, J., "Postfertilization Effects of Oral Contraceptives and Their Relationship to Informed Consent," Archives of Family Medicine, vol. 9, Feb 2000, 126-133).
Whether ECs prevent conception or act as an abortifacient depends on when in the woman's fertility cycle intercourse occurs and ECs are used.
If taken before the beginning of the fertile phase, their only effect would be to cause withdrawal bleeding completely out of phase with the woman's ordinary cycle. (Klaus, "The Morning After Pill: Boon or Boondoggle?," March 11, 2001). If taken at the beginning of the fertile phase, "they may delay or suppress the [LH] surge. ... If ovulation is delayed by more than 72 hours, it is possible that the sperm may not survive. If ovulation is suppressed entirely, then there would be an out-of-phase bleed" (Ibid.). Therefore, taken during this period of several days, COCs and progestin would be somewhat more likely to prevent conception than to interfere with implantation.
ECs taken after the LH surge cannot inhibit ovulation. If an egg has been released in the preceding 24 hours, a sperm may penetrate the egg within 15 to 30 minutes after intercourse, beginning the process of fertilization. The new human embryo grows and develops over the next three to five days while traveling down the fallopian tube to the uterus to implant. The abnormally high level of synthetic progesterone present in the ECs, however, alters the uterine lining, inhibiting or preventing implantation. "This mode of action could explain the majority of cases where pregnancies are prevented by the morning after pill" (Grou, F. and Rodriguez, I. "The morning after pill, how long after?" American Journal of Obstetrics and Gynecology (1994), vol. 171: 1529-34).
Finally, if ECs are taken in the late infertile phase, they would simply cause premature menstrual bleeding.
For almost three weeks of the average cycle, then, ECs will neither prevent conception nor cause an abortion because a woman is infertile. During the remaining week or so, ECs are capable of both contraceptive and abortifacient actions, the former action predominating in the earlier days of the fertile phase and the latter action predominating after the LH surge. Unless a woman charts her fertility (quite an easy thing to do with methods developed for natural family planning) she cannot be certain which action has "prevented pregnancy" when the pills "succeed."
Issues of Informed Consent
Those who promote "emergency contraception" omit facts and publish inaccuracies and half-truths, depriving women of their right to informed consent. The foremost claim is that ECs do not cause abortion and have "no effect on a pregnancy." To make this claim they have had to redefine "pregnancy" as beginning after an embryo has implanted in the uterine lining, and redefine "abortion" as terminating a "pregnancy." Terminating a human being's life prior to successful implantation is not counted. These word games are designed to obscure what ECs do, and to prevent state abortion regulations from applying to the destruction of embryos' lives by synthetic hormones. They also prevent conscientiously objecting health care personnel - doctors, nurses and pharmacists - from being able to cite state and federal "conscience clauses" on abortion in their own defense.
For the same reason promoters of ECs refer to the implantation of a "fertilized egg." At the age of 6-7 days when an embryo begins implantation, it is not a "fertilized egg." It is an embryo in the blastocyst stage. "The term embryo covers the several stages of early development [single-celled zygote, multi-celled blastocyst, highly differentiated embryo] from conception to the ninth or tenth week of life" when all organs are present and the fetal stage begins. (Considine, D. (ed.), Van Nostrand's Scientific Encyclopedia, 5th ed. (1976), p. 943).
Women are also misled about the unpleasant side effects and health risks of ECs. Promoters of ECs trivialize the physical, emotional and psychological impact from using these drugs, assuming perhaps that any amount of such harm to women is preferable to continuing a pregnancy. In fact, ACOG seems willing to subject women to potential harm even when the likelihood of pregnancy is nil. The ACOG Practice Bulletin describes a candidate for emergency contraception as any woman of reproductive age who has had "unprotected" intercourse in the previous 72 hours, "independent of the time in the menstrual cycle" (emphasis added).
There are a number of common, relatively manageable, adverse reactions to Preven and Plan B. Over 50% of women taking Preven experience nausea, as do 23% of those taking Plan B. About 19% vomit after taking Preven, compared to 5.6% of those taking Plan B. (WHO Department of Reproductive Health and Research, "Improving Methods of Emergency Contraception," Progress in Human Reproduction Research, Bulletin No. 51, 1999). One out of every five or six women may also experience headaches, abdominal pain, menstrual irregularities, dizziness or fatigue.
But far more troubling is the long list of very serious contraindications and warnings given to doctors.
The risk of developing blood clots in the deep veins of the leg is three to six times greater among users of COCs than for non-users. "Blood clots that form in the leg can cause blockage of blood flow in the leg veins [and] can travel to the lung, causing serious disability or death. Rarely, clots occur in the blood vessels of the eye and may cause blindness, double vision, or impaired vision." These risks are substantially increased for women who smoke.
There is an increased risk of heart attack and stroke, both of which can cause serious disability or death. Women who have had a heart attack, and those with ischemic or valvular heart disease or very high blood pressure are at even greater risk and should not use combination ECs. Women are warned not to take combination ECs if they have diabetes with blood vessel involvement, severe headaches including migraine, current or past breast cancer, liver tumors or disease, or a known allergy to any component in ECs. Schering Health Care, a manufacturer of COCs marketed as ECs in England, provides the following warning to pharmacists:
There is a general opinion based on statistical evidence, that users of combined oral contraceptives ... experience, more often than non-users, venous thromboembolism, arterial thrombosis, including cerebral and myocardial infarction, and subarachnoid hemorrhage. Full recovery from such disorders does not always occur, and it should be realized that in a few cases, they are fatal.
Because it can be difficult to schedule a medical appointment during the 72 hour window in which the initial dose must be taken, promoters of ECs are lobbying the Food and Drug Administration and state legislatures to authorize over-the-counter availability. Currently only Washington State allows distribution by pharmacists. But a very public and busy pharmacy counter is no place for a distraught and embarrassed teen or woman to discuss her relevant medical and sexual history with a pharmacist - absolutely essential given the serious contraindications of the drugs. Nor will the average pharmacist have the time to explain all that a woman needs to know to make an informed decision.
Failure to properly advise a patient of risks and options can be actionable malpractice. And, although the National Federation of State Medical Boards "explicitly" states that prescriptions without a doctor's visit are "outside the bounds of professional conduct" except in the case of refills, prescriptions for ECs can now be obtained through several web sites operated in the U.S.
The availability of "emergency contraception" is not "the nation's best kept secret" as promoters like to claim. The secret best kept from the American public is that these drugs can cause abortions. The time for covering up this unpleasant reality is long past.
Many Americans believe that if a woman is abortion-minded, it's better to take the life of a week-old embryo than one at ten or 20 weeks. But it's wrong to consider hormonally induced abortion as a lesser evil than later-term abortions, simply because the embryo has less resemblance to what we think humans look like. In fact, we all once looked exactly like a week-old embryo. The essence, the effect of both abortions is the same: an individual is deprived of her entire earthly life span. She will never be kissed or cuddled, never walk on a beach or ride a bike, never sing in a choir or graduate from college, never fall in love, raise kids, have a fulfilling career or leave the world a better place for having lived here. For Catholics the choice is clear. Natural family planning - fertility awareness coupled with abstinence during the fertile phase - is the healthy, risk-free and morally sound way for couples to plan the spacing and number of their children. But all who believe in the sanctity of human life - and all who oppose giving potentially dangerous drugs to women with inadequate or extremely misleading information - can and should oppose the growing use of emergency contraceptives.
Susan Wills is assistant director for program development, USCCB Secretariat for Pro-Life Activities.
Copyright - 2001, United States Conference of Catholic Bishops, Inc., Washington, D.C. All rights reserved. Illustration by Dolores M. Daly.