The Other Morning After Pill

She was a student putting herself through school on tips. A Russian and international relations major, her dream was to become a translator for the United Nations.He was an architect with eyes the color of unripe blueberries. He wooed her with expensive entrees, straight-laced manners and Ken-doll looks.She never meant to sleep with him so soon, but after polishing off half a bottle of merlot on their second date, she awoke beside him in a panic. They'd had sex without condom, sponge or diaphragm. She just knew she was pregnant.Four-and-a-half weeks later, the home pregnancy test confirmed her intuition. So did the counselor at Planned Parenthood. The decision was agonizing, even for a lapsed Catholic. After days of tears and stunted conversations with a man she barely knew, she made an appointment at a downtown clinic. He demurred. Her body, he'd said -- and the choice -- were hers. She waited extra tables to get the $350 to pay for the abortion. When it was done, her tears were replaced by cramps, a dull feeling of relief and the nagging belief that she'd just consigned herself to Hell.Sixty percent of all pregnancies in the United States are mistakes. It is estimated that half of those unintended pregnancies are the result of contraceptive failure. The rest are the consequence of no protection at all.Of those American women who wait and worry and pray for a red spot on the panties that never comes, 1.5 million annually choose abortion.But what if there were a product on the market a woman could take if she thought she might be in trouble? A contraceptive designed to be used after the sponge has slipped? A last-ditch safety net for rape victims, women swept away by the moment or too drunk to care? A girl can dream.The news is, she doesn't have to.Such birth control technology already exists. And it's not languishing in the U.S. Food and Drug Administration's "Don't Open Till Xmas 2000 file." Nor is it only available in Amsterdam. It's here, a prescription away, at a local Planned Parenthood or university health clinic near you.A higher-than-normal dose of certain birth control pills taken within 72 hours of having unprotected sex can prevent pregnancy. Emergency Contraception Pills (ECPs), also known as "the morning- after pill" -- an unfortunate misnomer, as the drugs can be taken anywhere from three minutes to three days after risky intercourse -- were discovered more than two decades ago. ECPs act differently from one woman's body to the next, depending upon where she is in her menstrual cycle and when she had sex.Popping two pills containing estrogen and progestin, then another two pills 12 hours later, could do a number of things. The short, high burst of hormones may prevent or delay ovulation. Or it may block fertilization or the implantation of the fertilized egg in the lining of the uterus.There are two other emergency contraceptive options as well: the minipill, which contains smaller doses of the hormone progestin, and the copper-T I.U.D., which can be inserted up to five days after unprotected sex and reduces the risk of pregnancy by 99 percent. Contrary to popular belief, RU-486, or Mifepristone, the long- awaited "French abortion pill," is not the fabled morning-after miracle. Although there is evidence that RU-486, if used soon after sex, will prevent pregnancy, it belongs to an entirely different class of drugs and can be given through the end of the sixth week of pregnancy to induce a spontaneous abortion. ECPs, on the other hand, are only effective within a three-day window before a woman becomes pregnant. If you are already pregnant, emergency contraception will not work. Simply put, RU- 486 terminates a pregnancy; ECPs pills prevent pregnancy in three out of four women who swallow them.'Why did I have to make the decision at all?' "It was basically a one-night stand. It was one if the stupidest things I ever did."Sue was a 23-year-old cocktail waitress slinging drinks to get her bachelor's degree when she became pregnant. Has she known about ECPs then, she would have moved heaven and earth to get a prescription filled the next morning. But she didn't know she had that option and is haunted by that night of poor judgment. Now a lawyer in her 30s, "I don't like being a woman who's had an abortion," she says. "I live with my decision everyday -- it's not that I rue over it, but it's not a decision I will ever be completely comfortable with."I'm pro-choice and I always will be, but why did I have to make the decision at all?"At bottom, emergency contraception may be nothing short of a long sought-after patch of common ground, a place where both pro- choice advocates and abortion-stops-a-beating-heart devotees can stand.Yet, according to a 1994 survey conducted by the Henry J. Kaiser Family Foundation, only about 1 percent of American women have ever used emergency contraception. The same study found that although most U.S. obstetricians and gynecologists are in the know about ECPs, only 16 percent prescribe them "more than five times a year."So why aren't the drugs being handed out like jelly beans at Easter?One stumbling block has been the FDA's reluctance to approve birth control pills for use as emergency contraceptives. For 20 years, the white, orange and yellow tablets were legal, just not blessed - kind of like a common law marriage."Why is emergency contraception the nation's best-kept secret?" asks a Princeton University ECP Website. "One of the main reasons is that no company has applied to the Food and Drug Administration to market emergency contraception." Afraid of product liability lawsuits, picket lines and boycotts from the right-to-life front, pharmaceutical makers have never asked the FDA for permission to slap new labels and dosage instructions on oral contraceptives. Until then, birth control pills can be quietly prescribed as morning-after pills, but cannot be advertised for that purpose. As a result, emergency contraceptives have yet to receive the Madison Avenue fanfare that usually attends the debut of the drug du jour."The two biggest U.S. companies that market these pills - Wyeth-Ayerst and Berlex - have publicly said that they're not interested," says the FDA's Dr. Lisa Rarick. And the feds weren't interested in twisting drug makers' arms, despite a citizen petition filed in 1994 by the Center for Reproductive Law & Policy asking the FDA to do just that. The plea was swiftly declined. "It's something we've not done," says Rarick. "Companies have rights, too."That they do. Both Wyeth-Ayerst and Berlex package and sell their products as emergency contraceptives in Europe. 'Safe and effective'In June of 1996, the FDA dubbed postcoital pills "safe" and placed their average rate of effectiveness at 75 percent. "If 100 women have unprotected intercourse once during the second or third week of their menstrual cycle," the FDA concluded, "about eight will become pregnant. But if those same women use emergency contraception after intercourse, only two will become pregnant." But a spokeswoman for Wyeth-Ayerst told the Philadelphia Inquirer in February that the company still intended to cold- shoulder ECPs, for fear of getting sued. In the same article, Berlex made no comment on the FDA action.Interestingly enough, since the United Kingdom approved emergency contraception in 1984, more than 4 million women there have been prescribed the drugs. The British Medicines Control Agency has recorded only six "serious adverse reactions" to the pills from 1984 to 1996. Of these, only one was found to have been caused by ECPs.Before the FDA legitimized emergency contraception, the 16 centers making up Planned Parenthood of Greater Iowa (PPGI) were barred from promoting the use of ECPs. The group's insurance provider wouldn't allow it."We could give our patients the information and we could offer emergency contraception, but we couldn't publicize it," says PPGI's Becca Loftus-Granberg. Despite the ban, the organization began dispensing pills in 1989. "We were more willing to offer emergency contraception than anyone else in the state. We've written more than 900 prescriptions in the last year."Within that same period, according to the 1996 annual report, 7,058 women visited Planned Parenthood clinics throughout the state for a pregnancy test; 2,823 came back for an abortion. Although all prospective clients now receive a pamphlet on ECPs, if a woman is in the waiting room because she's missed a period, the information has come too late. But while most American women have been kept in the dark about ECPs, the drugs have been slipped to rape victims in emergency rooms for years.Drake University law student Julie Harders was 26 when she got her first exposure to the fabled morning-after medication. Upon checking into Broadlawns' ER, two days after being raped, "they gave me the sexual assault exam and part of the procedure was to give me the morning-after pill." Although Harders had heard about such a drug, "I thought it had only been recently approved in the U.S. I didn't think it was used that much except in cases like mine." While the prescription couldn't erase the horror of the violation, "at least I didn't have to deal with the additional worry of becoming pregnant."The drugs that gave Harders some sorely needed peace of mind simply haven't been offered to women outside the walls of trauma centers. It's as though we will allow the need for emergency contraception when a woman has been victimized, but grow squeamish for less sympathetic souls: teens who didn't abstain, sorority chicks who couldn't hold their liquor, the single mother of two who forgot to go in for her Depro-Provera shot. This "you play, you pay" mentality has kept the lid on a simple regimen that could, by some estimates, cut the number of abortions performed in America in half.I-888-NOT-2-LATELast Valentine's Day, four months before the FDA's long-overdue ruling, a non-profit group took the gloves off and began a 24-hour hotline to spread the word about emergency contraception. By June of this year, the toll-free number had logged 53,000 calls. Women dialing 1-888-NOT-2-LATE can learn about emergency contraception and the often unpleasant side-effects such as nausea, vomiting and breast tenderness. Callers can also access a directory of where to score ECPs anywhere in the country. Founded in 1988 with an eye on educating the public about RU-486 and other such drugs, hotline sponsor Reproductive Health Technologies Project (RHTP), took an unexpected detour five years ago."Initially, we worked on looking at the reasons why products like RU-486 were not being used in this country," says Project director Marie Bass. "We began our work with emergency contraception because we realized that, unlike RU-486, here was this technology already available - regular old-fashioned birth control bills - and it wasn't being used as it could be." This summer, the Project plans to bomb Chicago, Los Angeles, Miami, San Diego and Seattle with bare-knuckled public service announcements. To get the message to the rest of America, Bass is hoping that smaller, local groups and national organizations such as Planned Parenthood will co-opt the Project's slick advertisements and educational materials. She's also banking on free press, especially from women in the media."Emergency contraception has been in the closet for too long," she says. "Doctors have withheld this information from women for years. It's not some big conspiracy. The sad truth is, doctors in this country haven't been good about speaking to women about birth control in general and that has resulted in a sort of 'Don't ask, don't tell' situation."Planned Parenthood's Loftus-Granberg also believes ob-gyns are skittish about prescribing medications for off-label use. And, like drug companies, they want to avoid the static from pro-life groups. The irony is, peddling ECPs probably won't merit a visit from Operation Rescue."We have seen absolutely no evidence that right-to-life groups are going to make a huge deal out of this," says Bass. "Emergency contraception is absolutely not, according to the medical definition, abortion."Ruth Beyer, executive director of the Iowa Right to Life Committee, says that she is unfamiliar with ECPs. Her group "takes no position on contraception."Beyer, for her part, will abide by whatever stance is taken by parent group, the National Right to Life Committee. NRLC has made it clear that it won't be marshaling the troops to oppose the use of emergency contraceptives any time soon. In an uncharacteristically laissez-faire moment, it suggested that any woman considering taking ECPs should consult her physician. Although some groups - most notably the American Life League and the Family Research Council - have publicly decried ECPs as chemical abortions, it still appears that the pro-life movement is reserving its considerable bile for the Stateside debut of RU-486. Like an antidote for poison"While pharmaceutical companies have balked out of fear of potential boycotts, my own slightly cynical approach is that they may not see a huge profit in something that hopefully won't be used that often," says Marie Bass. "It shouldn't be anybody's regular method of birth control."Planned Parenthood counselors tell patients exactly that: Emergency contraceptives are more expensive, less effective and have more side effects than other forms of birth control. And, like the Pill, ECPs won't protect against sexually transmitted disease like condoms will.A check-up, pregnancy test and packet of emergency contraceptive pills at an Iowa Planned Parenthood center runs about $44. Students and other low-income clients can ask for a sliding scale rate. (Toss in another few bucks for a bottle of Dramamine II to soothe the nausea plaguing half of the women who take ECPs.) Some finger-wagging critics have argued that most women, upon learning about ECPs, would burn their sponges and remove their IUDs. It's doubtful, considering the side effects. What's more likely, says Bass, is that women will become much more regular in their use of birth control after dodging the bullet of an unwanted pregnancy."Emergency contraceptives are meant for one-time emergency protection," stresses PPGI's Becca Loftus-Granberg. "But once unprotected sex has occurred, it is by far the best option - the responsible thing to do."An even better option would be to have a prescription on hand, under the bathroom sink, like an antidote for poison. Pharmaceutical entrepreneur Roderick Mackenzie - the man responsible for making the copper-T I.U.D. available - seems to have noticed the free-market potential of oral emergency contraceptives. Mackenzie formed small, upstart Gynetics, Inc. for the express purpose of packaging and selling ECPs by 1998. "Every sexually active woman of reproductive age should have a supply of these in her medicine chest," says Bass. "And that means a huge profit for drug companies."


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