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EMERGENCY CONTRACEPTION - Part II
1. THE 2 HORMONES PILL GROUP (Estrogen and Progestin Pill) - continued
There are two types of combination EC pill regimens:
brands specifically packaged to be used as EC (dedicated regimen)
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regular combination birth control pills (Yuzpe-type regimen)
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DEDICATED BRANDS: Dedicated brands of combination EC pills have been available in Europe for years. In 1998, one such brand, called Preven also became available in the U.S. However, in recent years dedicated brands manufacturers have decided to stop production, so brands like Preven and Tetragynon are no longer available.
Progestin-only EC pill brands are more effective and cause less nausea than the dedicated (or regular, Yuzpe-type) combination EC pill brands.
Briefly, dedicated brands contained 4 pills. The first dose was 2 pills, and the second dose was also 2 pills.
REGULAR BRANDS (YUZPE): For the Yuzpe-type regimen, you use a regular brand of combination birth control pills. You can use any brand which contains these two hormones: ethinyl estradiol and levonorgestrel. This type of EC regimen has been available for more than 25 years and, in 1997, several of these regimens were also approved for use in the United States.
Because the regular combination birth control pills are not packaged for EC use, the number of pills you need to take, per dose, depends on which brand of pills you use.
For example, if we look at Alesse, in the table below:
The First dose is 5 pink pills, taken ideally within 72 hours (up to 120 hours) after unprotected sex.
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The Second Dose is 5 pink pills, taken 12 hours after the first dose.
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COMBINATION EMERGENCY CONTRACEPTION PILL: REGIMENS
BRAND
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MANUFACTURER
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PILLS PER DOSE AND COLOR
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ETHINYL ESTRADIOL
(microg./dose)
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LEVONORGESTREL
(mg/dose)
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Wyeth-Ayerst
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5 pink
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100
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0.50
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Duramed
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5 rusty-red
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100
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0.50
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Duramed
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4 white
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120
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1.20 (Norgestrel)
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Duramed
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4 orange
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120
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0.50
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Berlex
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4 light orange
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120
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0.60
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Berlex
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5 pink
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100
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0.50
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Watson
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4 white
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120
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0.60
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Barr
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5 pink
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100
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0.50
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Wyeth-Ayerst
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4 white
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120
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1.20 (Norgestrel)
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Watson
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4 white
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120
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1.20 (Norgestrel)
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Wyeth-Ayerst
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4 light orange
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120
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0.60
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Watson
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2 white
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100
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1.00 (Norgestrel)
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Wyeth-Ayerst
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2 white
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100
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1.00 (Norgestrel)
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Barr
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4 pink
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120
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0.60
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Barr
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4 pink
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120
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0.60
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Berlex
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4 yellow
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120
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0.50
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Wyeth-Ayerst
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4 yellow
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120
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0.50
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Watson
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4 pink
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120
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0.50
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Tetragynon***
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Schering
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2 rusty-red
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100
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0.50
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Preven**
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Gynetics
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2 blue
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100
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0.50
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*The original Yuzpe regimen.
**The only dedicated combination EC brand in the U.S., no longer available.
***No longer available.
2. THE ONE HORMONE PILL GROUP (Progestin-only Pill)
Plan B NorLevo
This group of EC is also a pill regimen. The pills are single hormone EC pills--they contain only one hormone.
The hormone is a progestin, a synthetic progesterone. Recall that progesterone is the hormone produced by our bodies.
The progestin-only EC pills work by delivering a high dose of the hormone to the body. This inhibits ovulation, the release of the egg from the ovary. Since there is no egg, there can be no pregnancy. This is the main mechanism of action of these pills.
These pills also block sperm from entering the uterus, so fertilization, the union of the egg and sperm, is inhibited.
Again, these one hormone EC pills may sound familiar to you because they are similar to the regular progestin-only birth control pills ("mini-pills"). What differs is the timing of the pills and the amount of hormone they contain.
Regular progestin-only birth control pills have a lower amount of hormone, and you take them continuously, every day of the month. Progestin-only EC pills have a higher amount of hormone and you only have to take two doses, after you've had unprotected sex.
This is how you take the two doses of progestin-only EC pills:
take the first dose as soon as possible and, ideally, no later than 72 hours (up to 120 hours), after you have unprotected sex
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take the second dose 12 hours after the first dose
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or
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take both doses at the same time as soon as possible, up to 120 hours after you have unprotected sex
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After you take the second dose, you may expect to start your period on time . If your period is more than 5 days late, take a pregnancy test and talk to your doctor to make sure you aren't pregnant. This is especially important if you have a history of ectopic pregnancy. An ectopic pregnancy is an abnormal pregnancy that occurs outside the uterus, usually inside one of the fallopian tubes. This is a very serious condition that requires immediate medical attention.
The effectiveness of progestin-only EC pills is very good--better than that of combination EC pills. Your risk of an unintended pregnancy is decreased by 89%. In other words, if 100 women have unprotected sex, statistically, 8 would be expected to become pregnant. However, if progestin-only EC pills are used, only 1 would be expected to conceive.
The same two characteristics that apply to the effectiveness of combination EC pills, also apply to the effectiveness of progestin-only pills.
The progestin-only EC pills do not protect against Sexually Transmitted Infections (STIs).
Progestin-only EC pills have the same side effects as combination EC pills. However, you have a 33% lower chance of vomiting if you use the progestin-only EC pills. To avoid this side effect, take a medication against vomiting (an antiemetic) 1 hour before each dose. If vomiting occurs within 2 hours of a dose, repeat that dose only.
The safety of progestin-only EC pills is excellent. There are no contraindications to their use, other then a known pregnancy.
If you are already pregnant you should not take these pills because they will have no effect.
Also, if you are already pregnant and you take these EC pills by mistake, they will not cause any birth defects.
There are two types of progestin-only EC pill regimens:
brands specifically packaged to be used as EC (dedicated regimen)
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regular Progestin-only birth control pills
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DEDICATED BRANDS: Dedicated progestin-only brands have been available for years, worldwide (except in the U.S.). They are sold over-the-counter. In the U.S., a dedicated product became available in 1999, under the name of Plan B. It is available by prescription only for those under 18 years old, and over-the-counter (proof of age required) for those 18 and over.
A Plan B packet contains 2 white pills. The first dose is 1 pill and the second dose is also 1 pill. Alternatively, both pills can be taken at the same time. Because one packet only has enough pills for two doses, you should always have an additional packet handy, just in case you experience vomiting and need to retake one dose.
REGULAR BRANDS: For the regular progestin-only birth control pills you can use any brand which contains the hormone levonorgestrel, or norgestrel.
Because the regular progestin-only pills are not packaged for EC use, the number of pills you need to take, per dose, depends on which brand of pills you use.
For example, if we look at Ovrette, in the table below:
The First dose is 20 yellow pills, taken ideally within 72 hours (up to 120 hours) after unprotected sex.
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The Second Dose is 20 yellow pills, taken 12 hours after the first dose.
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or
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Take Both Doses (40 yellow pills) at the same time, within 120 hours after unprotected sex.
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PROGESTIN-ONLY EMERGENCY CONTRACEPTION PILL: REGIMENS
BRAND
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MANUFACTURER
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PILLS PER DOSE AND COLOR
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LEVONORGESTREL
(mg/dose)
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Wyeth-Ayerst
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20 yellow
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1.50 (Norgestrel)
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Duramed
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1 white
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0.75
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Schering
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1 white
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0.75
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Lab.HRA Pharma
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1 white
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0.75
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Postinor-2
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Schering
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1 white
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0.75
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*The only dedicated progestin-only brand in the U.S.
For information on how to purchase these pills, please click here.
Before we move on to the next group, you should know that the older EC regimens were also single hormone pill regimens. However, the hormone was an estrogen, not a progestin. An example of an older estrogen-only regimen is the so called "5 x 5" regimen: 5 ethinyl estradiol pills taken for 5 days, for a total of 25 mg. These older regimens are rarely, if ever, used today.
3. THE IUD GROUP (Intrauterine Device)
ParaGard GyneFix*
The third group of EC is a no-pill group. Instead of pills an Intrauterine Device (IUD) is used.
The IUD is a small (usually plastic) device, which is inserted inside the uterus. There are many types of IUDs, but the ones used for EC are the copper IUDs.
The copper IUDs work by killing sperm. This prevents fertilization, the union of the egg and sperm, and is the main mechanism of action.
Of course, you are probably already familiar with IUDs, since they are also used as regular birth control methods. What is different is the timing of the IUD insertion.
When used as a regular method of birth control, the IUD is inserted before you have sex. When used as EC, the IUD is inserted after you've had unprotected sex.
This is the timing of IUD insertion for EC:
the IUD is inserted up to 5 days after unprotected sex
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After the IUD is inserted, your next period will usually start on time. It might last a few more days and be a bit heavier, but this is normal. Your doctor will instruct you when to come back for a follow-up.
The ability of the IUD to prevent a pregnancy after unprotected sex is excellent. The risk of pregnancy is reduced by more than 99%.
Like with the EC pill regimens, time is of the essence when the IUD is used for EC. So, the sooner the IUD is inserted after unprotected sex, the more effective the protection. However, unlike the EC pill regimens, once the IUD is inserted, you are protected for as long as you use the IUD.
This added protection is one of the benefits of using an IUD for EC. In other words, once the IUD is inserted, you can choose to continue to use it as your regular method of birth control. Depending on the IUD brand, you can leave the IUD in for 5 to 10 years. Of course, if you want to use another method for regular birth control, you wait until you have your period, and then you can have the IUD removed.
The IUD does not offer any protection against Sexually Transmitted Infections (STIs).
The side effects of the IUD depend on which brand of IUD you use. Please check with your doctor for the particular side effects of the brand you plan to use.
The safety of IUDs is very good. However, if you can't use an IUD as a regular method of birth control, you should not use it for EC. For example, you can't use an IUD if you have a copper allergy, or a history of Pelvic Inflammatory Disease, or any abnormal vaginal bleeding. And, of course, you shouldn't use an IUD if you are already pregnant.
If you are already pregnant and use an IUD by mistake, it will not cause any birth defects.
ParaGard has a plastic frame, shaped like the letter T, with copper wire wrapped around it. You can use this IUD for 10 years, continuously. GyneFix doesn't have a plastic frame at all. It consists of 6 small copper cylinders, threaded on a special nylon thread. GyneFix may be used for up to 5 years.
The IUD is inserted and removed by a qualified physician. In the U.S., about half of the private health insurance plans cover the cost of the IUD and so does Medicaid. The cost of the only EC type of IUD available in the U.S., ParaGard, is ~$170.00.
4. THE MISUNDERSTOOD PILL GROUP (Antiprogesterone Pill)
The fourth group of EC is a pill group. However, these pills do not contain hormones. They contain a substance that is an Antiprogesterone.
An a ntiprogesterone blocks the action of progesterone, a body hormone. Progesterone is important for the establishment of a pregnancy.
The name of this a ntiprogesterone substance is Mifepristone (RU-486). The brand name in the U.S. is Mifeprex.
Mifepristone prevents the release of the egg from the ovary. Since there is no egg, there can be no pregnancy. This is the main mechanism of action of the EC regimen.
This pill also cause changes in the lining of the uterus, which inhibit implantation.
Mifepristone, and especially the name RU-486, may sound familiar to you because this pill is often called "the abortion pill". This, of course, is incorrect. Before we continue our discussion on EC, let's quickly clarify the meaning of an "abortion pill":
By definition, an "abortion pill" causes an abortion, meaning it terminates an already established pregnancy.
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An "abortion pill" has no mechanism by which to prevent a pregnancy from becoming established.
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A good example of an "abortion pill" is a drug called Misoprostol. The only mechanism of action of this drug is to induce labor. So, this drug has no way of preventing a pregnancy; it can only terminate one.
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In contrast, the mechanism of action of Mifepristone (RU-486) can either block the release of the egg from the ovary, block implantation, or cause the lining of the uterus, together with an implanted egg, to shed. So, this drug can either prevent a pregnancy, or terminate one.
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Mifepristone (RU-486) can be used both as EC, as birth control to prevent a pregnancy, or as a Medical Termination of Pregnancy (MTP) drug, to end a pregnancy. What differs is the mechanism of action, the dosage used and the timing of the doses.
When Mifepristone (RU-486) is used for MTP, an established pregnancy must already exist, and different dosage regimens are used.
Because of this dual use, Mifepristone (RU-486) is, indeed, "the misunderstood" pill.
Returning to our EC discussion, when used for EC, Mifepristone (RU-486) prevents a pregnancy and you only need to take one dose. The amount of the dose is either 10 mg, 50 mg, or 100 mg. The older dose was 600 mg.
This is how you take the one dose of Mifepristone (RU-486):
take on dose, ideally within 72 hours, up to 5 days after having unprotected sex
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After you take the one dose you can expect your period to start on time, if you use the lower 10 mg or 50 mg dose. If you take the higher 100 mg dose, your period may be delayed a bit. If your period is more than 7 days late, take a pregnancy test and talk to your doctor, to make sure you aren't pregnant.
Mifepristone (RU-486) is excellent in preventing an unintended pregnancy. The success rate is 99% to 100%.
As with the other EC regimens, the sooner you take this pill after unprotected sex, the better. Also, one dose only works against one single act of unprotected sex. So, you must use a back-up birth control method, if you have sex again before the start of your next period. Barrier methods, like the sponge or the diaphragm are good back-up options.
This EC pill does not protect you against Sexually Transmitted Infections (STIs).
The main side effects of Mifepristone (RU-486) are nausea, vomiting and stomach cramps.
The safety of Mifepristone (RU-486) is excellent. There are no contraindications to using it, except a known pregnancy.
If you are already pregnant don't use the EC regimen of Mifepristone (RU-486) because it will have no effect. This is very important to remember.
The EC regimen of Mifepristone (RU-486) stops the eggs from being released from the ovary. If you are already pregnant and wish to terminate the pregnancy, this mechanism will have absolutely no effect on the pregnancy.
To terminate a pregnancy, you need to use a drug regimen specifically intended for that. And, although that regimen may include Mifepristone (RU-486), the dosage, mechanism, and the timing of administration are completely different from the EC regimen. In addition, you'll also need to take a second drug to terminate a pregnancy.
Returning to our discussion of Mifepristone (RU-486) as EC, if you are already pregnant and take this pill by mistake, there is no evidence that it will cause any birth defects.
Mifepristone (RU-486) has been available in Europe since 1987. In 2000 it was also approved for use in the U.S., where it is available through a physician's office. The FDA* has only approved its use for Medical Termination of Pregnancy, however, it may be used as an Emergency Contraceptive in an off-label use.
In the U.S. the approximate retail price for 600 mg of Mifepristone (RU-486) is $270, so the cost for the 50 mg EC dose should be about $23.
*The FDA is the U.S. equivalent of the Medicine Control Agency.
5. THE SELDOM USED PILL GROUP (Progesterone Production Blocker Pill)
The last EC group is also a non-hormonal pill group. The pills contain a substance which is a p rogesterone synthase inhibitor, called e postane.
A p rogesterone synthase inhibitor blocks the production of progesterone, a body hormone that is important for the establishment of a pregnancy.
Epostane prevents a pregnancy the same way mifepristone (RU-486) does.
Like mifepristone (RU-486), epostane can be used as either an EC birth control method or as a Medical Termination of Pregnancy drug. What differs is the mechanism of action, the dosage used and the timing of the doses.
When epostane is used for MTP, an established pregnancy must already exist, and different dosage regimens are used.
When used for EC, there are several dosage regimens--100 mg to 200 mg, in repeated doses--depending on how much time has passed since the unprotected sex.
The effectiveness and side effects of Epostane are similar to those of mifepristone (RU-486).
Epostane has been available for over 30 years, in Europe, and it requires a doctor's prescription. Epostane is seldom used today.
EMERGENCY CONTRACEPTION: FINAL NOTES
Emergency Contraception is a safe and effective way to prevent an unintended pregnancy.
Emergency Contraception should only be used occasionally, when an accident happens, and not as your regular method of birth control. It should also be used in cases of sexual assault.
Emergency Contraception works after sexual intercourse has occurred, but before a pregnancy has been established. Medical Termination of Pregnancy treatments also work after sexual intercourse has occurred, but, in contrast, they act on a pregnancy that has already been established.
If you live in a country where Emergency Contraception is not available over-the-counter, ask your doctor for an Advanced Prescription. Then go to the pharmacy and fill out the prescription. This way you have a handy supply of Emergency Contraceptive Pills at home.
In the future, it's likely that the Progestin-only and the Antiprogesterone regimens will became the Emergency Contraception treatments of choice, because they are more effective and have less side effects.
EMERGENCY CONTRACEPTION: RESOURCES
ADDITIONAL EC LINKS:
For a valuable list of links to sites with general information on birth control, sexual health, and sites aimed at teenagers, please visit the
Levonelle
site, maintained by Schering.
For a comprehensive list of Frequently Asked Questions about EC, please visit the
NorLevo
site, maintained by Laboratoire HRA Pharma.
Here you will find
information
on EC and NorLevo in Arabic/ , Bosnian/Croatian/Serbian, Finnish, French, German, Persian/ , Somalian/Soomaali, Spanish and Turkish.
More information on Plan B at
go2planb
.
LOCATE A PROVIDER IN THE U.S.:
If you live in the U.S. you can call a special hotline ( 1-888-668-2528) to find a referral for EC pills in your State.
Because EC treatment is birth control, current U.S. federal guidelines state that parental consent is not necessary; laws requiring parental consent for abortion do not apply.
TO PURCHASE EC:
In the UK and Europe EC is available over-the-counter, in any pharmacy. The cost of Levonelle is £24.00 (~USD $38.00) and NorLevo costs ~ $20.00.
In Canada, EC is available over-the-counter in Quebec and British Columbia. In Canadian pharmacies, the cost of Plan B is approximately CAD $50.00 (~USD $32.00).
In the U.S., you can buy Plan B over-the-counter if you are 18 and older (a prescription is still required if you are under 18).
You can also purchase Plan B on-line, from
drugstore.com
($39.95), or
getthepill
. (The cost is $24.95 for the on-line consultation, plus the cost of the pills. You pick-up, and pay for the pills at your local pharmacy. )
Two important things about buying EC:
TIME IS OF THE ESSENCE, so, if you order on-line, make sure the sites are able to deliver your order no later than 48-60 hours. Of course, it is always better to buy EC before you actually need it, and keep it handy.
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Not all pharmacies have EC pills available and not all pharmacists are willing to sell them. Make sure your local pharmacy can fill the order. If not, ask them to refer you to another pharmacy in your area that can provide EC.
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References
1. Williams Obstetrics 21st. Ed.
2. The Female Patient. Vol.26, No 3, March 2001
* GyneFix IUD picture courtesy of Dr. D. Wildemeersch, Contrel Research, Technology Park, Ghent, Belgium
Copyright 2001-2004 GHO. All rights reserved.
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