No Rx Required

The Fight to Make Morning-After Pills Available Over the Counter

Trussell engaged in a bit of hyperbole: "Emergency contraceptives may work by inhibiting implantation as do regular oral contraceptives—and breast-feeding, too. So we'd have to ban all of that. Anyway, more than half of all fertilized eggs don't implant but go away. It's called having your period—we would have to bury tampons with honor."

Emergency contraception pills are too expensive, too unpleasant, and not effective enough to replace your usual form of contraception. (See below: "How Morning-After Pills Work.") The major side effects are nausea and vomiting, fatigue and headaches. They also do not prevent STDs. But these problems are not serious enough to cancel out the evident benefit of the drugs."People need counseling about how to use them, but only if they have major medical conditions," says Jini Tanenhaus, vice president for clinician training at New York Planned Parenthood. "And screening takes only a few minutes."

Planned Parenthood writes a multiple-use prescription for clients who request it. It also gives out "prophylactic" prescriptions to those who use condoms and other barrier methods as their regular means of birth control. Women can then have a supply at hand whenever the need arises.

illustration by Frances Jetter
illustration by Frances Jetter

Still, the argument that emergency contraception requires better medical supervision than a pharmacist can provide attracts support from across the political spectrum. One pro-choice staffer in the U.S. House of Representatives, who spoke off the record, said, "There is a legitimate debate among people who care about women's health. Would people stop going to gynecologists if they could get the drugs over the counter? An opportunity to educate and examine women would be lost, some people think." Such sentiments are not far from those advanced by the antiabortion group Pharmacists for Life International.

Yet many druggists would gladly accept the challenge of informing their customers, says Craig Burridge, executive director of the Pharmacists Society of the State of New York. He points out that there is a national trend to improve pharmacists' training and involve them in patient counseling on a wide range of medical issues. The society is now cooperating in a program for training pharmacists on the use of emergency contraception.

In the end, the Food and Drug Administration may decide to remove all counseling and prescription restrictions across the country. Last Valentine's Day, a coalition of 76 organizations petitioned the agency to allow morning-after pills to be sold over the counter in pharmacies and other stores. That same day, the OB-GYN professional society issued its own statement supporting this arrangement. "Because emergency contraception poses no known health risks, has minor side effects, and can be taken in two simple, identical doses without medical supervision," says Bonnie Scott Jones, staff attorney at the Center for Reproductive Law and Policy, "it meets all the criteria necessary for over-the-counter status."

A 1996 petition by a similar coalition led the FDA to declare emergency contraception safe and effective. It invited companies to submit marketing applications for specific products. One of the two start-up companies that responded, the Women's Capital Corporation, is now pursuing a traditional testing program to convert its brand, Plan B, to over-the-counter use. Sharon Camp, the company's president, met with FDA officials in February and termed the meeting "positive and constructive." Her application for making Plan B available over the counter is about a year away.

Emergency contraception will be the first new reproductive rights issue confronting the Bush administration. Bush and Tommy Thompson, his new secretary of Health and Human Services, have already shown themselves hostile to abortion. Their handling of this issue will be a sign of how far that opposition extends. "Emergency contraception has been on the brink of going over the counter," says Rosemary Dempsey, director of CRLP's Washington office. "The FDA was clearly leaning in that direction. But Thompson could reverse this. We don't know what's going to happen."


How Morning-After Pills Work

Women can conceive only during the 24-hour ovulation phase in the middle of the menstrual cycle, when an egg is released. At that point, the chances of pregnancy after unprotected sex reach 33 percent. Sperm can survive in a woman's body for up to five days, so that the window for pregnancy is considerably longer than it might appear. But even after sperm fertilizes egg, pregnancy is not assured. A critical step called implantation takes place five to seven days later. That's when the primitive embryo—just a tiny ball of cells—has to attach itself to the wall of the uterus. Much of the time, implantation fails and pregnancy does not occur.

Emergency contraceptives provide a large hit of female hormones that probably affects all these steps. They are known to delay ovulation when taken before that date. They also have considerable effect when sex occurs on the day of ovulation. That is why many researchers believe the drugs also interfere with implantation. But emergency contraception does not interfere with the development of an implanted embryo.

Until 1998, anyone wishing to use the morning-after pill had to take four or five tablets in two doses 12 hours apart and within 72 hours of intercourse. There are now two drugs on the U.S. market that are much more convenient to use. Preven is a combination of estrogen and progestin; Plan B contains progestin only. A large study by the World Health Organization compared the two drugs and found that Preven prevented 57 percent of expected pregnancies while Plan B reduced the number by 85 percent. Nausea, the principle side effect of emergency contraceptive pills (ECPs), occurred in half the women receiving Preven and in a quarter of those taking Plan B. Vomiting was infrequent with Plan B.

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