Emergency Contraception: A Win-Lose Proposition?

When family practice doctor Jessica Dalby prescribes birth control pills, she also usually writes a prescription for emergency contraceptive-or “morning after”-pills, just in case.
 
Dalby, an assistant professor at the University of Wisconsin School of Medicine and Public Health, acknowledges that she might not be typical. Emergency contraceptive pills aren’t used as widely as they could be-one possible explanation for the fact they have yet to make a dent in the unintended pregnancy rate-and health care providers deserve some blame, Dalby and her coauthors wrote last year in the Journal of Family Medicine. Physicians often are “unfamiliar with the options or uncomfortable discussing them with patients, particularly sexually active teens,” she and her colleagues said.
 
Dalby has been trying to change that. “I routinely teach the residents that when they’re talking contraception with patients they should also talk about emergency contraception,” she says.

There’s a lot to talk about. In June, the FDA approved Plan B One-Step, a single pill of the progestin levonorgestrel, for over-the-counter sales to people of all ages, and in August it became available on the family planning aisle in drugstores nationwide. Previously, teens younger than 17 had to get a doctor’s prescription before they could buy Plan B One-Step. Generic levonorgestrel pills, sold as Next Choice One Dose and My Way, can still be sold only by prescription to people age 16 and younger.

The decision to make Plan B One-Step available without a prescription for all ages was viewed as a victory for women. The pill can help prevent a pregnancy if taken within 72 hours of having unprotected sex or experiencing contraceptive failure. However, the sooner it is taken, the better, and it was thought that eliminating the need for a prescription would make Plan B One-Step more easily accessible.

That is if women are aware it exists. “One of the known but unintended consequences of having ECPs (emergency contraception pills) available without a prescription is that the potential educational opportunity . . . was lost,” says James Trussell, a professor of economics and public affairs at Princeton University and a faculty associate of the school’s Office of Population Research. “I doubt that many clinicians of any specialty . . . now routinely talk with women about EC.”

Since anyone can now buy Plan B One-Step without ever talking to a doctor, they might miss out on learning about the various options for regular ongoing contraception or emergency contraception, says Trussell, who maintains an emergency contraception Web site, not-2-late.com, and launched a toll-free emergency contraception hotline, 1-800-NOT-TOO-LATE. Other relatively little-known emergency contraceptive methods are the Copper-T intrauterine device, or IUD, which can be inserted up to 120 hours after unprotected sex and is more effective than the pills, and ella, a newer morning-after pill that can be taken up to 120 hours after unprotected sex. Ella contains ulipristal acetate, which is thought to be more effective than levonorgestrel, and is available only by prescription.

Which brings us back to why Dalby is still writing prescriptions for emergency contraception and encouraging patients to fill them before they need to. For one, she thinks ella is the most effective morning-after pill. For another, Dalby says, Plan B One-Step and its generic versions cost about $35 to $50, and since it’s an over-the-counter drug, patients have to pay for it entirely out-of-pocket. “I think that really puts it out of reach for a lot of people,” she says.

When a woman can’t take ella because she is breast-feeding (that pill’s label says it is not known whether it is safe for children), she has to take levonorgestrel. Even then, Dalby says, she’ll still write a prescription even if one isn’t needed, because sometimes that results in coverage by insurers.

Under the Affordable Care Act, insurers are supposed to cover all FDA-approved contraceptives with no copayments or other out-of-pocket fees, but, Trussell says, it’s not yet clear whether over-the-counter contraceptives are included.

Dalby J, Hayon R, Paddock E, Schrager S. Emergency contraception: an underutilized resource. J Fam Pract. 2012;61:392-397.