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Morning after pill

Sometimes accidents happen, condoms split, several missed pills or no contraception is used. The emergency contraceptive pill, also known as the morning after pill, offers women the ability to prevent an unwanted pregnancy. This article will focus on how emergency contraceptive pills such as Levonelle® and ellaOne® work, where they're available from, how they should be taken and alternatives to emergency contraceptive pills.

Where can I get it from?

In the UK, there are currently two types of emergency contraceptive pills: Levonelle® and ellaOne®. EllaOne® is a relatively new drug and not easily available. I will focus on ellaOne® later in this article. The use of Levonelle® is well established and is readily available from:

Your GP
Pharmacist
Family planning clinics
Accident and Emergency

Levonelle® is free when obtained from your GP, using an NHS prescription and from family planning clinics. Certain pharmacists are able to provide the emergency contraceptive without a doctor's prescription, however a charge of £26 is levied. Accident and Emergency departments should only be used as a last resort.

How does it work?

Levonelle® is a progesterone based hormone (a female sex hormone). We still don't know for certain the exact mechanism of how it works. The general consensus is that it inhibits ovulation (release of an egg from the ovaries); however, it may also prevent fertilization (fusing of sperm and egg) and possibly implantation. The emergency contraceptive pill does not cause an abortion. Technically speaking, an abortion can only occur once a fertilized egg has implanted it self into the lining of the womb.

Levonelle® is extremely effective when taken correctly and has been shown to reduce the risk of pregnancy down to 1%.

How do I take it?

Levonelle® is not suitable for everyone; it is contraindicated in the following cases:

Prophyria (a very rare condition)
Severe liver disease
Previous ectopic pregnancy
May not be suitable in conditions such as Crohn's disease

Time is crucial when it comes to taking Levonelle®. It must be consumed within 72 hours of unprotected intercourse. Ideally, it should be taken within 12 hours after unprotected intercourse. As time elapses after unprotected intercourse the effectiveness of the drug decreases significantly:

Levonelle® taken 0-24 hours after unprotected sex - 95% effective
Levonelle® taken 25-48 hours after unprotected sex - 85% effective
Levonelle® taken 49-72 hours after unprotected sex - 58% effective

Levonelle® is well tolerated by most women, however some women may experience nausea and vomiting. If you vomit with in 2-3 hours of taking Levonelle® then another dose must be taken. Other common side effects include headache, dizziness and breast tenderness. Less common side effects can include irregular spotting and bleeding. After taking Levonelle®, if you suffer with an early or delayed withdrawal bleed, or your period is on time but is abnormally heavy, then an ectopic (implantation as occurred, but not in the womb) pregnancy must be excluded, and it is advisable to see your doctor as soon as possible.

Alternatives to Levonelle®

If the time elapsed after unprotected intercourse is greater than 72 hours, or if Levonelle® was not tolerated, then alternative emergency contraception must be considered to prevent an unwanted pregnancy. There are currently two options:

EllaOne®
Intrauterine emergency contraceptive device

EllaOne® (ulipristal)

EllaOne® is a new emergency contraceptive which was given a license last year. Small trials including women from the UK, USA and Ireland have shown ellaOne® to be effective at preventing unwanted pregnancy even after the 72 hour limit normally advised for Levonelle®. This means the drug could be taken up to 120 hours (five days) after unprotected intercourse.

EllaOne® is a prescription only medication. It will not be available over the counter until more is known about its long term safety profile.

The Intrauterine Emergency Contraceptive Device

The Intrauterine emergency contraceptive device, also known as the emergency IUD, is a small copper device that is inserted into the uterus (womb) via the vagina. It has the benefit of being effective up to five days after unprotected intercourse and can continue to be used as a regular contraceptive. The disadvantage is that it must be fitted, which would normally take place at a family planning clinic.

Long Term Contraception

Studies examining the emergency contraceptive found that many women went on to become pregnant in the next cycle, as they continued to have unprotected intercourse. This indicates the importance of considering long term, or continued contraception.

After taking Levonelle® or ellaOne®, it is wise to discuss continued contraception with your doctor or family planning clinic. Suitable methods for long term contraception may include:

Combined oral contraceptive
Progesterone only pill
Progesterone injection (taken every 3 months)
Contraceptive implant (inserted into the skin of the arm and lasts 3 years)

Sexually Transmitted Infections

It is important to point out that having unprotected intercourse not only exposes you to the risk of an unwanted pregnancy, but also to sexually transmitted infections (STIs), which are presently on the increase. You may not wish to get pregnant now, however chronic infections with bacteria, such as Chlamydia, can lead to infertility later in life as well as chronic pelvic inflammatory disease. Additionally, through unprotected intercourse with multiple partners, women can expose themselves to multiple strains of the Human papilloma virus, which increases the risk of cervical cancer. Please remember to use condoms. Keep well informed and read our article on STIs.

Further Information

To find out where your local family planning clinic is, or for more information on sexual health and contraception, visit the Family Planning Association's website (FPA). The FPA is the UK's leading sexual health charity. They aim to help people make informed decisions about sex and maintain good sexual health.

Sources

1. Westhoff, C. Emergency contraception. The New England Journal of Medicine, 349(19), 2003, pp. 1830-1835.

2. Levonelle-2 for emergency contraception. The Drugs and Therapeutic Bulletin, 38(10), 2000, pp. 75-77.

3. GPnotebook. Emergency contraception (evidence relating to efficacy). Available at: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1590362041&linkID=5727&cook=yes (Accessed: 8 February 2010).

Author: Dr Shazan Chughtai MB BS

Editor: Mr Shiraz Mughal, MPharmS

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