EMERGENCY CONTRACEPTION
"THE MORNING AFTER PILL"
by Dr Rosemary Birkill, MB BChir., MRCPsych, DObstRCOG, MFFP, Senior
Doctor, Brook Advisory Centre
YOU'VE HAD SEX, AND
You didn't use a contraceptive, or
The condom broke or came off, or
You remembered afterwards that you forgot your pills, or
For some other reason you think there might be a risk of pregnancy
THEN EMERGENCY CONTRACEPTION GIVES YOU THE CHANCE TO REDUCE THE RISK!
It's still called the "Morning After Pill" by many people in the
UK, but the most widely-used method is a short course of pills which must be
started within THREE DAYS (72 HOURS) of when sex first took place. The
second dose of pills is taken 12 hours later.
It is also possible to have a COIL fitted into the womb up to FIVE
DAYS after sex, or even longer if the woman is early in her period cycle-
but this method is harder to get quickly, and having a coil fitted may be
painful (see "Emergency Coil Fits" below).
How can you get emergency contraceptive pills?
You can't buy them direct from chemists in the UK; a doctor has to prescribe
them.
GPs (family doctors) can prescribe them, though it can be difficult to get
an appointment quickly. You may be able to see a GP at a practice where you are
not registered as a patient.
Family Planning Clinics and Brook Advisory Centres should be happy to see
you, but are not always open when you need them or it may be hard to get there.
Some hospital Accident and Emergency Departments ("Casualty")
provide them, but you may be waiting a long time while people with more urgent
problems are seen.
SO: try our Useful Contacts page; if what you want isn't there, you
may need to do some research: checking the phone book or other sources of
information, ringing or asking around. DON'T JUST TURN UP at Brook or
anywhere else unless you are fairly sure that you will be seen, or you may
waste precious time.
What are emergency pills?
They are a special, stronger than usual, dose of contraceptive hormones,
given for a very short time (2 doses of 2 pills, 12 hours apart). They are in
your body for a very short time and do not appear to carry any risks to your
health. But you will need to answer some questions about your medical history
before being given the pills.
The pills may delay the release of an egg from the ovary, or they may change
the womb lining slightly for a short time, making it very difficult for a
fertilised egg to implant in the womb lining. If the egg cannot implant, it
cannot develop into a pregnancy, in the same way that a seed falling on a bare
rock cannot grow into a plant.
Do they have side-effects?
There is no evidence of any serious or lasting side effects, such as cancer,
thrombosis or problems getting pregnant in the future. Some women may get
unpleasant, short-lasting symptoms such as nausea (feeling sick), vomiting,
tiredness and breast discomfort or bloated stomach. These symptoms last a few
hours or maybe a day. The next 2 periods may be earlier or later than usual.
Women who vomit within 2 hours of taking their pills may weaken the effect of
having taken them. Extra pills may be provided to take in case of vomiting
within 2 hours.
Do they always work?
Studies show that the pills are about 98% effective overall. This means that
about 2 out of every 100 women who use the method still get pregnant. But in a
group of women who had unprotected sex at the most risky time of their monthly
cycle, the failure rate was higher- about 5 out out of every 100 women.
How will I know whether the pills have worked?
Many people think that the pills will make you start a period straight away,
but this is not true. You should still have a normal period at about the normal
time. If the period comes on time and seems the same as usual, it is very
unlikely that you are pregnant. However, YOU MAY BE PREGNANT IF the only
bleeding you have is very early (within a week of taking the pills OR if
your period comes on time or late, but is lighter or shorter than usual.
If you have no bleed at all or are not sure that your bleed was a normal
period, you should arrange to have a pregnancy test, but you need to wait until
at least three weeks from when you took the emergency pills- any test done
earlier than 3 weeks may show up as negative even if you are pregnant. Some
people prefer to buy a test from their chemist and others prefer to go and see
their GP (where the test should be free, but you might have to wait several
days) or to a Family Planning Clinic, Pregnancy Advisory Centre or Brook
Advisory Centre, where tests usually take a few minutes and are usually free or
cheaper than buying a test at the chemist or pharmacy. You may need to bring a
urine sample when you have a test done- the first urine passed after getting up
in the morning is best.
What if they don't work?
There is no evidence that the pills can harm either the woman or her unborn
child, but obviously she did not want to be pregnant or she would not have
taken the pills in the first place. Some women will find an unwanted pregnancy
very upsetting, and will want to talk to their partner, family or friends, a
doctor or a counsellor. Brook Advisory Centres provide useful information and
support, whether clients decide to have the baby or to seek an
abortion/termination of pregnancy.
What if I need emergency pills again?
If you have unprotected sex AFTER taking emergency pills, you are at
risk of getting pregnant and should consider how to reduce this risk.
If you have had at least one normal period before needing emergency
contraception again, there is no medical reason why you should not use them a
second, third or any number of times again, as they do not appear to be in any
way harmful. However, you should be looking for a safer, more reliable and
convenient method of contraception for your future! You can get advice about
different methods from a GP, Family Planning Clinic or Brook Advisory Centre.
If you have had emergency contraception less than 3 weeks ago, and have
unprotected sex before having had a normal period, some doctors may not be
willing to prescribe them again; others will discuss the situation carefully
with you and may then issue a prescription.
If you have had emergency contraception more than 3 weeks ago and have not
had a normal period, what you need is a PREGNANCY TEST! If this test is
negative and you have had unprotected sex again, the doctor may prescribe
emergency pills again.
Emergency coil fits: advantages and drawbacks
Having a contraceptive coil fitted into the womb is even more effective in
preventing pregnancy after unprotected sex than the emergency pills. The
failure rate is so small that it cannot be measured accurately. Unlike the
pills, the coil will also continue working as a contraceptive as long as it
remains in the womb.
It can be fitted up to 5 days after unprotected sex, or up to 5 days after
the woman is likely to have released an egg- the doctor will need to work this
out from information about the timing of the woman's periods.
The fitting can be painful, especially if the woman has not had children.
If the woman has had an infection of the womb or tubes (which she may have
caught at the time she had unprotected sex) the coil can make the infection
harder to treat successfully and more likely to cause damage to the womb or
tubes- such damage may affect the chances of a normal pregnancy in the future.
Not all doctors are trained to fit coils. The clinic may be too busy to
offer you this method within the time-limit.
Do I really need contraception if I have just finished my period or am due
to start my period soon?
This is actually very complicated, as periods may be irregular or
unpredictable, especially if you are stressed and worried. Also, no one knows
how long sperms can live in a woman's body- we know they can last 3 or 4 days,
during which time they could fertilise an egg...
If your periods come exactly every four weeks like clockwork, you are most
fertile around days 9 - 15, counting the day your period STARTS as day one.
Most women need to add a few days before and after (to be on the safe side) and
YOU CAN NEVER BE ABSOLUTELY SURE! It's best to talk it over with a
doctor or nurse.
AND REMEMBER, IT'S VERY DIFFERENT IF YOU ARE ON THE PILL!
Do I need emergency contraception if I have missed just one pill?
Probably not, BUT- If you take the everyday "mini-pill"
(progestogen-only pill, prescribed for some women who do not want, or for
medical reasons should not have, the "combined" pill) you are at risk
of pregnancy IF YOU TAKE A PILL MORE THAN THREE HOURS LATE! But most
healthy young women are on the "combined" pill, and take pills every
day for three weeks, then stop for a week.
"ED" (everyday) pills have 7 inactive "dummy" pills,
and 21 active pills. The inactive pills contain no hormone, so taking them is
like having a week off the pill. They look different to the active pills
(different size and/or colour).
While you are taking (active) pills, your ovaries "go to sleep"
and don't ripen eggs. If you have taken at least 7 (active) pills, they are not
doing anything towards ripening an egg. They stay in this "resting"
state as long as you carry on taking (active) pills.
When you stop taking pills, or (take the "inactive" hormone-free
dummy pills) your ovaries start "waking up". Some women's ovaries
wake up more quickly than others, and by the end of the seven days without
hormones can be close to releasing a ripe egg. If this happens, you can get
pregnant even if you only had sex a few days before the egg was released,
because sperms can survive for some days inside a woman's body.
If you start back on pills after no more than 7 days, your ovaries
"stop trying" and "go back to sleep", the egg is not
released and you will not get pregnant. THIS MEANS THAT:
- Missing pills at the beginning of a packet is RISKY especially (a) if you
miss more than one, or (b) or the one you miss is right at the start of a
packet. You can get pregnant unless you avoid sex or use other protection UNTIL
YOU HAVE TAKEN (ACTIVE) PILLS CORRECTLY FOR 7 DAYS WITHOUT A BREAK!
- Missing pills in the middle of your packet is not risky UNLESS YOU MISS A
LOT OF THEM- but see below about stomach upsets or taking other tablets- as
your ovaries will have had at least 7 pills already and will have had at least
7 more pills before you finish the packet, so preventing an egg being ripened.
Missing pills in the last week of your packet is NOT RISKY RIGHT AWAY as
your ovaries have to "start from cold" to ripen an egg- BUT IF YOU
THEN TAKE YOUR WEEK OFF (OR INACTIVE) PILLS AS USUAL, by the end of that week
your ovaries may well have been without hormones long enough to have ripened
and released an egg!
THE BEST WAY TO AVOID PREGNANCY IF THIS HAPPENS IS TO START THE NEXT PACKET
OF PILLS AT ONCE- in other words, don't take your "week off" or, for
"ED pill" users, any of the seven "inactive" pills. You
probably won't see a period by doing this, but that doesn't matter at all.
DON'T FORGET THAT SICKNESS AND DIARRHOEA CAN STOP YOUR BODY ABSORBING
CONTRACEPTIVE PILLS! ALSO, SOME OTHER TABLETS AND MEDICINES (E.G. ANTIBIOTICS)
CAN STOP YOUR BODY ABSORBING PILLS- AND THIS EFFECT CAN LAST FOR A WEEK AFTER
YOU STOP TAKING THEM! If in doubt, ask your doctor or chemist.
IT IS ALWAYS WORTH USING A CONDOM AS WELL AS THE PILL: NOT JUST BECAUSE OF
SAFER SEX AND INFECTION PROTECTION, BUT BECAUSE THE PILL CAN BE FORGOTTEN, LOST
BY VOMITING OR DIARRHOEA, OR NOT ABSORBED BECAUSE OTHER TABLETS HAVE BEEN TAKEN
(see last paragraph).
Are there any women who shouldn't take emergency pills?
Many women who, for medical reasons, should not take the ordinary
"combined" pills can still take emergency pills. The pills do not
stay in the body long enough to produce changes in the blood which could
increase the risk of a blood clot in an artery or vein (thrombosis). However,
if a woman has actually had a thrombosis or similar condition, the doctor may
feel that even emergency pills are too dangerous for her- although getting
pregnant would be even more dangerous! A coil may be suggested instead. A
family history of thrombosis or other serious illness does not mean that you
cannot take emergency pills.
Women who get migraine headaches of the "focal" or
"aura" type, when there is loss of part of the field of vision, loss
of speech or numbness, tingling or weakness in part of one side of the body,
should not take the combined pill, and should be extra careful with emergency
pills. If they feel a migraine coming on before they take the first dose they
should not start the course of pills, and if a migraine comes on after the
first two pills, they should not take the second two. Again, fitting a coil may
be considered.
Although there is not actual proof that emergency pills might harm an unborn
baby, they should be avoided if the woman might already be pregnant- that is,
if she had unprotected sex more than 72 hours ago, but too soon for a pregnancy
test to be reliable (three weeks). Sometimes, if the earlier risk of pregnancy
seems to be very small, a doctor will prescribe emergency pills. If it is not
too late, a coil may be more suitable (see above).
If a woman is breastfeeding, it is possible that the emergency pills may
stop her milk or that it may harm a very young baby when passed into the milk.
(The woman might be able to "express" milk and bottle-feed until the
pills have worn off.) If her baby is less than 6 months old, fully breastfed,
and the woman has not had a period since the baby's birth, she is so well
protected from getting pregnant that she really doesn't need emergency pills,
even if she has had sex without any other protection; this is because she will
not have started releasing eggs yet.
If she is bottle-feeding, and her baby is under three weeks old, she won't
have started releasing eggs yet either, and doesn't need emergency pills even
if she has had unprotected sex. THIS DOES NOT APPLY TO A WOMAN WHO HAS HAD A
MISCARRIAGE OR AN ABORTION who could be fertile again very soon after her
pregnancy ended.
If the woman has had an ectopic pregnancy (outside the womb) in the past, it
is possible that emergency pills might increase the risk of this happening
again- but there is no strong evidence for this, and a coil might increase the
risk more.
SOME MEDICINES (NOT ORDINARY ANTIBIOTICS) INTERFERE WITH EMERGENCY
PILLS. This includes some drugs used for epilepsy, fungus infections, TB
and meningitis. A doctor should be able to check which medicines act in this
way, and a stronger dose of emergency pills may be needed or a coil fitted
instead.
Can I treat myself with emergency contraception, using some of my own or my
friend's pills?
If you or a friend has some spare emergency pills (brand name
"PC4"), perhaps given to cover in case of vomiting pills, it could be
very tempting to use these if you have unprotected sex again, so you don't have
to go to the trouble of seeing a doctor again. This might even be a good idea
IF: (1) You actually need to take them (2) You are not already pregnant (3)
There are no medical reasons why you shouldn't take them (see above). (4) You
know exactly how to take them. (5) You know what to expect- e.g. you might get
sick or vomit. (6) You know about having a pregnancy test if you don't have a
normal period. BUT they are still "prescription-only"
medicines in the UK, although many experts believe that it would be useful to
make them available to buy "over the counter" from a chemist's shop.
Legally, they are only supposed to be taken on the advice of a medically
qualified person, who has the knowledge to decide whether the pills are right
for you and to make sure that all the six points listed above are covered. If
it is really difficult to get to a doctor or clinic within the 72 hours,
occasionally it may be possible to talk to a doctor on the phone, and arrange
for someone to collect pills for you. YOU ARE STRONGLY ADVISED NOT TO TAKE
THE PILLS WITHOUT DISCUSSING THE SITUATION WITH A MEDICALLY QUALIFIED
PERSON.
The situation is even more complicated if you or your friend try to use
ordinary contraceptive pills for emergency contraception, by taking a larger
dose than usual. This can work if you know exactly what to do, but if you take
too few pills it won't work, and if you take too many of the wrong sort, you
might be extremely sick! Things could end in a serious muddle. AGAIN,
CONTACT A SUITABLE MEDICALLY QUALIFIED PERSON AND DISCUSS THE SITUATION WITH
THEM RATHER THAN ATTEMPTING TO TREAT YOURSELF!
Is there any other method of stopping a pregnancy after unprotected sex?
Mini pill hormones have been used as a method of emergency contraception.
The best-known method must be started within 48 hours of unprotected sex, with
a second dose 12 hours later. In parts of Eastern Europe and Asia, there is a
tablet available with the right dose of hormone for this treatment, but this is
not yet available in Britain. The same dose can be obtained by taking 25 of one
type of mini pill (Microval or Norgeston) as a single dose- but swallowing so
many tablets at one time can be a problem! This method seems to be as reliable
as the usual method and is much less likely to cause nausea or vomiting. It may
become more widely used in this country.
Other hormones have been tried out, but none has been developed as a method
for use in Britain yet. Any method which attempts to disturb a fertilised egg
which has or may have implanted in the womb lining is illegal in Britain,
unless the conditions of the 1967 Abortion Act are adhered to. The methods
described above either delay the release of an egg from the ovary or prevent
implantation of an egg into the womb lining. EMERGENCY CONTRACEPTION IS NOT
A FORM OF ABORTION.
This information is brought to you by courtesy of Birmingham Brook Advisory
Centres (BBAC) but does not necessarily reflect the views or practice of
Birmingham Brook Advisory Centres or National Brook. The information has been
compiled by Dr Rosemary Birkill, MB BChir., MRCPsych, DObstRCOG, MFFP, Senior
Doctor BBAC and attempts to reflect the best information available to her at
the time of writing (Dec 97). It is not intended to act as a substitute for a
consultation with a suitably qualified doctor or nurse.
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