In spite of widespread availability of effective birth control, half of all pregnancies are still unintended. And although “morning after pills” (or “emergency contraception”) have been available over the counter since 2006, this rate has not fallen. Which leads OB/GYNs like myself to sit up and take notice whenever people get all atwitter about new ways to prevent unwanted pregnancy.
So here’s the skinny: a federal advisory board that usually whispers into the ear of the FDA voted unanimously on Thursday to approve a new type of emergency contraception, called Ella (ulipristal). This medication, which blocks progesterone, a hormone that is a necessary part of both ovulation and maintaining a healthy pregnancy, is a close cousin of the abortion pill RU-486 (mifepristone) and is already available in Europe, marketed as ellaOne. As you can imagine, this has caused ripples in the red-and-blue tinged waters of our politically charged American population.
Currently available emergency contraception options like Plan B, Plan B One Step, or Next Choice, which are all available over the counter without a prescription for those 17 and over (and by prescription for younger women), must be taken within 72 hours of unprotected sex and are most effective when taken in the first 24 hours.
But what happens if you’re an 18-year-old college kid who doesn’t even know Plan B exists? You lament to your roommate about the date rape you just experienced, and she eventually gets you to go to the university clinic where they offer you emergency contraception - but by then it’s too late. That was five days ago.
Enter Ella. Studies show that Ella is effective up to five days after unprotected sex, and seems to be equally effective whether you take it on day one or day five. And since 1 in 10 women seeking emergency contraception do so after the 72 hour window is over, Ella may be a welcome addition in the fight against unwanted pregnancy.
The mechanism of action behind what fuels Ella is still a bit iffy. We know that it blocks progesterone, which is a necessary hormone in pregnancy. What is unclear is whether the drug acts to block ovulation (as manufacturers suggest), or to prevent a new pregnancy from implanting (as anti-abortion advocates insist).
What trips people up is that some say five days would be too long after intercourse to prevent ovulation. And if you’re actually preventing implantation, are you aborting a fetus (even though you don’t even know you’re pregnant yet, and may not know for weeks)?
Unlike RU-486, which aborts pregnancies in animals, animal studies show that Ella does not appear to abort already existing pregnancies - at least not the ones that are far enough along to diagnose. But there’s the rub. Does it abort a new pregnancy that is too early to be diagnosed? Maybe. No one seems to know for sure. And if you’re one of the women who took it - and it worked - you’d never know the difference.
Yes, it does. An episode of unprotected intercourse leads to a 1/20 chance of conceiving. Plan B, Next Choice, and Plan B One Step reduce this chance to 1/40, while Ella appears to reduce it to 1/50.
So if emergency contraception exists, why do we still have so many unplanned pregnancies? Ah … there’s the big question. The bummer is that too many women still don’t know emergency contraception even exists. So ladies, do me a favor. Tell your daughters. Tell your girlfriends. Tell your sisters. This way, we can all make our own choices about what is right for our individual bodies, minds, and spirits. Let’s not let ignorance rule our reproductive lives. Spread the word.
With all the options available on the market, which emergency contraception should you take if you just had unprotected sex? Years ago, all we had for emergency birth control was off-label use of a high-dose oral contraceptive, such as two doses of Ovral, followed 12 hours later by another two doses. This regimen was available only by prescription, and the problem was that the high dose of estrogen made women want to hurl their guts out. This could result in throwing up the very medication you’re trying to ingest, landing you back at square one.
So Plan B and its knock-offs leaped us forward. By utilizing higher doses of progesterone, minus the estrogen, side effects were significantly reduced.
Plan B consists of Levonorgestrel 0.75mg (a type of synthetic progesterone). According to the FDA, Plan B “acts primarily by stopping the release of an egg from the ovary (ovulation). It may prevent the union of sperm and egg (fertilization). If fertilization does occur, Plan B may prevent a fertilized egg from attaching to the womb (implantation). If a fertilized egg is implanted prior to taking Plan B, Plan B will not work.”
There you have it. The first dose must be taken within 72 hours of unprotected sex, with the second dose 12 hours after the first. Plan B is available over the counter without a prescription if you’re 17 or older, and with a prescription if you’re younger than 17. The sooner you take it, the better. It’s most effective within the first 24 hours. At a California CVS, the cost was $49.59.
Next Choice is the generic version of Plan B, so ditto on the above. Since Plan B is no longer under patent and Next Choice is available as a generic, the advantage of both is that they tend to be the budget choice. At a California CVS, the cost of Next Choice was $40.
Plan B One-Step
Plan B One-Step consists of Levonorgestrel 1.5mg taken as one dose. Like Plan B and Next Choice, it must be taken within 72 hours of unprotected sex and is available over the counter if you’re 17 or older. The advantage to Plan B One Step is that you don’t have to remember to take that pesky second dose exactly 12 hours later. Like Plan B and Next Choice, this pill works best if you take it right away. At a California CVS, the cost was $49.99.
Ella works by blocking the effects of progesterone and is a chemical cousin to the abortion pill RU-486 (mifepristone), but experts swear it’s not an abortion pill and does not work to terminate an existing pregnancy. The exact mechanism of how it works is still unclear. If approved by the FDA, the advantage Ella will offer is that it is effective up to five days after unprotected sex, and does not appear to be less effective if taken on day five than on day one. This means that if you make a boo-boo and it slips your mind to race to Walgreens right away, or if you don’t discover that emergency contraception exists until day four or five, you may still be covered. Also, early studies suggest that Ella might be more effective in reducing unwanted pregnancy than the other options.
The down side is that, chances are, Ella will cost more than the other options, so if you’re on a budget, you might still go for Plan B or Next Choice. And although manufacturers are shooting for over-the-counter status, it’s not looking likely that it will be over the counter, at least not at first. The other down side is that this drug is new. We don’t know much about it yet, and I’m rarely the first doctor to run out and prescribe something until I know my patients are safe.
What do you think about Ella? If you knew there was a chance you were aborting a pregnancy you’d never know you had, would you use it if you had unprotected intercourse and didn’t want to have a child? Would you recommend it to your friends or daughters? Is this good news, or does it scare you? Do tell…
Just trying to empower you,
Lissa Rankin, MD
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