New 5-day morning-after pill in 'promiscuity' claims

“The promiscuity pill: £30 morning-after tablet that can be taken five days later ‘will lead to unsafe sex’”, is the Daily Mail’s over-the-top headline today. The paper announces that women aged 18 or over will be able to buy a newly introduced ‘powerful medication’ (ulipristal acetate, brand name ellaOne) over-the-counter from certain branches of the Co-Operative Pharmacy.

The difference between this new form of ‘morning-after pill’, or emergency contraceptive pill, and the current widely used pill containing levonorgestrel (brand name Levonelle), is that it can be taken up to five days after sex (whereas you can only take Levonelle for up to three days after sex). However, both drugs should ideally be taken as soon as possible after unprotected sex to ensure maximal effectiveness.

EllaOne is already available on prescription, and Levonelle emergency contraception has been available to buy over-the-counter without prescription for women aged 16 years and older for some time. Therefore, suggesting that over-the-counter availability of ellaOne may encourage sexual promiscuity is a huge assumption.

The Mail reports that ‘campaigners’ consider that the move will encourage unprotected sex and that it is an early form of abortion. However, neither form of emergency contraception is medically considered to be a form of abortion - which is defined as the early termination of a viable pregnancy.

Also, the reporting on this story does not make it clear that the five-day window of opportunity to take some emergency contraception pills is not unique to ellaOne. The alternative non-hormonal form of emergency contraception is the IUD (intra-uterine device), sometimes called the coil. This can be fitted by a doctor up to five days after unprotected intercourse.

Ideally, you should practice safer sex and use an effective form of contraception. This is particularly important as no form of emergency contraception is effective against sexually transmitted infections (STI).

What is the basis for these current reports?

The Daily Mail has reported that ellaOne will be available to purchase over-the-counter from around 40 branches of the Co-operative Pharmacy in southern England and Wales. The drug will reportedly cost £30. Until now, ellaOne has only been available on prescription. This is said to have raised concerns among campaigners over whether the drug will lead to increased promiscuity and unprotected sex, and whether it is a form of abortion.

What is ellaOne?

EllaOne is an emergency contraceptive pill - a so-called ‘morning after pill’. There are currently two licensed emergency contraceptive pills, which are based on slightly different chemicals and have slightly different modes of action – the key practical difference between them being the time window in which they are effective. Both are one-dose, single tablets.

The most commonly used, and most commonly known, is the synthetic progesterone hormone, levonorgestrel, which has the brand name Levonelle. Levonelle is already available to buy over-the-counter to people aged 16 and above, or it can be prescribed by a doctor. To ensure maximal effectiveness, this pill should be taken as soon as possible after unprotected sex (preferably within 12 hours), but it can be taken up to three days (72 hours) after sex.

The pill that has made the headlines is an alternative, less commonly known, pill that is made using the chemical ulipristal acetate, brand name ellaOne. Ulipristal acetate acts slightly differently to levonorgestrel, by acting on a progesterone receptor rather than being an artificial progesterone hormone itself. Like Levonelle, it should be taken as soon as possible after unprotected sex, but the key difference is that it has a longer effective time window and can be taken up to five days (120 hours) after sex. Until now, this pill has only been available on prescription.

There is a third, non-hormonal, form of emergency contraception (ignored in the media reporting) which, like ellaOne, can also be used up to five days after unprotected sex. This is the IUD, though this can only be fitted by a doctor. It is not only a form of emergency contraception, but also an ongoing form of longer term contraception. However, there are additional considerations that the doctor and patient would need to take into account when considering this method – for example you cannot have an IUD fitted if you currently have a STI.

How does ellaOne work?

Both ‘morning after’ pills act via the hormone progesterone – Levonelle being a synthetic progesterone hormone and ellaOne being a chemical that acts on the progesterone receptor that binds to the progesterone hormone.

Progesterone is a hormone that women’s bodies naturally produce, it works by:

• stopping the ovaries from releasing an egg
• making it harder for sperm to penetrate the cervix (the entrance to the womb) and fertilise an egg
• reducing the chances of a fertilised egg implanting into the womb

Are there any side effects?

The side effects most commonly caused by both types of morning after pill – ellaOne and Levonelle - are gastrointestinal disturbances (nausea, vomiting and diarrhoea), tiredness, irregular menstrual bleeding before your next period, and sometimes back pain, breast tenderness, headache and dizziness. EllaOne has less commonly been associated with tremor, dry mouth, hot flushes, blurred vision, itching and rash. The main warning is that ellaOne should not be used by people with asthma.

It is also important that women using either morning after pill are aware of certain issues:

• ellaOne may be less effective if you vomit within three hours of taking it (or within two hours if it is Levonelle). If this happens, you need to speak to a health professional as a second tablet is likely to be needed
• a barrier method of contraception (such as a condom) must be used until the next period (which may be either early or late)
• you should see a doctor if you experience abdominal pain after taking the pill (this is rare, but could be a sign of an ectopic pregnancy, where a fertilised egg has implanted outside of the womb) - though there is no evidence that emergency contraception increases the risk of an ectopic pregnancy
• women who do not experience a subsequent period, or have a period that is different from normal – light or heavy – should consult a doctor in case there is the possibility of pregnancy
• you should discuss any medications you are currently taking with the healthcare professional providing the pill (doctor or pharmacist), as the effectiveness of ellaOne or Levonelle may be affected by certain drugs
• ellaOne is contraindicated in pregnancy; this is because there is limited information available on the potentially harmful effects that ellaOne could have upon a developing fetus. This should not prevent use of ellaOne within the recommended time frame (i.e. within 5 days of unprotected sex), but if there is any doubt (e.g. you may have also had unprotected sex at another time beforehand) then a pregnancy test is recommended

Where is the morning after pill usually available?

Both forms of emergency contraceptive pill can be accessed, free of charge, from:

• GPs
• most family planning and contraception clinics
• most sexual health clinics (sometimes referred to as genitourinary medicine or GUM clinics)
• most young persons' or Brook clinics
• most NHS walk-in centres
• most NHS minor injury units
• some hospital accident and emergency departments

Women older than 16 years can buy the emergency contraceptive pill (Levonelle) from most pharmacies and some private health clinics. The final availability of ellaOne – that is, which pharmacies will stock it – is not known at the current time.

What about the issues around promiscuity and abortion?

Neither of the two emergency contraceptive pills, or the copper coil, are medically considered to be forms of abortion, they are simply forms of emergency contraception. All forms of emergency contraception aim to either:

• prevent the release of an egg
• prevent fertilisation from occurring
• prevent a fertilised egg from implanting and developing further – if fertilisation has occurred

Emergency contraception aims to prevent pregnancy, not to terminate it. It is also important to note that ellaOne and Levonelle are completely different from the medical pills used to terminate an established pregnancy.

The basis for the assumption that the availability of ellaOne over-the-counter may encourage promiscuity is not clear. Levonelle has been available over-the-counter for some time. The main difference between this and ellaOne is that the latter can be taken within five days of unprotected sex, whereas Levonelle can only be used within three days. However, the five-day time window is not a feature unique to ellaOne, as the alternative non-hormonal form of emergency contraception - the IUD – can be fitted by a doctor up to five days after unprotected sex.

The IUD has now been used for several decades. It would be hard to imagine headlines about ‘the sexually impulsive IUD’.

The key thing to be aware of is that emergency contraception is not intended as a routine contraceptive measure. The best way to protect against unwanted pregnancy is to use effective contraception. Also, emergency contraceptives do not protect against sexually transmitted infections (STIs), a condom is still the best way to prevent yourself contracting an STI.