THE MORNING AFTER PILL: FACTS AND FICTION

UPDATED JANUARY 2018Morning after pill

“The morning after pill is dangerous”. “You can’t take it more than once or twice in your lifetime”. “If you take it you won’t be able to become pregnant in the future”…

You may have heard all these rumours about the morning after pill and, in case “an accident” happens, you will think twice whether to take it or not… The truth is, the morning after pill has been around for more that 40 years now, but still many misconceptions and controversies persist.

In this article we will try to sort fact from fiction regarding the morning after pill in order to help you make your educated decision…

What is the morning after pill?

Emergency contraception by doctor emergency-contraception_171x200_M9201502The morning after pill, or post-coital pill is a form of emergency contraception that will prevent you from becoming pregnant after an unprotected intercourse, or if a condom breaks during intercourse.

In most countries, there are two types of emergency contraception pills (ECP):

-one containing levonorgestrel (LNG: Norlevo, Levonelle, Plan B, in different countries)

-another containing ulipristal acetate (ella in the USA, EllaOne in Europe).

In many countries such as the UK, France, USA, you may be able to get it (just LNG or both of them) without a prescription.

-When these ECPs are not available, certain ordinary birth control pills can be used as emergency contraception. The regimen is one dose of 4 to 6 pills -depending on the brand- followed by a second dose 12 hours later (the Yuzpe regimen, read more here). If you choose this method, though, it may be a good idea to talk to a health care provider for guidance.

Mifepristone is another highly effective emergency contraception method, available in few countries. However, this medication is also used to induce medical abortion, which may limit its widespread acceptability for use as ECP.

How does it work? Does it cause abortion?

The morning after pill prevents pregnancy by temporarily blocking the egg from being released (that is, inhibits ovulation). In addition, it may stop fertilization. Some people are concerned that the ECP may prevent a fertilised egg from becoming implanted in the uterus, which may be considered as an early abortion. Recent studies have shown that this medication is not effective when ovulation has already occurred, thus it does not seem to prevent implantation. Furthermore, in case an implantation has already occurred before you took it, the morning after pill will not provoke an abortion.

Do I have to take it right away?

Actually “morning after” is a bit of a misnomer: you can take ECP up to five days following unprotected sex. 

Until recently, it was accepted that pills containing LNG (Norlevo, Levonelle, Plan B) should be taken within 72 hours (three days) after the “accident”. However, recent evidence shows that LNG pills continue to be moderately effective if started between 72 and 120 hours; therefore LNG ECP can be taken up to five days after unprotected intercourse.The same is true for EllaOne/ella: it can be safely used up to five days after non-protected sex.

But the sooner you take it, the more effective it is (see below).

Is it effective?

Emergency contraception uhoh_poster_collageNeither type of morning-after pill is 100 per cent effective, but the failure rate is quite low. Like we said, you should take it as soon as possible after unprotected sex, no matter which pill you use. If you take LNG pills within the first 24 hours after sex, they reduce your risk of pregnancy by up to 95%; the efficacy will be reduced the more you delay the ingestion of the pill, roughly to 85% the 2nd day, 60% the third day.

Recent studies have confirmed that EllaOne/ella is more effective than the LNG pill, not only when taken 3-5 days after an unprotected intercourse, but also within the first three days.

Will I get severe side effects?

Emergency contraception pills are very safe: no deaths or serious complications have been ever linked to their use. Moreover, emergency contraception pills do not harm future fertility.

In general, side effects are uncommon and generally mild: the most common are nausea, vomits and menstrual abnormalities (your period may come earlier, later, with more or less blood than usual); more rare side effects are fatigue, breast tenderness, headache and abdominal pain.

There is some controversy as to whether the morning after pill is associated with an increased risk of ectopic pregnancy (a pregnancy outside the uterus, usually inside the fallopian tube). Available evidence suggests that ECP do not increase the chance of ectopic pregnancy; moreover, like all contraceptive methods, they reduce the absolute risk of ectopic pregnancy by preventing pregnancy in general.

Is there any limit to the number of times I can take it?

Emergency contraception womant taking 47929

It has been suggested (mostly by internet rumours) that it could be dangerous to take the ECP more than one or twice in your life. The following is an excerpt from the World Health Organization’s (WHO) site which throws light on this subject:

“There are no restrictions for the medical eligibility of who can use ECPs. Some women, however, use ECPs repeatedly (…) as their main method of contraception. In such situations, further counselling needs to be given on what other and more regular contraceptive options may be more appropriate and more effective. Frequent and repeated ECP use may be harmful for women with conditions classified as medical eligibility criteria (MEC) category 2, 3,or 4 for combined hormonal contraception or Progestin-only contraceptives (POC). Frequent use of emergency contraception can result in increased side-effects, such as menstrual irregularities, although their repeated use poses no known health risks”.

In other words, you shouldn’t take the ECP very often because: 1) you’d rather take the regular contraceptive pills and you will be better protected from unwanted pregnancy; 2) you may get some abnormal periods, BUT IN MOST WOMEN, ECP ARE NOT DANGEROUS! 3) in case you have a severe health problems such as history of stroke, blood clots, certain cancers, etc, then you should avoid frequent and repeat use.

In fact, the Royal College of Obstetricians, says that the LNG pill can be used even more than once in the same cycle. However, it does not recommend taking EllaOne in this way because, being a newer medication, we have not enough evidence for repeated use in the same cycle (although recent evidence indicates that it can be safely used more than once per cycle).

If you find yourself using the morning after pill very often, it might mean that you haven’t yet found a regular method of birth control that works for you. In that case, talk to your doctor about some of your other options.

If ECP fails and I get pregnant, will it affect my unborn baby?

LNG has been used for many years, and evidence shows that there is no increased risk of birth defects or other effects on the baby; new data supports that Ellaone/ella is as safe as LNG and no birth defects have been reported so far.

Can I take ECP if I breastfeed?

You may safely take the LNG pill if you are breastfeeding. Although EllaOne was not recommended during lactation until recently, updated guidelines state that ellaOne is not contraindicated for breastfeeding women, but that breastmilk should not be given to a baby for 24 hours (in the USA guidelines) or one week (in Europe) after a woman has taken the product.

Some final warnings…

  • Emergency contraception keep-calm-and-take-the-morning-after-pill-7The ECP will protect you from an unwanted pregnancy, but it will not provide any protection from sexually transmitted diseases. It is very important that you are aware of safe sexual practices and  incorporate them into your relationships.
  • There is some evidence that the LNG pill might be less effective in women weighting 75kg or more, while the efficacy of EllaOne does not seem to be affected by body weight. Thus, if you are over 75 kg you may prefer to take EllaOne.
  • The efficacy of the ECP will be decreased if you vomit after taking it. If you vomit within 2 hours of taking LNG pill, or 3 hours of taking EllaOne, you will need to take it again.
  • Contraindications: according to the WHO: “There are no medical contraindications to the use of levonorgestrel emergency contraception pills”. Some experts advise against its use in women with severe liver disease.
  • Interaction with other medications: some medications may eventually reduce the effectiveness of the ECP: Saint John’s wort, barbiturates, rifampicin, among others.
  • When to see your doctor: although the ECP may delay your period, contact you doctor if your period doesn’t come some days after the expected time. Likewise, it’s very important that you see your doctor right away if you have irregular bleeding and abdominal pain, to rule out the possibility of an ectopic pregnancy.

The bottom line:

Emergency contraception plan B 1258645.largeThe emergency contraception pill is a safe and effective method of contraception. Most of the rumours you may have heard  about it, are unfounded.

Having said that, it should not be abused.

The (very clever) brand name of the ECP in the USA, Plan B, indicates clearly how this medication should be used: as an option when your plan A (your regular contraception) failed…or wasn’t there.

Related reading:

Contraception: 14 common myths – busted

Fact or myth? Truths, half-truths and misconceptions about the Birth Control Pill

References:

World Health Organization: Emergency Contraception. Fact sheet N°244  June 2017

Trussell J, Raymond E, Cleland K; Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy. November 2017