J

TWO METHODS

Using Combined Pills or Minipills

IN A NUTSHELL

EMERGENCY CONTRACEPTION

Emergency contraception means using a copper IUD or birth control pills to prevent pregnancy after unprotected intercourse. If pills are used within 72 hours after unprotected sex has taken place, they prevent about 75 percent of the pregnancies that would have occurred. An IUD can be effective if it is inserted up to 7 days after unprotected sex.

The emergency method used most often is a double dose of one of the stronger combined contraceptive pills. Twelve hours later, another double dose is taken.

Emergency contraception is not the same as a medical abortion. Emergency contraception prevents pregnancy.

Emergency contraception is prescribed by a doctor or clinic nurse after unprotected sex or an accident with a birth control method. It is also used after a rape.

Emergency contraception does not protect against STDs.

You can get toll-free information about this method by calling 1-888-NOT-2-LATE.

mone is moderate, yet it is sufficient to have an effect: to inhibit ovulation, to slow the passage of the fertilized egg so it reaches the uterus at the wrong time, or to alter the lining of the uterus, which prevents the implanting of a fertilized egg. (For more information on the Pill, see Chapter 7.)

The standard emergency contraception is the Yuzpe method, which uses a birth control pill called "Ovral." Taking two Ovral as soon as possible within 72 hours after the unprotected intercourse and two additional Ovral 12 hours after the first dose adds up to a total of 200 micrograms of estrogen (ethinyl es-tradiol) and 2 milligrams of progestin (norgestrel). This regimen is very safe—there are no known reasons for not using it.

Minipills. The progestin-only pills that have been tested for this use are those containing levonorgestrel. You will need to take 20 of these pills within 48 hours after unprotected sex and a second dose of 20 more pills 12 hours later. These minipills seem to be as effective as combined birth control pills for this purpose, but are less likely to cause nausea and vomiting and other side effects (see Chapter 8.)

Using a Copper IUD

If you choose to have an IUD inserted instead, it can be put in place up to 7 days after the unprotected intercourse in order to prevent pregnancy. This method, however, should be chosen only if you want to continue to use it as a contraceptive. (For more information on IUDs, see Chapter 11.) The ParaGard can be left in place to provide continuous and very effective contraception for up to 10 years.

IUDs are not ideal for all women, however. Women at risk for sexually transmitted diseases because they or their partners have other sexual partners are not good candidates for IUDs. Insertion while an infection is present can lead to pelvic inflammatory disease, which can cause infertility if not noticed and treated. Because of this concern, women who have been raped are not good candidates for emergency insertion of an IUD. However, the risk of pelvic infection from an IUD insertion is small among women in long-term, mutually monogamous relationships who are at little risk for STDs.

The copper IUD alters the endometrium by causing an inflammatory reaction that makes the endometrium inhospitable to implantation by the egg. It also interferes with the fertilization and movement of the egg in the fallopian tubes.

EFFECTIVENESS

A regimen using the combined oral contraceptive Ovral was developed by Canadian physician Albert Yuzpe in the mid-1970s and tested on 1,300 Canadian women. Almost all the women began a menstrual period within 21 days of treatment.

Minipills and combined oral contraceptives reduce the chance of pregnancy by about 75 percent. This does not mean that 25 percent of women will become pregnant. If 100 women have unprotected sex once during the second or third week of their menstrual cycles (when a woman is most fertile), about eight will become pregnant. If those same 100 women had used the Pill or minipill treatment for emergency contraception, only two would have become pregnant, a 75 percent reduction. The efficacy of the treatment may be affected

USING PILLS FOR EMERGENCY CONTRACEPTION

Number of Pills to Take

Brand Name As soon as possible 12 hours later

Ovral

2

2

Lo/Ovral

4

4

Nordette

4

4

Levlen

4

4

Triphasil (yellow only)

4

4

Tri-Levlen (yellow only)

4

4

Alesse

5

5

Ovrette

20*

20

*Must be taken within 48 hours of unprotected intercourse (a progestin -only pill)

*Must be taken within 48 hours of unprotected intercourse (a progestin -only pill)

by the same medications that reduce the effect of birth control pills (see Chapter 7).

Emergency insertion of a copper IUD is 99 percent effective. If 1,000 women had unprotected sex once during their fertile days, an average of 80 would get pregnant. If they had had a copper IUD inserted, at most only one would become pregnant.

HEALTH EFFECTS

The side effects associated with emergency contraception are similar to those associated with the respective methods. For example, with a combined pill treatment you may experience some nausea (sometimes associated with vomiting) and breast tenderness. Some physicians and clinics automatically provide an antinausea medication to use in case of vomiting. Extra contraceptive pills are usually provided in case the first pills are vomited in the first hour. Some women may also experience abdominal pain, headache, or dizziness with this treatment, but all side effects usually subside quickly.

The progestin-only pill is less likely to produce such side effects. The possible side effects of having an IUD inserted are described above and in Chapter 11.

Emergency contraceptive pills may change the timing of your next menstrual period so that it is a few days earlier or later. If bleeding does not start within 3 weeks after the treatment, however, you should have a pregnancy test.

Another health issue associated with emergency contraception is the possible effect on the fetus if the treatment does not succeed and you become pregnant and decide to have the baby. Studies have found no increased risk of birth defects in cases where women continued to take birth control pills after they unknowingly were pregnant. Failure of the IUD method is extremely rare, but if it occurs, the IUD is removed and there is no known increased risk of birth defects.

USING EMERGENCY CONTRACEPTION

If you decide you need emergency contraception, obviously it is important to act swiftly. Although it is steadily becoming more available, in some parts of the United States it may take a little time to locate a provider.

Finding a Clinic or Practitioner

If your own doctor is not familiar with emergency contraception or unwilling to prescribe it, many women's health centers and family planning clinics, including Planned Parenthood clinics, offer emergency contraception. (Although many family physicians and gynecologists may be aware of this treatment, they may not be accustomed to providing it.) Doctors and nurse practitioners can provide this care. University and college health centers also may offer this service. If you are not a student, the centers may able to give you information or a referral.

Because this treatment is successful only if started very soon after unprotected intercourse, it is important to find assistance immediately.

When you telephone a practitioner or clinic, be prepared to an swer the following questions:

• What -was the date of your last menstrual period?

• On what date and at what time did the unprotected intercourse occur?

• Have you had unprotected intercourse at any other time since your last period?

Telephone screening saves vital time in scheduling you for emergency contraception or when referring you to another source of care, which sometimes is necessary. If you have serious health problems, for example, you almost always will be told to see a private physician for emergency contraception. If you call a clinic or practitioner because you were raped, you will probably be referred to the nearest rape crisis center or the emergency room of the local hospital. Rape is a criminal act, and rape centers are trained to gather evidence and deal with the other legal issues involved, as well as provide medical care and emotional counseling.

You should be aware that some antiabortion groups advertise in the Yellow Pages as "family planning centers" or abortion providers. They may discourage you from using emergency contraception. It can be difficult to tell the difference; however, if they will not set up an appointment for that day, they may not be a real health clinic. If they sound at all reluctant to see you promptly, ask why. If you are a candidate for emergency contraception, a legitimate clinic will schedule you to be seen right away or, if its schedule is too crowded, it will refer you to another source of care.

NOTE: If you do not have ready access to a health clinic that offers this treatment, you can call the emergency contraception hotline (1-888-not-2-late) for the name of clinicians in your area who provide emergency contraceptives.

The hotline will provide information on the methods and give you the names and telephone numbers of three health care practitioners in your area who provide this care. The hotline is accessible from any touch-tone telephone. If you live in an area where there are few providers, the nearest one may be several hours away, but you will still receive the names, locations, and telephone numbers of three practitioners.

EMERGENCY CONTRACEPTION TREATMENT

If you already are a patient of a particular health care provider or clinic and you have had a recent checkup, it may be possible to have the pills prescribed over the telephone.

If the practitioner you call does not know you or have your medical record, you will need to be scheduled for an emergency visit. You should be seen as soon as possible; if this cannot be done, find another provider right away.

If you are not a regular patient of the doctor or the clinic, a health history and a physical examination may be part of emergency contraception. You also will be asked to read and sign a simple informed consent form. Along with the contraceptive pills, you will be given an emergency telephone number to call if you experience any side effects. If an emergency number is not supplied, ask for it.

You will be given the pills and will probably be told to take the first ones at the clinic. The sooner the hormones enter your blood stream, the more effective they will be. You take the second set 12 hours after the first. You may want to time the first set of pills so that you do not have to wake up in the middle of the night to take the second set. (For example, if it is still within the 72 hour period, take them at 7 p.m. instead of 3 p.m.) Even if you become nauseated, the symptoms usually are very mild and disappear by the next day. (Some physicians suggest having a snack with the pills.)

If you vomit within 60 minutes of taking the pills, however, use the antinausea medication supplied by the clinic and then take the extra pills you were given. Follow them with the final set of pills 12 hours later. (If the practitioner is using Ovral, the most common method, you will take two pills.)

EMERGENCY CONTRACEPTION FOLLOWING RAPE

If you have been the victim of a sexual assault, seek care immediately. The best care is almost always found at a Rape Crisis Center, because you will need expert counseling, you may have been exposed to an STD and need to be tested and treated, and rape is a criminal act that should be reported to the police.

You can locate a Rape Crisis Center by calling the nearest hospital, a women's health center, or your local police or health department. If there is no such center in your community, the emergency room of the local hospital may have health care workers trained to handle this sort of emergency. If none is available, seek care at a family planning clinic, women's health center, or sympathetic private physician. Or call the Planned Parenthood clinic in the nearest large city for assistance.

At a Rape Crisis Center, you will be given a physical examination. Information is gathered on the sex acts performed, whether ejaculation took place, what sort of contraception you are using, and where you are in your menstrual cycle. A pregnancy test is performed to rule out the possibility of an earlier, unknown pregnancy. If you are not pregnant but are at risk for pregnancy from the rape, you will be treated with combined oral contraceptives to avert a pregnancy.

(If you do not get your next period after the rape, arrange for a pregnancy test. Many Rape Crisis Centers or Planned Parenthood clinics offer such tests if you do not have a physician of your own.)

A health care provider also will take blood and vaginal samples to test for gonorrhea, chlamydia, and syphilis. You will be given antibiotics to protect you against these STDs. You will also be counseled on how to deal with the possibility that you may have been infected with herpes or AIDS.

As part of the physical examination, evidence of the assault is collected. It is sent to the police crime laboratory and filed in case the rapist is caught and you want to have him prosecuted. In most cases, the evidence is labeled by number rather than name, in order to protect your privacy.

You may find it useful to discuss emergency contraception with your doctor or clinic before you need it. Practitioners are increasingly comfortable giving women a dose or two of emergency contraception in advance so they have it on hand just in case. And if your physician does not wish to provide emergency contraception, it is a good idea to locate a clinic or practitioner who will.

Emergency contraception is meant only for very occasional use and should not be considered a substitute for regular birth control. Regular birth control methods are much more effective and are less likely to cause nausea. If you need emergency contraception more than once or twice because your contraceptive method failed, you may want to consider changing methods.

COST

The cost of emergency contraception depends on what method you use and where you receive it. The cost for oral contraceptive treatment averages $60 for the office visit and the pills. If a pregnancy test is required, the cost is higher. If you want to be treated with minipills, the cost will be about $80 because two packs of Ovrette are needed. Most expensive is the emergency insertion of an IUD, which can range from $300 to $700 and includes the device itself, counseling, a physical exam, any necessary tests, and the insertion. Although this initial cost is high, the ParaGard IUD provides extremely effective contraception for at least 10 years.

Some clinics subsidize these costs for low-income women through sliding fees. Some insurance plans pay for emergency contraception. HMOs charge their usual low co-payments for office visits, prescriptions, and IUD insertion.

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