MMSA Statement Emergency Contraception – MAP Fact Sheet
In light of the recent controversy regarding the introduction of the Morning After Pill (MAP), the Malta Medical Students’ Association (MMSA) would like to express its concern regarding to the misinformation circulating amongst the Maltese population. It has therefore compiled the following information, derived from reliable and health information sources, and also consulted with the relevant medical specialists. Emergency contraception, in the form of a drug or/and IUD, is used to try to prevent pregnancy in cases such as following unprotected intercourse, contraceptive accidents (e.g., torn condoms), coerced sex and rape. It may even be relevant when the mother is not physically fit to carry a child, financially stable or for other reasonsIt is important to understand why emergency contraception might be considered an option in the first place. To date, Malta is the only EU country which does not offer access to emergency contraception. [1] Other countries, such as the United Kingdom, sell it over the counter or with prescription, requested after such cases as above. [2] The only form of emergency contraception available in Malta is the Yuzpe regimen [3], which involves taking an increased dose of the oral contraceptive pill after unprotected sexual intercourse. The normal dose of the oral contraceptive pill is not enough to prevent pregnancy after intercourse. This is where the MAP comes in. Two types are available on the market: Levonelle (Plan B) and Ullipristal (EllaOne). Contents of the MAP Levonelle is the most commonly used option for emergency contraception. It consists of a single (1.5mg) dose of the progesterone levonorgestrel. [4] (The amount of the active hormone in a single dose is less than half of that found in the normal cycle of contraceptive pills, therefore having less side effects). [5] EllaOne consists of a selective progesterone receptor modulator which blocks the action of progesterone. [9] Mechanism of action
Levonelle works by affecting sperm functionality, andendometrial receptivity and preventing follicular rupture if taken before ovulation. EllaOne works by affecting how the sperm works and how receptive the lining of the uterus is. It may also prevent release of the egg. It’s main side effect is that it reduces the effectiveness of progesterone-containing contraceptives. [4] According to the WHO, the evidence available to date is that Levonelle does not prevent the fertilized egg from attaching to the uterine lining. The primary mechanism of action is to stop ovulation; it may also prevent the sperm and egg from meeting. [5] When used for emergency contraception, the mechanism of action of EllaOne is to stop or delay of ovulation.[8] There is insufficient evidence to exclude the fact that EllaOne affects implantation.
In summary, MAPs primarily work by: o preventing the release of an egg(ovulation) o stopping the egg and sperm from meeting o EllaOne may interfere with the implantation of a fertilised embryo (Levonelle does not) Research has shown that the first two mechanisms are the primary actions of the MAP andtherefore, do not interfere with an established pregnancy, as they do not work primarily by preventing implantation. [6] Availability The price of the MAP is substantially higher than that of other oral contraceptives on the market, and is only available for those who are at the legal age of sexual consent [2] The levonorgestrel emergency contraceptive, (Levonelle One Step®) is available over the counter (OTC) in most pharmacies in the UK [9] while Ullipristal acetate (EllaOne®) is not currently available over the counter, but only on prescription. Levonorgestrel costs approximately £25 per pack in the UK. Side Effects
As with every drug Levonelle has a few, usually uncommonside effects, such as nausea, vomiting, fatigue, abdominal discomfort and menstrual disturbances in the next cycle. [4] These side effects also occur with Ulipristal acetate. Levonogestrel, the active ingredient in Levonelle is well tolerated and does not interact with other medications. It leaves the body after a few days, and therefore has no additive potential or risk of overdose. It also does not increase the risk of cancer, stroke, venous thromboembolism or ectopic pregnancy and has no effect on future fertility. [5] EllaOne may affect the ability to drive or use machines due todizziness;, sleepiness and blurred vision are uncommon [8] Efficacy and Success Rates The sooner one takes the MAP after unprotected intercourse, the more effective it is. [6] . Levonelle is best taken within 24hrs of unprotected intercourse (with 95% success rate) and not later than 72hrs (with 58% success rate). [4] The World Health Organisation (WHO) recommends that a single dose be taken within 120hrs after unprotected intercourse (repeated doses do not pose any known health risks). [5] EllaOne is more effective than Levonelle and can be used up to 120hrs after unprotected intercoursehowever if ovulation has occurred this pill will no longer work. Limited and inconclusive data suggest that there may be reduced effectiveness of EllaOne with increasing body weight. [8]
The WHO has shown that progestogen-only tablets (such as Levonelle) are more effective as an Emergency Hormonal Contraceptive, compared to the Yuzpe method (only method available in Malta) and have fewer side effects. Therefore Levonelle is is a safer form of emergency contraception than the Yuzpe method. [7]
Other forms of emergency contraception: The Intra Uterine Device (IUD) Another way of preventing a pregnancy after unprotected intercourse is by introducing an IUD. This is the most effective form of emergency contraception andmay be inserted up to 5 days after unprotected intercourse or up to 5 days after
the due date of ovulation and works by preventing implantation. [4]
The MMSA hopes that the above information is helpful in for igan educated opinion on the issue. We believe that whether or not the MAP is made available, the use of condoms and getting tested against sexually transmitted infections is essential for reproductive health. We encourage all women to familiarize themselves with their menstrual cycleand have a pregnancy test if their period is delayed. Comprehensive sexual education from early ages is the way forward to a sexually healthier society.
References (1) An update on access to emergency contraception in European Union countries, European Consortium for Emergency Contraception, April 2016 (2) http://www.nhs.uk/conditions/contraception-guide/pages/where-can-i-getemergency-contraception.aspx (3) http://www.ec-ec.org/emergency-contraception-in-europe/country-by-countryinformation-2/malta/ (4) Obstetrics and Gynaecology, 4th Edition by Lawrence Impey and Tim Child (5) Fact sheet on the safety of levonorgestrel-alone emergency contraceptive pills (LNG ECPs), 2010 by WHO (6) Emergency Contraception: Questions and Answers for Decision Makers, 2013 by International Consortium for Emergency Contraception (7) WHO Task Force on Postovulatory Methods of Fertility Regulation, 1998, Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception, The Lancet , Volume 352 , Issue 9126 , 428 – 433 (8) http://www.ema.europa.eu/docs/en_GB/document_library/EPAR__Product_Information/human/001027/WC500023670.pdf (9) European Medicines Agency Review of Emergency Contraception and
Weight: Update from the Faculty of Sexual and Reproductive Healthcare, June 2014