Talk:Emergency contraception

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EC annual effectiveness

This sentence: The annual failure rate of EC is estimated at 19-38%,[10] which means that over the course of a year, EC averages to less effective than it does for a single use implies both the 19% and 38% numbers are for levonorgestrel EC (perfect and typical use?), when actually the 38% number is for Yuzpe. I will speculate that the 19% figure is the effectiveness of Postinor? Not Postinor-2, marketed as EC, but the original Postinor, marketed as an ongoing postcoital contraceptive. Which is somewhat problematic in estimating the annual effectiveness of EC, because Postinor is only approved for use four times a month. Although, the PubMed-listed studies of Postinor imply failure rates lower than 19% (PMID 6362451, PMID 12334868).

So, I'm not sure we should leave those annual numbers in (they are of suspect validity - though further research might be able to resolve that issue). If they are left in, I think we should specify which number is levo and which is Yuzpe, and that they are for perfect use (not typical use). Also, "less effective than for a single dose" doesn't appear to be true - levo 75% reduction in pregnancies single dose, annual (100-19=) 81% prevention of pregnancy - Yuzpe 57% reduction in pregnancy single dose, annual (100-38=) 62% prevention of pregnancy. So technically more effective annually (though I think that's a result of inaccuracies in the estimates) - or can we even compare "reduction in pregnancy" numbers with "annual pregnancy rate" statistics? I think the data does not support the "less effective..." statement and it should go. However, looking for other opinions before I go a-editing. Lyrl ^Talk _Contribs 04:48, 2 December 2006 (UTC)

I was just looking at the same sentence. The reference is a BMJ "rapid response" and doesn't actually cite the numbers in question, just says it's "no more effective" than withdrawal. Since the BMJ letter referenced Trussell, I found this on the Princeton/Trussell EC website, which cites a 20% annual failure rate for progestin-only and 40% for combined (close enough to 19-38%). But I think the main issue is that those estimates (19-38%) are for annual use of EC as the sole means of contraception. As Lyrl points out, this is problematic - EC is clearly not intended for use as a sole means of contraception, so the numbers seem a little meaningless. I rewrote the sentence, leaving in the numbers, but emphasized that those numbers are estimated failure rates for EC as sole means of contraception, which absolutely no one is advocating. I also moved it below the numbers on single-use effectiveness in the emergency setting, since this is the more meaningful real-world context. MastCell 22:14, 2 December 2006 (UTC)

Postinor (the original) is still sold, so obviously someone is advocating EC as sole means of contraception (however, only for women having intercourse four or fewer times per month). Reviewing the article, there is actually a section on EC as an ongoing birth control method. I'm going to move the discussion of annual failure rates to that section and make some related changes. Lyrl ^Talk _Contribs 23:15, 2 December 2006 (UTC)

Effectiveness of ECPs, again

I've been reading more about the effectiveness after the recent anonymous edits pointing out the support of major organizations (AFP, FDA) for higher failure rates than currently listed in this article (75% for Yuzpe, 89% for levonorgestrel). Although, there does seem to be some acknowledgement of uncertainty - the Princeton website says The exact effectiveness of emergency contraceptive pills is difficult to measure and some researchers believe the effectiveness may be lower than that reported on package labels. I'm thinking of rearranging by:

• shortening the initial effectiveness discussion to simply state the officially supported numbers ("so and so says such and such effectiveness") - no discussion, no history, and shorten the quote by excluding text before "these numbers do not translate..."
• moving the last paragraph ("Because women in clinical trials...") to the "Controversy" section
• renaming the "Controversy" section "Uncertainties in calculation" (or something similar? Suggestions welcome) as there doesn't really seem to be a controversy (definition) - the general public is not involved, and there do not seem to be high feelings amoung the researchers - just a calm, evolving exchange of opinions and research on which methods of calculating effectiveness are most accurate and useful.
• giving ranges of effectiveness rates found by different studies in the renamed section, to supplement official numbers given at beginning of "Effectiveness" section
• summarizing the other information in the renamed section - mention sources of uncertainty, provide references for readers interested in more information, done. (Working in this wikilink could significantly reduce the need for a lot of text explaining the uncertainties of calendar methods).

Lyrl ^Talk _Contribs 01:22, 3 December 2006 (UTC)

I agree with pretty much all of those suggestions - specifically, I agree with a leaner approach to citing the published efficacy data in the effectiveness section (along with attribution of which sources these numbers come from). I think a "Controversy" section is appropriate for dealing with issues of pro-life objections, conscience clauses, WalMart, politics of OTC approval in the US, etc - but agree that methodologic issues re: efficacy stats could be moved out of "Controversy" to reflect that it's more of an area of ongoing research than controversy per se. MastCell 08:49, 3 December 2006 (UTC)

Can someone please add the source for 14? I have it listed here, and the quote comes from the section under "Effectiveness". http://www.aafp.org/afp/20040815/707.html

The Effectiveness of ECPs subsection was expanded to correct previous inaccuracies, but the subsection could be condensed substantially to, preferably:

1. levonorgestrel regimen: 84% - citing the current Levonelle 1500 (Levonelle One Step) SPC and PIL, which cite the large 2002 WHO clinical trial PMID 12480356

1. Yuzpe regimen: 74% - citing the updated 1999 Trussell et al. combined estimate from 8 Yuzpe regimen clinical trials PMID 10382076
2. mifepristone regimen: 83% - citing the 2003 WHO combined estimate from 3 mifepristone 10 mg clinical trials PMID 14698074

or, alternatively:

1. levonorgestrel regimen: 87% - (7 out of 8) citing the current FDA-approved Plan B label information, which is based on the large 1998 WHO clinical trial PMID 9708750
2. Yuzpe regimen: 75% - (6 out of 8) citing the original 1998 FDA-approved (discontinued) Preven label information and the 1998 Trussell et al. combined estimate from 7 Yuzpe regimen clinical trials PMID 9693395
3. mifepristone regimen: 83% - (equivalent to levonorgestrel regimen; i.e. 7 out of 8) citing the 2003 WHO combined estimate from 3 mifepristone 10 mg clinical trials PMID 14698074 and the 2002 WHO clinical trial PMID 12480356

All of the blockquotes, including the explanation of the effectiveness of the Yuzpe regimen from the highlighted 2004 American Family Physician review article PMID 15338783 (outdated with references to discontinued products like Preven and Ovrette), could be removed.

69.208.172.92 16:48, 3 July 2007 (UTC)

Wiki Education Foundation-supported course assignment

This article was the subject of a Wiki Education Foundation-supported course assignment, between 10 January 2020 and 23 April 2020. Further details are available on the course page. Student editor(s): Cguti132.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 20:29, 16 January 2022 (UTC)

FDA has not approved Ovrette® as EC

The Aug 15, 2004 AFP Emergency Contraception review article [1] is a WP:RS, but its statement: "The FDA has cleared 13 brands of oral contraceptives for safety and efficacy when used for emergency contraception (Table 2)" listing 12 combined oral contraceptive pills and the progestin-only oral contraceptive Ovrette® is not correct.

On Feb 25, 1997, the FDA posted a notice in the Federal Register (Certain combined oral contraceptives for use as postcoital emergency contraception. Fed Regist 62(37):8610-2) which said the FDA Commissioner had concluded that certain COCPs (containing ethinylestradiol and norgestrel/levonorgestrel, i.e. the Yuzpe regimen) were safe and effective for off-label use as postcoital EC, was prepared to accept NDAs for COCPs labeled as ECPs, and listed 6 then available COCPs that could be used as ECPs (Ovral®, Lo/Ovral®, Nordette®, Levlen®, Triphasil®, Tri-Levlen®).

On Sep 2, 1998, the FDA approved the prescription Yuzpe regimen Preven® Emergency Contraception Kit (which contained a urine pregnancy test and 4 COCPs equivalent to 4 Ovral® pills).

On Jul 28, 1999, the FDA approved the prescription progestin-only Plan B® (two 750 µg levonorgestrel pills) emergency contraceptive.

The FDA never approved the use of 40 regular progestin-only Ovrette® (75 µg norgestrel) POPs as safe and effective for use as EC.

Since the 1997 FDA notice almost 10 years ago that the COCP Yuzpe regimen for EC was safe and effective, 16 additional COCPs containing ethinylestradiol and norgestrel/levonorgestrel have been marketed in the U.S. that contain doses equivalent to the 6 COCPs listed in the 1997 FDA notice.

Forty Ovrette® pills containing 3 mg of norgestrel is equivalent to the 1.5 mg of levonorgestrel in two Plan B® pills and would work as EC, but is much less convenient and the likelihood of already having (or being able to purchase) over a month's supply of one brand of regular POPs is much lower than the likelihood of finding 4 to 10 pills of one of the 22 available brands of COCPs usable for the Yuzpe regimen.

References:

• Oct 20, 2006 - Planned Parenthood - Emergency Contraception [2]
• Nov 29, 2006 - Emergency contraception: Pill brands, doses, and instructions [3]

68.255.31.5 07:28, 5 December 2006 (UTC)

Proposed rewrite of "Contraindications" et. al. sections

Adverse effects

Plan B and Yuzpe should not be used by women who are already pregnant, because they are not effective after implantation.

Because they contain estrogen, combined estrogen-progestin emergency contraception (Yuzpe regimen) pills should not be used by women with a history of heart attack, stroke, blood clots, or patients with severe liver disease or the very rare condition of porphyria.

If pregnancy occurs despite use of ECPs, the women is at slightly increased risk of ectopic pregnancy. A history of ectopic pregnancy is not a contraindication to use of ECPs, but consumers and health providers should be alert to the possibility of an ectopic pregnancy in women who become pregnant or complain of lower abdominal pain after taking levonorgestrel EC. Ectopic pregnancy is a medical emergency which can be fatal.

The herbal preparation of St John's wort and some enzyme-inducing drugs (e.g. anticonvulsants or rifampicin) may reduce the effectiveness of ECP, and a larger dose may be required. (Levonorgestrel 1500mcg initial dose and an extra 750 mcg after 12 hours).

Three cases of convulsions have been reported following use of levonorgestrel ECPs. Two cases occured in women with epilepsy, and are surmised to be caused by interaction of contraceptive hormones with antiepileptic drugs.

Ten cases of hypersensitivity (allergic) reaction, seven of which were considered life-threatening, have been reported following use of levonorgestrel ECPs.

Breast cancer cells are often hormone-sensitive, therefore hormonal birth control methods (including ECPs) are not recommended for women who have, have had, or suspect they have breast cancer. Laboratory studies have suggested levonorgestrel might have an effect on breast cancer. Human studies to date have been too small to draw definite conclusions about breast cancer risk of ongoing progesterone-only contraception, though it is known that ongoing use of combined hormonal contraceptives slightly increases breast cancer risk.

Side effects

The most common side effect of emergency contraception pills is nausea (50% of users of combined pills, 23% of progestin-only users), and a significant number of users vomit. Estrogen in combined ECPs is responsible for the increased incidence of nausea and vomiting. Antiemetics may be prescribed for both methods. Consider antiemetics 1 hour before each ECP dose. If vomiting occurs within an hour after taking ECPs, it may be necessary to repeat the dose.

Other common side effects are abdominal pain, fatigue, headache, dizziness, breast tenderness. These side effects normally resolve within 24 hours.

Temporary disruption of the menstrual cycle is also common and may manifest as early or late periods, spotting or breakthrough bleeding, and (less commonly) missed periods. The primary mechanism of EC is delaying ovulation. Menstruation occurs, on average, 14 days after ovulation, so delayed ovulation results in delayed menstruation. Suppression of ovulation may cause anovulatory bleeding, which could manifest as an early period.

This would combine seven sections of heavily related topics into one section (though I'm not sure 'adverse effects' is the best title for the new section). I believe combining them improves readibility in general (many short sections in a row are difficult to read), makes the related nature of the effects more understandable (for example, by putting the discussion of women taking antiepileptics needing a higher dose next to reports of epileptics having seizures associated with ECPs), and helps the table of contents look less unbalanced with so many negative headings.

This edit would also put discussion of the menstrual disruption side effect directly above the section discussion when pregnancy testing is appropriate, which I think would be a helpful tie-in. Comments and suggestions? Lyrl ^Talk _Contribs 02:47, 8 December 2006 (UTC)

I like this a lot. Good work. I agree that combining sections, and making things more concise is better (and do we really need a new section header for one sentence paragraphs?)--Andrew c 04:02, 8 December 2006 (UTC)

I think it's a good idea, and the proposed wording is a good start. MastCell 05:27, 8 December 2006 (UTC)

References

France & ECs

I'm confused as to what is meant by the sentence "...parochial high school nurses were allowed to dispense Norlevo in schools." I checked the link, but it seems to say the same exact thing with no explanation. Is it saying that nurses at french parochial schools can dispense ECs whether the school allows it or not if they so choose, or are they forced to do it? I think that this section needs a little clarification even though it is just a minor detail. Is there any way we can actually find a copy of whatever law approved this? Chooserr 04:52, 10 December 2006 (UTC)

I don't think France (or any European country) has had the conscience refusals so publicized in the U.S. So I would assume French school nurses would have no objection to dispensing ECPs. The law would seem to say that schools were required to allow nurses to dispense ECPs upon request. Does that help any? Lyrl ^Talk _Contribs 14:03, 10 December 2006 (UTC)

Yes, but I'm talking about catholic schools. In which case you wonder is the law forcing the nurses to dispense ECs, or saying that they can dispense ECs, if they want, regardless of the opinions of those who own and run the school. Allow seems to me to be the wrong word here, and it'd be better if we can link to and quote from the actual law. Chooserr 01:43, 11 December 2006 (UTC)

I also found this. Not sure if you will have access or not, but it says similar things that the AGI article, but in different words. Same with this and "Without Fanfare, Morning-After Pill Gets a Closer Look", GINA KOLATA October 8, 2000, NYT. It seems like they were 'granted the right' to dispense, not necessarily required to. Maybe a French speaker with access to French sources could help out, but I agree with Lyrl that refusal probably isn't as big of an issue in France as it may be in other places. Regardless our sources support our wording. Just because we don't have all the answers to your questions doesn't mean we need a fact tag.--Andrew c 03:12, 15 December 2006 (UTC)

Andrew C, I don't think that it is good enough just because our source claims it, especially since they probably don't follow the NPOV rules that wikipedians should hold in mind while writing articles. I don't think that quoting some external source just makes it POV. These cases should be looked into, for I am certain that this isn't the only one. And if it can't be verified it should be removed or reworded or something. Chooserr 03:34, 15 December 2006 (UTC)

I don't understand what isn't verifiable. We have the New York Times, the Guttmacher Institute, and two employees of HRA Pharma Laboratoire in Paris writing to a peer-reviewed, scholarly journal. Can you please explain to me what your objection is? A law was passed in France on a national level in late 2000 that gave permission (authorization, allowed, etc) to school nurses to give out EC in schools. This is verifiable by all of these sources, right? And this is basically what our text says, right? So what is the problem? I apologize for my confusion.-Andrew c 04:58, 15 December 2006 (UTC)

Maybe I wasn't saying what I meant properly, or maybe you just misunderstood, but while this may be verifiable it is still in my opinion vague. I don't know the implications. Would this force a school nurse, even those at catholic schools, to dispense ECs inspite of their opinions, or allow them to distribute them regardless of the opinions of those who own and run the schools if they so choose? Those are my two questions. Chooserr 05:18, 15 December 2006 (UTC)

I agree that we do not have every fine detail included in the article (and maybe that section could use expansion). But I feel that this issue is independent of verification and citation claims. I'll look further into this. If that section needs a tag, I feel an Template:Expand-section tag would work better. And yes, I was a little confused and I'll take the blame for the misunderstanding. Hopefully we can get more detail, but I personally think the current state of that section isn't terrible or anything. You wouldn't happen to know French, would you?-Andrew c 06:03, 15 December 2006 (UTC)

Ok, I found this. It is "Bulletin Officiel du ministère de l'Education Nationale et du ministère de la Recherche" or Official Bulletin for the Ministry of National Education and for the Ministry of Research. Scroll down to "Application de la loi n° 2000-1209 du 13 décembre 2000 relative à la contraception d'urgence" or Application of the law # 2000-1209, Dec. 12, 2000 regarding emergency contraception. And in the "Annexe" for that section is PROTOCOLE NATIONAL SUR LA CONTRACEPTION D'URGENCE EN MILIEU SCOLAIRE or National Protocol on Emergency Contraception in Scholastic Environments. And there list what I believe to be the text of the law. And from what I can gather, your concerns are not addressed in the text of the law. Therefore, you are asking sticky legal questions that can only be answered by French courts. Have these questions been asked? Maybe we should look into that, but further speculation seems like OR without sourcing. Feel free to use google or babblefish to translate the text and see if I missed anything (or if you know French, ignore that last part). Hope this helps.-Andrew c 06:38, 15 December 2006 (UTC)

I know a little bit of french so I may check this out, especially your link. Thanks, by the way. Chooserr 07:31, 15 December 2006 (UTC)

Scratch that my french is no where near standing up to this document, but it seems like there is a lot of information if we can just get someone to read it. It talks about the situations and the "right" so it's gotta be there. Chooserr 07:34, 15 December 2006 (UTC)

From what I can gather from babelfish, wiktionary, and my year and a half living in Montréal, it describes the following: The law deals with the methods of administering EC without a perscription in secondary schools. Each school is responsible for making sure the following provisions are respected and enacted. 1. To be able to administer EC, the nurses associated with the school should have a private room for confidentiality. 2. Regardless of the student's age (minor or not) before EC is dispensed, there must be a discussion. This gives the nurse time to assess if the situation meets both the criteria of article L. 5134-1 of the code of the public health and the drug infosheet. The nurse then must tell the student that EC is not a regular method of BC, that it is not always effective. If the student doesn't meet the criteria for the drug, they shall be directed to a family planning center, hospital, OBGYN, or other doctor. 3. Describes the situations for minors and those 18 and over. For minors, the nurse describes the usual routes for obtaining EC, and recommends going to a doctor. Parental/guardian involvment is encouraged, but not required. If the student is distressed and cannot obtain EC in the normal means, then the nurse can dispense the drugs in exceptional circumstances. For those 18 and over, it is basically the same. 4. The nurse must keep a record of dispensing EC in a "cahier de l'infirmière" or similar log book. Statistics must be compiled at the end of the year. 5. The nurse should set up a follow-up appointment for the student with a medical professional, where pregnancy tests, STD preventions, and regular method of contraception can be discussed. That's all I could get from there. Nothing seems to suggest anything about refusal clauses or anything. I'm fine with how the article is, and I think I'm going to give up on researching more. If you find anything else, or have more concerns, please voice them (and if you are so inclined, you could contact Wikipedia:Reference desk/Language or Wikipedia:Translation or Wikipedia:Translation into English. Good luck.--Andrew c 19:23, 15 December 2006 (UTC)

Some of the earlier comments in this section make reference to French schools being Catholic. For the most part (I'm relying on 'real world knowledge' here) schools in France are government subsidised and secular. That is why sex education that informs rather than discourages is taught in them. Also: I believe the issue of "the morning after pill" in French secondary schools revolves around its being made available under the Jospin government in 1979, to be made shortly after unavailable due to a clause in French law stating that this contraceptive device required a prescription to be obtained, thus negating nurses in French schools from distributing the "morning after" to adolescents enrolled in them. —Preceding unsigned comment added by 132.156.43.8 (talk) 17:11, 22 November 2007 (UTC)

St. Croix

I removed the International Availability entry for the United States Virgin Islands (population 112,000 in 2005) that stated:

The Yuzpe regimen and diethylstilbestrol are used on the island of St. Croix.

citing, on the Women's Coalition of St. Croix website (last updated May 24, 2005), a webpage of information on what to do:

• If You've Been Sexually Assaulted, listing under:
  • Choices You Need To Make
    • In order to prevent pregnancy from the assailant, there is the option of taking the "Morning After Pill." Up to 72 hours following your assault, and preferably less than 24, you may choose to take the Morning After Pill. The Morning After Pill treatment actually consists of four pills, two taken initially and two more taken twelve hours after the initial dosage. This is not a form of contraception. Each of the pills contains a high dosage of the synthetic hormones estrogen and/or progesterone. The pills prevent implantation of a fertilized egg in the uterus. Some women may experience side effects including headache, nausea and vomiting. More serious side effects may occur, and those women who are advised against using birth control pills are advised not to use the morning after pill.
    • Some physicians recommend a drug called Diethylstilbestrol (DES), or another pregnancy preventing drug. This drug prevents pregnancy if you begin taking it within 48 hours after the rape and continue the medication for the next 5 days. DES has potential side effects, the most common being cramps and vomiting. Ask the doctor what you can expect when taking the drug, so you can decide if it makes sense to you.

Although I'm sure the Women's Coalition of St. Croix is a wonderful organization, they are not a WP:RS on the medication currently prescribed by U.S. physicians on St. Croix for emergency contraception.

Why would U.S. physicians on St. Croix (population 52,324 in 2000) still use DES, a medication that the FDA ordered labeled "THIS DRUG PRODUCT SHOULD NOT BE USED AS A POSTCOITAL CONTRACEPTIVE" over three decades ago, was superseded by the Yuzpe regimen two decades ago, and has not been commercially available in the U.S. for a decade, OR the Yuzpe regimen, still be used an emergency contraceptive INSTEAD OF Plan B, which is more effective, has fewer side effects, and has been FDA-approved over six years ago for emergency contraception??

As stated in WP:RS: Exceptional claims require exceptional evidence. Not a webpage containing some information that appears to have not been updated for two decades or more.

FP101 23:31, 10 December 2006 (UTC)

Planned Parenthood "controversy"

In reading the recent edits by FP101, I couldn't find the information about $25 million in EC sales, and 3% of the annual budget, in the cited source. Perhaps I'm not looking in the right place - are those figures given in the PP annual report? MastCell 18:20, 15 December 2006 (UTC)

PPFA Annual Report 2004-2005, p. 5, Affiliate Service Summary:

EC kits distributed in 2004 = 983,537

STOPP (Stop Planned Parenthood) survey:

average Plan B price at Planned Parenthood clinics = $25

$25 Plan B price x 983,537 EC kits distributed in 2004 = $25 million Plan B revenue

PPFA Annual Report 2004-2005, p. 22, Combined Statement of Revenue, Expenses & Changes in Net Assets:

total revenue in 2004 = $882.0 million

$25 million / $882 million = 3% of total revenue from Plan B in 2004

I actually don't think this is a real "ethical and legal controversy" and don't think it should not be in an encyclopedia article on emergency contraception. What is the "ethical and legal controversy" here?

The United States legal and ethical controversies section lists three real ethical and legal controversies:

1. the FDA Plan B OTC approval process (and OTC age restrictions)
2. legal and ethical issues in requiring Catholic hospitals to provide EC as an option for rape survivors
3. legal and ethical issues in the refusal of pharmacies to carry and/or pharmacists to dispense EC

and two phony "ethical and legal controversies" that are neither:

1. Planned Parenthood's financial "conflict of interest"
2. A 2002 letter from the FDA to W.C.C. (which formerly distributed and marketed Plan B) objecting to the exact wording used in one radio ad and one newspaper ad placed to inform women in Washington State about a pilot program there to allow pharmacy access to Plan B. What is the legal and ethical controversy here?

FP101 23:44, 15 December 2006 (UTC)

I've said this in the past, (and it was controversial to the other party involved back then, sorry Cindery), but I really think that doing math like this is Original Research. The 2004 number from PP is a reliable source. The price, put out by an anti-PP organization is not a RS. Furthermore, we are not sure if PP gave out any free or discounted doses, or did anything to help low income clients. Also, is this net or gross revenue? Is it taking into consideration the actual cost of the medication? etc. We cannot say that PP for sure makes $3 million off of EC each year. This is simply speculation, and in this case I believe 'doing math' is original research. I think the point can be made without giving specific figures that are not derived from PP financial documents.--Andrew c 00:07, 16 December 2006 (UTC)

If I'm understanding FP101's position correctly, that the last two "controversies" in the list should not be in the article, then I agree with that position. I would support wholesale removal of those entire discussions. Lyrl ^Talk _Contribs 03:15, 16 December 2006 (UTC)

That is my main point. I included the additional information for context to make the point that the Planned Parenthood "financial conflict of interest controversy" is not a real financial conflict of interest and not a real controvery and should not be in the article.

FP101 05:17, 16 December 2006 (UTC)

I agree with Andrew c that combining figures from diverse sources to make a unified mathematical argument (like the % of PP's budget accounted for by EC's) is original research, and that the point can be made without going down that particular road. On the other hand, I agree with both FP101 and Lyrl that the Planned Parenthood "controversy" could be removed - it seems the sources alleging a conflict of interest are predominantly ones whose entire reason for being is to stop PP, and its relevance to the EC article (as opposed to, say, the Planned Parenthood article) is questionable. That said, although we are all in agreement here, Cindery's opinion should be sought and will need to be taken into account, although I believe she's currently on a Wikibreak. MastCell 00:25, 17 December 2006 (UTC)

Approval controversy (U.S.)

I've shortened the U.S approval controversy section a little further, as an opinion had been expressed that it was too long, recentist, America-centric, etc. I'm including an excised portion below, so as not to be accused of "removing sourced content" without a trace (once bitten...)

In 2005, a study was published demonstrating that direct access to ECPs without a prescription doesn't result in fewer unintended pregnancies than controlled access via prescription.

Cheers. MastCell 23:25, 18 December 2006 (UTC)

References

International availability - spin off into own article

The "International availability" section seems designed to list EC availability status in every one of the world's nearly two hundred countries. This documentation goal seems worthy, but the list is already quite long and taking up a disproportionate share of the article. I propose spinning it off into List of emergency contraceptive availability by country.

Availability is currently dealt with in summary form in the "Types of ECPs" section: Progestin-only EC is available as a dedicated emergency contraceptive product under many names worldwide, including: in the U.S., Canada and Honduras as Plan B; in the U.K., Ireland, Australia, New Zealand, Portugal and Italy as Levonelle; in 44 nations including France, most of Western Europe, India, and several countries in Africa, Asia and Latin America as NorLevo; and in 44 nations including most of Eastern Europe, Mexico and many other Latin American countries, Portugal, Australia and New Zealand, Israel, China, Hong Kong, Taiwan and Singapore as Postinor-2. I'm not sure anything else is needed in this article, other than adding a "See also" hatnote linking to the new article in the "ECPs" section.

There is currently some historical information in the availability list. That could be moved to the "History" section before spinning of the list. Lyrl ^Talk _Contribs 02:04, 29 December 2006 (UTC)

I think that's a good idea. The lengthy list of countries under "Availability" was wreaking havoc on the table of contents, too. A sub-article in list format sounds like a good idea. MastCell 03:21, 29 December 2006 (UTC)

"Pregnancy rate" rather than "failure rate"

Note discussion at Talk:Birth control#"pregnancy rate" rather than "failure rate" re replacing occurrences of "failure rate" with "pregnancy rate". I would also like to see the same change on this page. Please make any comments there. --Coppertwig 03:59, 8 January 2007 (UTC)

On the one hand, "failure rate" is most descriptive and intuitive, since pregnancy does represent a failure of birth control methods in such a setting. On the other hand, I can understand the desire not to refer to a pregnancy as a "failure". I guess I'm on the fence and don't feel particularly strongly one way or the other. MastCell 17:31, 8 January 2007 (UTC)

If I were to take it and it failed I'd very much call it a failure. 22:58, 16 February 2008 (UTC) Girl —Preceding unsigned comment added by 63.201.26.232 (talk)

Mifepristone

I'm proposing that the sections about Mifepristone be removed, as it is generally not known as emergency contraception, aka the "Morning After Pill". There should probably be a link to the Mifepristone article, but as it is now, the article risks confusing readers. MaskedEditor 01:56, 9 January 2007 (UTC)

Generally known to who? It's licensed for use as emergency contraception in China, home of one-fifth of the world's population. Besides, isn't part of reading an encyclopedia learning things you didn't know before? I'm not sure "not generally known" is a criteria for excluding things from an encyclopedia. Lyrl ^Talk _C 02:03, 9 January 2007 (UTC)

I meant "not generally known" in the sense that Pluto is not generally known as a planet, not in the sense that an obscure fact is not generally known. That said, I can appreciate the argument that the Chinese government considers it emergency contraception, even though the rest of the world does not. The article is still misleading, given that the intro paragraph says that emergency contraception is also known as the morning after pill, giving the impression that these two terms are synonymous. I'll clean this up if nobody does it first. MaskedEditor 16:10, 9 January 2007 (UTC)

We have citations of mifepristone being used as EC instead of an abortifacient, and I do not believe we are giving undue weight. I believe the current state of the article is fine and clearly explains the two uses of mifepristone. But maybe you could explain your proposed changes here so I understand your complaint more.-Andrew c 16:26, 9 January 2007 (UTC)

I added a citation for Mifepristone being used in China and Russia, hope it's clear.Nimravid (talk) 09:55, 16 March 2011 (UTC)

Abortion rates and risky sex

While the "risky sex" section currently only deals with STDs, the same behavior leads to unplanned pregnancy and abortion - currently dealt with in a separate section "Abortion rates and EC". I feel these topics are sufficiently inter-related they should be combined. What do others think? Lyrl ^Talk _C 22:55, 18 February 2007 (UTC)

I think that makes sense. MastCell 18:07, 19 February 2007 (UTC)

Mechanism of Action

This page doesn't say anything about how the pill works! Would anyone care to explicate?--Heyitspeter 22:14, 19 February 2007 (UTC)

From the introduction to the article: "ECPs," or "ECs", or "morning-after pills"—are drugs that act both to prevent ovulation or fertilisation and possibly post-fertilisation implantation of a blastocyst (embryo). ECPs are distinct from medical abortion methods that act after implantation. More detailed information is presented in the "Controversy" section, though I can see why someone looking for "mechanism of action" would not go looking under "controversy". Maybe that section should be renamed. Lyrl ^Talk _C 23:47, 19 February 2007 (UTC)

Mechanism of Action and Mathematics

From the article: Studies in humans have shown that the rate of ovulation suppression is approximately equal to the effectiveness of emergency contraceptive pills, suggesting that might be the only mechanism by which they prevent pregnancy.

But that doesn't mathematically make sense, and wouldn't suggest that. In order to suggest that the only mechanism by which ECPs prevent pregnancy is ovulation suppression, the rate of ovulation suppression among women who have not yet ovulated needs to be higher than the effectiveness. After all, some of the women who take ECPs to prevent pregnancy have already ovulated by the time that they take the pills; if ECPs work only by preventing ovulation, then they aren't effective in that situation at all.

There's a mathematical upper bound on the effectiveness of ECPs if they work only by ovulation suppression. The exact upper bound depends on:

• The length of time after ovulation that the egg can be fertilized (less than 24 hours, AIUI), which puts a bound on how long the woman may have ovulated before sex and fertilization occur
• The length of time after sex that the ECPs are taken, which provides a further window for ovulation and hence fertilization (and decreases the window for ovulation suppression)
• The length of time that sperm remains in the uterus after sex (3-5 days, AIUI) and the rate of decreasing concentration (and presumably chance of fertilization), which puts a bound on the rate of pregnancies preventable by ovulation suppression

27 Feburary 2007 —The preceding unsigned comment was added by 71.163.137.186 (talk • contribs).

some of the women who take ECPs to prevent pregnancy have already ovulated by the time that they take the pills; if ECPs work only by preventing ovulation, then they aren't effective in that situation at all. - From the article, Recent studies in rats and monkeys have shown that post-ovulatory use of progestin-only and combined ECPs have no effect on pregnancy rates.

Also, effectiveness for ECs is calculated very differently than any other method of contraception. Please carefully read the effectiveness section of the article. Hopefully that will help explain why, if ovulation suppression is the only mechanism, ovulation suppression rates would be equal to (not higher than) the reduction in pregnancy rates. If not, ask here and maybe we'll get ideas for rewriting the effectiveness section to make it more understandable. Lyrl ^Talk _C 00:31, 28 February 2007 (UTC)

so-called "Conscience Clause"

I've removed the scare quotes and so-called's from the section on ethical questions about EC. Scare quotes are inherently POV and thus not appropriate for an encyclopedia article. Miraculouschaos 22:27, 11 March 2007 (UTC)

I removed the sentence altogether because it has been fact tagged for a while (the bot mislabeled it because it isn't smart enough to search the archives). Also, why did you insert "federal law"? Do you have more information about this? If you do, please feel free to restore the sentence with your source. Thanks!-Andrew c 22:43, 12 March 2007 (UTC)

I was just trying to re-word the sentence after deleting the scare quotes...I believe there was a federal law under consideration a couple of years ago that would have required pharmacists to stock and dispense contraceptives, but included a conscience clause for those who had documented religious objections to doing so.Miraculouschaos 16:50, 13 March 2007 (UTC)

If that is the case, mentioning that would be helpful here. But sourcing I guess is the issue. If anyone is reading this and knows more, or wants to do the research, please help this article out! Thanks.-Andrew c 21:38, 13 March 2007 (UTC)

Not aware of any federal law (although federal law does allow providers to decline to participate in abortion). Conscience/refusal clauses vary on a state-by-state basis, although some nationals (Target, WalMart) have uniform policies. Useful references are here and here. As far as Walmart specifically, I'll look into it. MastCell 22:20, 13 March 2007 (UTC)

This seems to be the source for the Walmart thing (read the last paragraph on the bottom right). They were more or less forced to stock EC, which was the controversial issue, but retain a conscience clause permitting refusal. MastCell 22:20, 13 March 2007 (UTC)

There is dead link in the footnotes; the article by Cantor and Baum (fn 127) can however be found at bixbyprogram.ph.ucla.edu/letters_articles/cantor_baum111504.pdf —Preceding unsigned comment added by 66.108.184.224 (talk) 08:58, 29 April 2009 (UTC)

Possible bias

"Although EC is in wide use as an option for victims of sexual assault, some researchers believe it is underutilized as a public health measure.[87] Abortions because of rape account for less than one percent of all annual abortions.[88]"

The last sentence, though true, seems out of place in this article. It seems likely that it was placed there to advance a belief rather than to improve the article.

Feel free to correct me if I'm wrong. Mike 71.248.152.37 23:10, 15 March 2007 (UTC)

Postcoital high-dose progestin-only oral contraceptive pills as ongoing contraception

I moved Cindery's out-of-place "ECPs as ongoing contraception" subsection about Postinor, a postcoital high-dose progestin-only oral contraceptive pill used for ongoing contraception, out of the "Emergency contraceptive pill" section, because it is not an emergency contraceptive pill.

I think the discussion of Postinor (not marketed as an emergency contraceptive pill) should be deleted from this article about emergency contraception.

The caution against using emergency contraceptive pills as a primary method of contraception because of their low efficacy when misused in this way should be folded into the "Effectiveness of ECPs" subsection in the same way it is discussed in this emergency contraception Effectiveness FAQ.

I also think Cindery's "Uncertainties in calculation" sub-subsection should be pruned and folded into the "Effectiveness of ECPs" subsection.

69.208.161.131 21:07, 23 March 2007 (UTC)

OK. MastCell ^Talk 22:15, 23 March 2007 (UTC)

I also contributed substantially to those sections (redacting the information Cindery inserted, if I remember correctly). Postinor is the exact same drug as Postinor-2, which is marketed as emergency contraception. Do we really need to talk about the two different packaging systems in two different articles because these identical drugs are marketed differently? I'm fine with moving the section, but I would object to deleting it entirely.

How do you propose pruning the "uncertainties" section? I'd be fine with deleting the first paragraph, for example, and also removing the subsection title. I find the second and third paragraphs interesting and relevant, though, and am not sure how I would feel about prunes to them. Lyrl ^Talk _C 00:08, 24 March 2007 (UTC)

It is not just different marketing, it is also different instructions for use and presumably different efficacies depending on how they are used. Gedeon Richter's Postinor (a postcoital contraceptive) and Postinor-2 (an emergency contraceptive) are both levonorgestrel 750 µg tablets, but the dose and time limits for taking them are different. A Postinor tablet is supposed to to be taken immediately after unprotected sex as a regular postcoital contraceptive, two Postinor-2 tablets are supposed to be taken together (or 12 hours apart) within 72 hours of unprotected sex as an emergency contraceptive.

I would suggest that:

1. the first paragraph and first bullet about Postinor as a (non-emergency) postcoital contraceptive be incorporated into the "History" section noting how it was adapted for use as an emergency contraceptive.
2. the second bullet and the last paragraph be incorporated into the "Effectiveness of ECPs" subsection to explain (as the fourth paragraph of this FAQ does) that it is not recommended that ECPs be used as a primary method of contraception because of their low efficacy compared to other contraceptive methods.
3. the third bullet about ECPs, like other non-barrier contraceptives, not protecting against STDs could be moved to the "Effectiveness of ECPs" subsection which, though primarily about contraceptive effectiveness, would be an appropriate place to mention effectiveness in protecting against STDs.

I think deleting the first paragraph of the "Uncertainties in calculation" sub-subsection and deleting the sub-subsection title would be a good idea, the second and third paragraphs could then be incorporated in the "Effectiveness of ECPs" subsection.

69.208.161.131 04:50, 24 March 2007 (UTC)

That all sounds good. Lyrl ^Talk _C 13:12, 24 March 2007 (UTC)

Confirmation of results

Confirmation of results

A pregnancy test is the only reliable way to confirm that EC has been effective. EC can cause menstrual changes that are similar to early signs of pregnancy, and some doctors therefore advise all women who take EC to take a pregnancy test afterwards to confirm results.[verification needed]

Pregnancy tests will not give positive results until after an embryo has implanted, which occurs six to twelve days after ovulation.[34] The most sensitive tests can detect pregnancy the day after implantation, so the earliest a positive result would be seen would be one week after intercourse (assuming intercourse occurred on the day of ovulation). Sperm life of up to five days is considered normal,[35] and less sensitive tests may not detect pregnancy until three to four days after implantation. Thus, a pregnancy test may give false negatives up to three weeks after intercourse (five days between intercourse and ovulation, twelve days between ovulation and implantation, four days between implantation and detectable levels of the pregnancy hormone hCG).

The above subsection and its (unsourced) first paragraph (which originally said "most doctors" advise women to take a pregnancy test after taking an ECP to confirm results) was added by an anonymous editor (85.154.19.197) on 7 July 2006.

The next day, on 8 July 2006, Lyrl revised the (unsourced) first paragraph to say "some doctors" advise women to take a pregnancy test after taking an ECP to confirm results, and added the second paragraph with information about how long after ovulation implantation occurs and how long sperm live.

Five months later, on 3 December 2006, Lyrl added two references to the second paragraph to support the information on how long after ovulation implantation occurs and how long sperm live.

Over three months ago, on 17 December 2006, I flagged the first paragraph as needing verification as a very dubious statement.

No editors have provided a source for the paragraph and subsection, and I could find no reliable source (prescribing information, journal articles, textbooks, etc.) where doctors advise women to take a pregnancy test after taking an ECP to confirm results).

I have therefore moved the misleading, unsourced subsection from the article to this talk page.

69.208.161.131 23:07, 23 March 2007 (UTC)

That makes sense. We get it, you think the article is misleading, deceptive, etc. I would say I partways agree with you, particularly about Cindery's editing habits - but you've made your point there. Your edits look fine; could I ask you to tone down the rhetoric a little? MastCell ^Talk 23:10, 23 March 2007 (UTC)

Because ECPs can disrupt the next menstrual cycle, I find information about when pregnancy tests are accurate more relevant to this article than to any of the other contraceptive articles. I'm fine with deleting the unsourced first paragraph, but is there a way to add the information on pregnancy test accuracy (abbreviated version?) back in? Lyrl ^Talk _C 00:10, 24 March 2007 (UTC)

I would suggest:

1. leaving the previous "Confirmation of results" subsection out of this article.
2. incorporating information on pregnancy test accuracy into the existing "False positive/negative tests" section of the Pregnancy test article.
3. noting in a revised "Side effects" subsection discussion of possible menstrual changes: that if a woman's menstrual period is more than a week late, she should get a pregnancy test.
4. revising the unsourced "Side effects" subsection dicussion of possible menstrual changes, that currently says:

Temporary disruption of the menstrual cycle is also common and may manifest as early or late periods, spotting or breakthrough bleeding, and (less commonly) missed periods. The primary mechanism of EC is delaying ovulation. Menstruation occurs, on average, 14 days after ovulation, so delayed ovulation results in delayed menstruation. Suppression of ovulation may cause anovulatory bleeding, which could manifest as an early period.

• the primary mechanism of action of progestin-only EC is inhibition of ovulation, not delay of ovulation (FFPRHC Guidance - EC)
• in the 2002 WHO trial (PMID 12480356), of women using progestin-only EC:
  • more than half had a menstrual period within 2 days of the expected date
  • twice as many had an early menstrual period as had a late menstrual period
  • 4.7% had a menstrual period delayed by > 7 days
  • 16.1% had non-menstrual bleeding in the first 7 days after EC use
• the timing of the menstrual period after progestin-only EC use is dependent on when in the menstrual cycle (pre-ovulatory, peri-ovulatory, post-ovulatory) EC was taken (PMID 16531171, PMID 16860049)

69.208.161.131 06:17, 26 March 2007 (UTC)

If I understand correctly, ovulation occurs at the end of a "follicular wave" where a group of tertiary stage follicles were recruited to develop together. If taken during a follicular wave, EC causes that wave to be anovulatory (inhibits ovulation). After EC inhibits ovulation, two things can happen:

1. Anovulatory bleeding will occur, then normal follicular development will proceed in the next cycle (an anovulatory cycle), or
2. A new follicular wave will develop, ovulation occur, and then normal menstruation (a delayed ovulation).

If this understanding is correct, the terms inhibit ovulation and delayed ovulation are compatible. Ovulation is inhibited for that particular follicular wave, but is delayed in the context of the entire menstrual cycle. I believe explaining it as "delayed ovulation" is more useful to readers, because it lets them know ovulation can occur post-EC use even if they have not yet had menstrual bleeding.

I can find sources for these statements if all you are looking for is a source.

Pregnancy test accuracy is already addressed in the pregnancy test article, both in the "chemical markers" section and in the "false positive/false negative" section. The pregnancy test article discussion is centered around the date of expected menstruation, not date of intercourse. I believe a discussion around the date of intercourse is more appropriate for this article, because of the context in which EC is used. I believe something brief would be useful (Pregnancy tests will not give positive results until after an embryo has implanted. Depending on sperm life and the date of implantation, pregnancy tests may give false negatives for one to three weeks after intercourse) but like the idea of including it in the side effects section with the discussion of menstrual changes.

I do not find stand-alone blanket advice ("take a pregnancy test if your period is a week late") to be encyclopedic. I want to explain why. I find explaining why things happen to be more encyclopedic than repeating one-size-fits-all advice from web FAQs.

I find it frustrating that the WHO study gives all these statistics on bleeding, but relies only on the women's judgment of what was a "late" or "early" period and provides no context. Are these cycle abnormalities believed to be caused by the EC? Or are they just normal variation (most women do not have 28-day clockwork cycles)? Is the bleeding actually a deviation from the women's average, or did the psychological stress related to having to take EC affect their expectation of when their menstruation would begin? Or is the average women just bad at keeping track of her cycles? Without these related data, those bleeding statistics don't provide nearly the information they could.</off topic rant>

I do like the timing of the menstrual period after progestin-only EC use is dependent on when in the menstrual cycle (pre-ovulatory, peri-ovulatory, post-ovulatory) EC was taken. Also, converting the list of statistics to paragraph form would probably make it more readable (While over half of women who take EC menstruate within two days of their expected date, cycle disturbances such as early menstruation, late menstruation, and non-menstrual bleeding are common.)

In conclusion, how about replacing the last paragraph of the Side effects section with:

While over half of women who take EC menstruate within two days of their expected date, cycle disturbances such as early menstruation, late menstruation, and non-menstrual bleeding are common. The timing of the menstrual period after progestin-only EC use is dependent on when in the menstrual cycle (pre-ovulatory, peri-ovulatory, post-ovulatory) EC was taken. Inhibition of ovulation may result in an anovulatory cycle, or in a delayed ovulation. Some sources advise women to take a pregnancy test if their menstrual period is over one week late. Pregnancy tests will give reliable results within a few day of embryo implantation. Depending on sperm life and the date of implantation, false negative pregnancy tests are possible for one to three weeks after intercourse.

Lyrl ^Talk _C 01:07, 27 March 2007 (UTC)

• "Delayed ovulation"
  • "Follicular waves" in women (as opposed to animals) are part of a model of undetermined clinical significance proposed in July 2003 by two scientists, Angela Baerwald & Roger Pierson, at the University of Saskatchewan based on daily ultrasound tests on 63 women for one cycle performed by Baerwald as part of her Ph.D. research.PMID 12849812 [4]

• • When levonorgestrel EC prevents ovulation, it is followed by progestogen withdrawal bleeding. This is not the type of bleeding referred to by the term "anovulatory bleeding" (a synonym for "dysfunctional uterine bleeding" or "abnormal uterine bleeding" due to hormonal imbalance in the absence of organic pathology) for which progestogens such as Aygestin (norethindrone acetate) or Provera (medroxyprogesterone acetate) are FDA-approved treatments to intentionally precipitate progestogen withdrawal bleeding.

• • When given prior to the LH surge, levonorgestrel 1.5 mg usually prevents the LH surge and ovulation.PMID 11747872
    • In comparison, mifepristone 10 mg usually delays the LH surge and ovulation by 3-4 days.PMID 15192056
    • When levonorgestrel 1.5 mg prevents the LH surge and ovulation, the high dose of a potent progestogen with a relatively long half-life produces a secretory transformation of the endometrium, followed by progestogen withdrawal bleeding as levonorgestrel levels decline. This produces an early menstrual period, the timing and character of which may cause some women to interpret it as intermenstrual bleeding as opposed to a menstrual period and therefore interpret the menstrual period following the next cycle as a very delayed (by several weeks) menstrual period marking the end of the cycle in which the levonorgestrel ECP was taken.
      • In comparison, when mifepristone 10 mg delays the LH surge and ovulation by 3-4 days, and is followed by a normal length luteal phase, the next menstrual period will be somewhat delayed (by several days).
  • When given after the LH surge, levonorgestrel 1.5 mg does not prevent ovulation, a normal length luteal phase ensues, which is then followed by a normally timed menstrual period (unless an established pregnancy intervenes).

• • It is clear and straightforward to refer to delayed ovulation within a cycle (such as can be produced by many factors that have found to prolong the follicular phase--one of which being mifepristone 10 mg ECPs) as "delayed ovulation."
  • It is unclear and confusing to refer to ovulation in a cycle following a cycle in which levonorgestrel EC prevented ovulation as "delayed ovulation."

• Pregnancy test details
  • If the Pregnancy test article is too focused on the date of expected menstruation and neglects how long after intercourse pregnancy tests can still give false negatives, then additional information should be added to the Pregnancy test article, not the Emergency contraception article.

• • A pregnancy test is not recommended as routine follow-up to emergency contraceptive use, but is urged in situations where an expected menstrual period is a week late. This would usually be 2-3 weeks after ovulation, when a pregnancy test is likely to be accurate and not give a false negative. The Princeton University Emergency Contraception website has a FAQ When can I take a pregnancy test and be sure that it is accurate? that says a home pregnancy test is unlikely to be accurate unless it has been at least 10 days since a woman has had unprotected sex and has not gotten her period when she thinks she should have. If the test is negative at that time but the woman is still worried, she can take a second home pregnancy test a week later.

• • Providing details about the operating characteristics of pregnancy tests and the factors that determine the soonest after intercourse a pregnancy test could possibly be positive and the latest after intercourse a pregnancy test could possibly be negative is appropriate for the Pregnancy test article, but inappropriate as part of a discussion of the implications of menstrual disturbances in the ECP Side effects section of the Emergency contraception article.

• "Stand-alone blanket advice that is not encyclopedic"
  • The recommendation that if a woman's menstrual period is more than a week late, she should get a pregnancy test, is not un-encyclopedic "stand-alone blanket advice":
    • Plan B OTC product information:
      • Will I experience any side effects from Plan B?
        • "Some women have menstrual changes such as spotting or bleeding before their next period. Some women may have a heavier or lighter next period, or a period that is early or late. If your period is more than a week late, you should get a pregnancy test." (bold emphasis in the original)
    • Plan B Rx prescribing information:
      • Effects on Menses
        • "Menstrual bleeding patterns are often irregular among women using progestin-only oral contraceptives and in clinical studies of levonorgestrel for postcoital and emergency contraceptive use. Some women may experience spotting a few days after taking Plan B. At the time of expected menses, approximately 75% of women using Plan B had vaginal bleeding similar to their normal menses, 12-13% bled more than usual, and 12% bled less than usual. The majority of women (87%) had their next menstrual period at the expected time or within ± 7 days, while 13% had a delay of more than 7 days beyond the anticipated onset of menses.PMID 9708750 If there is a delay in the onset of menses beyond 1 week, the possibility of pregnancy should be considered."
    • Levonelle 1500 SPC (Summary of Product Characteristics)
      • 4.4 Special warnings and precautions for use
        • "If menstrual periods are delayed by more than 5 days or abnormal bleeding occurs at the expected date of menstrual periods or pregnancy is suspected for any other reason, pregnancy should be excluded.
        • After Levonelle 1500 intake, menstrual periods are usually normal and occur at the expected date. They can sometimes occur earlier or later than expected by a few days. Women should be advised to make a medical appointment to initiate or adopt a method of regular contraception. If no withdrawal bleed occurs in the next pill-free period following the use of Levonelle 1500 after regular hormonal contraception, pregnancy should be ruled out."
      • 4.8 Undesirable effects
        • "Bleeding patterns may be temporarily disturbed, but most women will have their next menstrual period within 7 days of the expected time.
        • If the next menstrual period is more than 5 days overdue, pregnancy should be excluded."
    • AAP (October 2005) Policy Statement. Emergency Contraception. PMID 16147972 p. 1043:
      • Common concerns about emergency contraception
        • "Use of emergency contraception may slightly alter the menstrual pattern depending on the timing of its administration within the menstrual cycle. Approximately 98% of patients will menstruate within 3 weeks of treatment, with more than half menstruating at the expected time.PMID 9708750 If treatment is initiated before ovulation, the menses are often 3 to 7 days earlier than expected. Treatment initiated after ovulation usually results in menses at the expected time or in a slight delay. Patients who are 3 weeks post-treatment without menses should be evaluated for pregnancy."
    • ACOG (December 2005) Practice Bulletin. Emergency Contraception. PMID 16319278 p. 1448:
      • What clinical follow-up is needed after use of emergency contraception?
        • "No scheduled follow-up is required after use of emergency contraception. However, the woman should be advised that if her menstrual period is delayed by a week or more, she should consider the possibility that she may be pregnant and seek clinical evaluation."
    • FFPRHC (April 2006) Guidance. Emergency Contraception. PMID 16824309 p. 124:
      • What are the side effects of emergency contraception?
        • "Disturbances to the cycle are common after LNG EC. In the WHO trial,PMID 12480356 16% of women experienced bleeding (unrelated to expected menstruation) in the 7 days following treatment. Around 50% of women menstruated a few days earlier or a few days later than their expected time. These bleeding disturbances are important in clinical practice as women and clinicians generally rely on the reassurance of menstruation as confirmation that EC has been effective and pregnancy has not ensued. It may be difficult to differentiate between non-menstrual bleeding in the early days after EC and actual menstruation. Clinicians and women should always err on the side of caution, and undertake pregnancy testing if there is any doubt that menstruation has followed EC use."

• Levonorgestrel ECP RCTs and bleeding pattern studies
  • Data on bleeding patterns after use of levonorgestrel ECPs from large double-blind randomized controlled trials of efficacy and side effects (summarized in Table 1 on p. 377 of PMID 16531171) have been inconsistent. For instance:
    • The reported frequency of menstrual periods ≥ 4 days earlier than expected ranged from: 15% (1998 WHO trial PMID 9708750), to 30% (2002 WHO trial PMID 12480356), to 41% (1993 Hong Kong trial PMID 8473453).
    • The reported frequency of intermenstrual bleeding ranged from: 3% (1993 Hong Kong trial PMID 8473453), to < 14% (1998 WHO trial PMID 9708750), to 16.1% (2002 WHO trial PMID 12480356), to 37% (2002 Nigerian trial PMID 12413624).
  • As noted in Trussell & Raymond's (March 2007) Emergency Contraception review article, the only two studies specifically examining bleeding patterns after levonorgestrel ECP use:
    • Raymond et al. (April 2006) PMID 16531171, PMID 16982238, PMID 17161121 study in Boston
    • Gainer et al. (August 2006) PMID 16860049 study in Yaoundé, Cameroon
  • were generally consistent with each other:
    • Raymond et al. PMID 16531171, PMID 16982238 found that levonorgestrel ECP use:
      • in the first 3 weeks significantly shortened that cycle (and the earlier in the cycle ECPs were taken, the shorter the cycle)
      • in the 4th week or later significantly lengthened that cycle:
        • median ECP cycle length (adjusted for usual cycle length):
          • 12.7 days (ECPs used in week 1, n= 3)
          • 18.3 days (ECPs used in week 2, n=32)
          • 24.7 days (ECPs used in week 3, n=52)
          • 29.4 days (ECPs used in week 4+, n=26)
      • subsequent cycle length was not significantly affected
        • median subsequent cycle length (adjusted for usual cycle length):
          • 26.8 days (ECPs used in preceding cycle)
      • intermenstrual bleeding in the ECP cycle was uncommon (5%) and similar to that in a comparison group not using ECPs (4%)
      • over half (52%) of women had bleeding (including menses) within the first 7 days of ECP use
      • "Most prior studies that reported bleeding patterns after ECP use did not use standardized definitions of cycles or periods. Without definitions, a pattern such as the one we observed of an early menstrual period followed by a cycle of normal duration could have been interpreted as early intermenstrual bleeding followed by delayed menses. Indeed, several large studies on levonorgestrel ECPs did report high incidences of such patterns: PMID 9708750, PMID 12480356, PMID 12413624. Our data suggest that ECPs hasten the end of the current menstrual cycle, but thereafter the hormonal cyclicity is "reset" and proceeds normally."
    • Trussell PMID 17161121, in a follow-on analysis, found that:
      • the menstrual period start date noted by women matched the start date as determined by applying a standardized definition of a menstrual period to their bleeding diary:
        • within 1 day in 81% (90/111) of ECP cycles; and within 5 days in 86% (96/111) of ECP cycles
        • was more than 7 days later in 14% (15/111) of ECP cycles
          • of those, 13 of 15 were among the 32 who had used ECPs in cycle week 2, and those 13 reported a menstrual period start date that was on average 32 days later than the period start date as determined by applying a standardized definition of a menstrual period to their bleeding diary.
          • 41% (13/32) of women who used ECPs in cycle week 2 may have interpreted an early menstrual period followed by a cycle of normal duration as early intermenstrual bleeding followed by (very) delayed menses.
    • Gainer et al. PMID 16860049 found, compared to baseline and post-ECP cycles, with levonorgestrel ECP use:
      • ECP cycle length was shortened by 0.8 days (with ECP use >2 days before estimated ovulation date)
      • ECP cycle length was unchanged (with ECP use within 2 days of estimated ovulation date)
      • ECP cycle length was lengthened by 1.7 days (with ECP use >2 days after estimated ovulation date)
      • "In our study, taking EC early in the menstrual cycle (two or more days before expected ovulation) was associated with a shortened cycle length and incident intermenstrual bleeding, which is consistent with the fact that levonorgestrel administration in the early follicular phase is associated with a blunted lutenizing hormone (LH) peak, shortened luteal phase length and ovulation blockade. Taking EC later in the menstrual cycle (two or more days after expected ovulation), on the other hand, tended to prolong the menstrual cycle, as can be expected in light of the direct relationship observed between circulating progestogen metabolite concentrations and luteal phase length."

69.208.169.248 18:19, 30 March 2007 (UTC)

Wow, that was an incredible amount of useful information. Thank you so much for taking the time to do that research.

I think I understand your objections to the longer explanation of pregnancy testing here. I agree now that it's more appropriate for the pregnancy test article, and I'll add that modification to my to-do list. In this article, I've added in my most recent edit that "earlier testing may not give accurate results". Hopefully this will satisfy my desire to explain why a woman should wait until her period is a week late to test, but be short enough to not stray off topic. Lyrl ^Talk _C 02:49, 1 April 2007 (UTC)

Was RU-486 ever called "the morning-after pill"?

A thesaurus I was using listed "morning-after pill" as a synonym for "RU-486." Obviously, what we now call the morning-after pill isn't RU-486 and doesn't have its abortifacient effects, but, supposedly, many people oppose it because they believe it is or does, respectively. If RU-486 had been known by that term, it may be a cause for the confusion about common emergency contraceptives' effects.

I don't even know where to start looking for an answer to this. OB/GYNs? Planned Parenthood? -Dan 04:10, 10 April 2007 (UTC)

Although mifepristone (RU-486) has been used as emergency contraception, it's far from synonymous with EC. As the article indicates, the most commonly used forms of "morning-after pill" in the West are levonorgestrel pills. Might want to get a new thesaurus. MastCell ^Talk 04:17, 10 April 2007 (UTC)

Agreed. Your thesaurus is wrong, Dan. RU-486 is very different from the "morning-after" pill.

However, emergency contraception does actually act as an abortifacient, sometimes. When taken prior to ovulation, it generally prevents ovulation, and thus does not act as an abortifacient. But when taken after ovulation, one of its mechanisms of action is to prevent implantation after fertilization, which thereby kills the embryo and causes an early abortion. NCdave (talk) 23:55, 4 February 2008 (UTC)

"Some pro-life groups?"

The intro says, "Some pro-life groups define pregnancy as beginning with fertilization, and consider those forms of EC that act after fertilization to be abortifacients."

I don't think that is an accurate paraphrase of the usual pro-life position, and it suggests four questions:

1) Why is the word "pregnancy" used here? Pro-lifers generally say that "human life" (not "pregnancy") begins at fertilization. The closest pro-life statement that I can recall seeing to "pregnancy begins with fertilization" was a bumper sticker that said, "if it's not a baby / you're not pregnant." The problem with substituting the word "pregnancy" for the phrase "human life" is that it is unclear how that applies to human embryos conceived in a laboratory.

2) Why is the word "define" used instead of "believe" or "contend?" Words are defined, natural processes can be discovered or understood, but not defined. The pro-life argument is not about grammar.

3) "Some pro-life groups?" I thought all pro-lifers believed that human life begins at fertilization. What pro-life groups do not contend that human life begins with fertilization? Are there any?

4) What forms of EC do not act after fertilization?

I don't know the answer to question 2 3, but I am pretty sure that most (if not all) pro-life groups consider human life to begin at fertilization. Can anyone name an exception?

I'm also certain that all forms of EC act after fertilization at least some of the time, and therefore work as abortifacients. Correct me if I'm wrong. Does anyone know of a form of EC that doesn't?

I suggest that we change the sentence to say, "Pro-life groups contend that human life begins with fertilization, and consider EC to be an abortifacient when it blocks implantation of a fertilized ovum." NCdave (talk) 00:51, 5 February 2008 (UTC)

I think your proposed edit is a good one, and recommend that it be adopted.The.helping.people.tick (talk) 00:59, 5 February 2008 (UTC)

To address "Does anyone know of a form of EC that doesn't?" I'd suggest reading Emergency contraception#Mechanism of action and checking out the cited sources. What it boils down to is there was some literature on this subject a few decades ago that speculatively suggested that these hormones affected the endrometrial lining and thus hindered implantation. Further studies have been inconclusive. Because it is a fairly common occurrence for zygotes to fail to implant, it has been difficult to determine if progesterone is doing anything when it comes to hindering implantation. In fact, statistically, in say the monkey study, the pregnancy rate when levonorgestrel administered post-fertilization was consistent with pregnancy rates without any drugs. So to make a claim that "EC... blocks implantation of a fertilized ovum" is not exactly consistent with the latest data. But again, the current wording we have is a little problematic as well. We say "those forms of EC that act after fertilization", and I'm not exactly clear to which forms we are referring.

As to the second issue, the United States Catholic Bishops Health Care Directives permit use of EC for rape victims, and some pro-life politicians have voted on the side of EC in a number of state legislatures (i.e. Wisconsin and Massachusetts). I do not believe we can accurately say that all pro-lifers believe EC causes abortions (because that's like saying all pro-lifers ignore the latest scientific studies on the mechanisms of action). Because there is a spectrum of beliefs when it comes to these issues, I'm not even sure we can make the claim that all pro-lifers believe human life begins with fertilization. What's worse is I just noticed that there isn't even a source to back this stuff up. I'm thinking that we take these things into consideration, and then look up some sources before coming up with a wording. It's a bit odd to phrase a movement's beliefs without even citing authorities. We may come up with something like "Some leading pro-life organizations believe EC may at times act as an abortifacient because of..." but of course that all depends on what our research yeilds! -Andrew c ^[talk] 02:00, 5 February 2008 (UTC)

TOPIC #1:

I noticed a problem with my proposed wording. "Ovum" is the wrong word, because by the time of implantation, is no longer an ovum, it is by then a blastocyst-stage embryo.

TOPIC #2:

I am not persuaded of the supposed doubt over whether levonorgestrel impedes implantation. There are believed to be three mechanisms by which it works: (1) by preventing ovulation, (2) by thickening mucous and thereby impeding the sperm's ability to reach the ovum, and (3) by making the uterine wall inhospitable for implantation of the embryo. The Plan B manufacturer's "Go Plan B" web site used to mention all three mechanisms:

"How does Plan B work (mechanism of action)?

Plan B is believed to act as an emergency contraceptive principally by preventing ovulation or fertilization (by altering tubal transport of sperm and/or ova). In addition, it may inhibit implantation by altering the endometrium."[5]

There are at least two very compelling reasons to believe that mechanism (3) is real:

• Considering the manufacturers' compelling business and PR reasons for not wanting to admit or publicize mechanism #3, there can be little doubt that they believe it works that way at least some of the time.
• The fact that EC can be effective when taken 72 hours after coitus seems to be conclusive evidence that it must be killing embryos. Sperm is believed to only be able to fertilize an ovum for 48-72 hours after ejaculation,[6] so by 72 hours after intercourse any fertilization that could happen has already happened. To take EC at 72 hours would therefore be pointless if it didn't kill embryos. Levonorgestrel enters the bloodstream pretty fast (Tmax 2 hours), but not instantly, so if it truly had no abortifacient effect then it could not possibly be effective when taken 72 hours after intercourse.

So, even sources very strongly supportive of EC admit that:

[even though] "some reproductive rights advocates [assert] that ECPs have no postfertilization effect whatsoever..."

women must know that ECPs — like all regular hormonal contraceptives ... may prevent pregnancy by delaying or inhibiting ovulation, inhibiting fertilization, or inhibiting implantation of a fertilized egg in the endometrium."[7]

TOPIC #3:

Obviously it is not possible to say much of anything about what "all pro-lifers" believe (that is, every pro-life person), but my proposed revision (like the the existing sentence) is about what pro-life groups say. Clearly, most pro-life groups contend that human life begins at fertilization. The question I asked is whether there are any exceptions. Are there any pro-life groups that do not contend that life begins at fertilization? If so, we should say, "Most pro-life groups contend" rather than just "Pro-life groups contend." NCdave (talk) 05:32, 5 February 2008 (UTC)

Well you are missing the main meat of my post. We can't say anything without sources. We don't, by default, get to put words into the whole pro-life movement based on absolutely nothing. If we are going to make a claim, our readers are going to have to verify it. We do that on wikipedia by attribution and citing sources. Next, on topic #2, the sources you cite say "may": it may inhibit implantation. It is a big step to go from "may" to "actually does". In the article, we need to avoid original research such as the uncited: The fact that EC can be effective when taken 72 hours after coitus seems to be conclusive evidence that it must be killing embryos. My point is the literature is shaky and there is conflicting evidence, and we cannot conclusively say either way whether EC affects implantation. I want to make it clear that I don't want to push the view that EC doesn't effect implantation whatsoever in the article, but I also want to avoid sneaky claims that it definitively does. This is why the word "may" is important. This is a good review (starting at the bottom of page 3 going on to the middle of page 5).-Andrew c ^[talk] 15:44, 5 February 2008 (UTC)

According to the USCCB, "If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation, or fertilization." (36) Andrew's claim that the bishops allow EC omits the condition of testing for conception. (whether such tests are accurate is another story). As summarized in Sulmasy, "a controversy has arisen within the Catholic community over the conditions under which this treatment can be undertaken. One camp argues that as long as the patient has a negative pregnancy test, treatment intended to prevent conception may be given. This has been dubbed the “pregnancy approach.” Another camp, convinced that the drugs used are at least sometimes abortifacient, has argued that one must conduct a further series of tests to establish not only that the patient is not pregnant, but also that the patient has not yet ovulated. This has been dubbed the “ovulation approach.” (Daniel Sulmasy, Kennedy Institute of Ethics Journal Vol. 16, No. 4, 305–331 © 2006 by The Johns Hopkins University Press). It might be appropriate to acknowledge the controversy in the article. The.helping.people.tick (talk) 18:34, 5 February 2008 (UTC)

Andrew, I'm fine with including the word "may." Really, I don't think it is Original Research to note that fertilization cannot be prevented after it has already occurred. But the pro-life community is not going to be approving of anything that "may" kill an unborn human, anyhow. So their positions will be the same on EC regardless of whether the scientific community has consensus that EC sometimes works as an abortifacient, or whether they say it may sometimes work as an abortifacient. Only if there is a consensus that EC cannot work as an abortifacient are the pro-life groups going to cease opposing it.

The Princeton EC advocates that I quoted above used the word "may" ambiguously. It could be interpreted to mean either that EC "may" inhibit implantation in a particular instance, or it could mean that EC "may" have a mechanism that inhibits implantation. We can do the same, and thereby dodge the argument.

The.helping.people.tick, that is excellent and highly relevant information, and I do think it would be a very worthwhile addition to the article. It is the soft of information that people look for in an encyclopedia, and are likely to actually find useful. NCdave (talk) 20:10, 5 February 2008 (UTC)

(reset indent) Just a comment on the 72 hour claim - all teachers of fertility awareness (including the best-selling book Taking Charge of Your Fertility) teach that it is normal for sperm to fertilize an ovum up to 120 hours (5 days) after intercourse. For what my anecdotal reports are worth, I have spent a number of years reading a fertility awareness-based message board, and have seen a significant number of pregnancies from intercourse five days before ovulation. A study by the World Organization Ovulation Method Billings found (regarding pregnancies while using fertility awareness for birth control): "Indications were that sperm survival in one case was 5-6 days, 6-7 in two cases and 7-8 on one other." [8]

Drinking two cups of coffee a day "may" kill an unborn human (25% miscarriage rate vs. 13% among women who drink no caffeine [9]), but pro-life groups aren't organizing anti-coffee campaigns. Uncertainty of mechanism and intent of the person taking it certainly do play roles in where pro-life groups stand on different drugs.

Some variation of this might work: Some scientists believe that EC sometimes acts after fertilization (see mechanism of action). Because of this, many pro-life groups consider EC to be an abortifacient. Lyrl^Talk _C 02:47, 6 February 2008 (UTC)

The disagreement over how long sperm are healthy enough to fertilize an ovum is interesting. Dr. Mazumdar's web site says, "Sperm... has been found in the uterus 5-7 days after coitus. But they are capable of fertilizing an ovum for only 48 - 72 hours after being ejaculated." If he is wrong about how long sperm are capable of fertilizing an ovum, then you are correct that the 72 hour efficacy of EC does not prove it works as an abortifacient. However, it is not merely "some" scientists who say EC may act after fertilization, it is the mainstream scientific assessment, reflected even in the mfg's own literature and studies. So we should certainly say "most" instead of "some."

So how about this: "Pro-life groups contend that human life begins with fertilization, and consider EC to be an abortifacient if it blocks implantation of an embryo (i.e., if it stops a pregnancy after fertilization of the ovum)."

Or, if anyone manages to find a pro-life group that is an exception to that general rule, we could add the word "most," like this: "Most pro-life groups contend that human life begins with fertilization, and consider EC to be an abortifacient if it blocks implantation of an embryo (i.e., if it stops a pregnancy after fertilization of the ovum)."

The main change from my previously proposed wording is that I changed "when" to "if" ("...if it blocks implantation..."). That's basically introducing the same ambiguity that the word "may" did in the Princeton EC site's statement.

However, the "mechanism of action" section also needs to be changed to reflect the fact that the mainstream scientific view is that EC can, indeed, work after fertilization. The current version is written to cast maximum doubt on the likelihood that EC can work after fertilization, which is to say that the current version gives disproportionate weight to a distinctly minority view.

The statement that "it is considered possible that these same mechanisms are also harmful to embryos that have not yet implanted" just oozes POV. "Possible?" It is the opinion of the vast majority of researchers who have studied it, and acknowledged by the mfg that it sometimes works that way. "Harmful?" Cummon, it doesn't just "harm" them, it KILLS them. There is no evidence at all that it harms them in any way OTHER than killing them. NCdave (talk) 22:23, 6 February 2008 (UTC)

BTW, if and when the scientific consensus (rather than just one study) is that drinking 2 cups of coffee per day doubles the risk of miscarriage, I'm sure you'll see not just pro-life groups fretting about it, but also the March of Dimes, the pediatricians groups, the FDA, and everybody else under the sun campaigning against coffee-drinking by pregnant women. Let's try to be serious here, please? You sound like you don't believe the pro-lifers are sincere in their reason for opposing EC. NCdave (talk) 22:29, 6 February 2008 (UTC)

Looking on the Planned Parenthood web site, I found that they say "EC is safe and can prevent pregnancy if used by women within five days of unprotected sex."[10] Certainly there can be no doubt that the vast majority of (if not all) impregnationsfertilizations occur when the sperm is less than five days old. So if the PP claim is true, there can be no doubt that EC is working after fertilization.

I googled for:

"life begins" site:nrlc.org

and immediately found the answer to the question of what the largest pro-life group says about this (they say life begins with fertilization). We could presumably do the same with all the other major pro-life groups, and I think we would find the same answer. But there are a lot of pro-life groups (though a few of the ones listed in that category are questionably categorized). I checked a few of the better-known ones:

• American Life League says the same thing.[11]
• Care-Net doesn't have the phrase "life begins" on their web site, but they say that Plan B (like birth control pills) causes an "early abortion" when it prevents an "already fertilized egg" from implanting.[12] (This document is specifically about EC, and would make a good external link for our article)
• Concerned Women For America says, "Scientifically, there is absolutely no question whatsoever that the immediate product of fertilization is a newly existing human being."[13]
• Democrats for Life says, "Democrats for Life of America advocates respect for life from fertilization to natural death."[14]
• Feminists for Life President Serrin Foster says, "life begins at conception—not implantation."[15]

So far, all the pro-life groups I checked are unanimous. They all say that life begins at fertilization. I have an appointment and have to leave, and this is a tedious process. But that is surely enough to establish that most, if not all, pro-life groups hold that position. I really doubt you will find any prominent pro-life group that does not contend that life beings at fertilization. NCdave (talk) 23:37, 6 February 2008 (UTC)

While I don't agree that it would make a good external link for our article, that IMO is the best link you have found, because we have to keep in mind what this article is about. It isn't about pro-life organizations' view on when life begins. It is about emergency contraception. And therefore, the opinion of pro-life organizations on EC is what is valid. It is original research to say "pro-life groups believe x" and cite all that stuff above, and then draw the conclusion that they oppose EC. We need to cite these organizations opposition to EC (and don't get me wrong, I don't doubt that they oppose EC). We just need to make sure we are following WP:V and not doing original research. Your first paragraph above is exactly the sort of thing we should avoid. We cannot personally draw conclusions about how EC works based on claims made on a pro-abortion website, mixed with your conjecture on how long sperm live. If it were that simple, we'd have the scientific papers to cite in that regard, correct? But as shown by the Princeton PDF I linked to, the literature on the subject varies. Therefore, I think Lyrl's wording is more on tract that NCdave's. NCdave's might be more workable if we remove the first clause about when these groups believe human life starts, and add a clause at the end like "which it may not do". I also believe the parenthetical explanation is a bit wordy. As for Lyrl's, I could live with NCdave's suggestion of changing "some scientist" to "many scientists" if we also add the important word "may". I'm not sure if "most" is applicable. But again, we need to make sure that "the leading pro-life organizations" feel this way about EC by citing them. While I do think it is a bit backwords to work on a specific wording without having our cited sourced in line first, I do believe we are making progress, and hopefully we will shortly have a consensus version we cvan all live with! -Andrew c ^[talk] 23:56, 6 February 2008 (UTC)

The claim of effectiveness up to 5 days is, as far as I can tell, from PMID 12480356, a 2003 study by WHO. This response to the study points out that the 95% confidence intervals for 4- and 5-day effectiveness are so wide the results are not statistically significant. Lacking a study with firmer results, I think it is reasonable to remain skeptical of EC effectiveness past 72 hours.

As far as sperm life, from sperm physiologist Dr. Joanna Ellington [16]: "Some men have almost no sperm attaching and they die quickly within hours, while some men have a very high attachment rate and survival rate with sperm living attached to the tubal cells for up to 9 days in the laboratory. This correlates with what has been in seen in women with live sperm found in one woman’s tubes 21 days after intercourse!"

In this Wikipedia article, I would like to remove the "pregnancy begins", "life begins" language altogether, instead just describing the possible timeframes of action (before/after fertilization, before implantation). As Andrew explained, this article is about EC, not about when life begins.

The pro-life community is divided over whether hormonal contraception in general is abortifacient (example). The.helping.people.tick provided a reference for controversy within the pro-life movement over EC specifically. I would be OK with "...most pro-life groups..."

It used to be the mainstream scientific assessment that EC worked by preventing implantation. I am not convinced that is still the case today. It seems very likely (to me) that the EC manufacturer's literature is just a copy of the hormonal contraception literature, which itself is an administrative relic: it would cause more bad publicity to remove it after all this time than to just leave it there, even though the scientific consensus has changed. I believe the current mainstream view is that postfertilization mechanisms (of both hormonal contraception in general and EC specifically) are untested theories (neither proven nor disproven) rather than established facts. I would be OK with "...many scientists..." as Andrew suggested, since that does not imply a majority. Lyrl^Talk _C 03:24, 7 February 2008 (UTC)

Strange: life of sperm: max 72 hours in the body of the woman

Sperm can survive maximum 72 hours in the body of the woman if the conditions are very good. AND, the WHO recognize that the ECP is effective even if taken 5 days (120 hours) after the sexual relation. The WHO pretends that it is not proven that the ECP hinders the nidification of the embryon. However, as the sperm survives maximum 72 hours and as the ECP is still effective after 120 hours, I consider that it is proven that the ECP has an effect against the nidification of the embryo. Thus ECP is abortifacient. Quod Erat Demonstrandum. 213.219.160.183 (talk) 16:49, 9 April 2008 (UTC)

Er... OK. However, since Wikipedia articles are based upon verifiable information published by reliable sources such as the WHO, rather than on "proofs" submitted by anonymous IP editors, this speculation is not appropriate for inclusion in the article. MastCell ^Talk 17:35, 9 April 2008 (UTC)

This has been discussed more than once on this talk page. I'll copy some of the relevant points here:

The claim of effectiveness up to 5 days is, as far as I can tell, from PMID 12480356, a 2003 study by WHO. This response to the study points out that the 95% confidence intervals for 4- and 5-day effectiveness are so wide the results are not statistically significant. Lacking a study with firmer results, I think it is reasonable to remain skeptical of EC effectiveness past 72 hours.

As far as sperm life, all teachers of fertility awareness (including the best-selling book Taking Charge of Your Fertility) teach that it is normal for sperm to fertilize an ovum up to 120 hours (5 days) after intercourse. For what my anecdotal reports are worth, I have spent a number of years reading a fertility awareness-based message board, and have seen a significant number of pregnancies from intercourse five days before ovulation. A study by the World Organization Ovulation Method Billings found (regarding pregnancies while using fertility awareness for birth control): "Indications were that sperm survival in one case was 5-6 days, 6-7 in two cases and 7-8 on one other." [17]

Also see this account from sperm physiologist Dr. Joanna Ellington [18]: "Some men have almost no sperm attaching and they die quickly within hours, while some men have a very high attachment rate and survival rate with sperm living attached to the tubal cells for up to 9 days in the laboratory. This correlates with what has been in seen in women with live sperm found in one woman’s tubes 21 days after intercourse!"

Lyrl^Talk _C 22:45, 9 April 2008 (UTC)

Perhaps the apparent inconsistency is because sperm do not transition instantly from virile & vigorous ("viable") to fully dead. It takes awhile for a sperm to burrow into an egg, so perhaps 4-day-old human sperm can be still alive, yet too old and weak to fertilize an egg. In any event, the conventional wisdom is that sperm is only viable for 72 hours, so I think it is safe to assume that it must at the very least be rare for sperm older than that to successfully fertilize eggs.

The Planned Parenthood web site says, "EC is safe and can prevent pregnancy if used by women within five days of unprotected sex."[19] If many authorities say that sperm is viable for just three days, then certainly there can be no doubt that at least the vast majority of (if not all) fertilizations occur when the sperm is less than five days old. So if the PP claim is true, then 213.219.160.183 is certainly right, and there can be no doubt that EC is working after fertilization.

But can Planned Parenthood's claims be trusted? I recall their false claims about partial-birth abortion, which were subsequently exposed by Ron Fitzsimmons[20]. This is not an organization with a spotless record of truthfulness. But, since this is Wikipedia, I guess a better question to ask is: is Planned Parenthood considered a WP:RS reliable source on Wikipedia? NCdave (talk) 17:14, 10 April 2008 (UTC)

Actually, since this is Wikipedia, a better question to ask is: what relevance does this talk page discussion have to the article? What are we proposing to change or add that's not in there already? If the goal is to string together a few tidbits from various sources to "prove" that EC is an abortifacient, then let's stop the WP:SYN express before it leaves the station and look at what reliable sources say about that question. MastCell ^Talk 19:55, 10 April 2008 (UTC)

GA Review

This review is transcluded from Talk:Emergency contraception/GA1. The edit link for this section can be used to add comments to the review.

Could use some images.--Doc James (talk · contribs · email) 00:49, 30 May 2009 (UTC)

Review by Jake Wartenberg

Thanks for the opportunity to review this article. Unfortunately, I think it does need a lot of work to meet the criteria:

• Images, as Jmh remarked above, would be nice. Perhaps one of an IUD from commons could be found.
• Some sections need more inline citations. I added a few {{fact}} tags to one in particular.
• Much of the article is hard for someone unfamiliar with the subject to understand. You need to explain jargon like "abortifacient", for example, but the issue is pretty widespread. This is the biggest issue, and the hardest to surmount.

I have placed the article on hold for one week while these problems are addressed. — Jake Wartenberg 02:13, 8 June 2009 (UTC)

✗ Fail as not all problems have been addressed. — Jake Wartenberg 15:34, 15 June 2009 (UTC)

"Hellinger Sciencia"

I've moved this out of the article and brought it here for discussion.

Little is known about long-term side effects, but these may include fibroids, in terms of physical health, and serious long lasting depression in terms of psychological health (as is the case with abortion and miscarriage). The systemic therapeutic method known as "Family Constellations" (now "Hellinger Sciencia") developped by Bert Hellinger reveals 'side effects' of a further reach in relation to any type of abortion (as well as miscarriage), including the discarding of fertilised eggs in artificial insemination procedures. Such deeper consequences may be, i.e., the break up of the couple, as both members tend to blame each other for the loss either consciously or unconsciously[ref]Hellinger, Bert (2008), Moving with the Spirit Mind. Constellations, Meditations and Teachings. London Seminar. DVD produced by Ochre Ireland.[/ref]

It isn't clear to me that this has anything at all to do with EC, and the author seems to confuse EC with abortion and miscarriage (things that can happen to pregnant women, where EC is not effective on pregnant women). Furthermore, I seriously question the reliability of the cited source. I'd like to discuss this further if anyone want to propose including it. Thanks. -Andrew c ^[talk] 23:49, 21 April 2010 (UTC)

It's absurd to say the only place there is medical information regarding these side effects is some Spirit Walk, new age DVD. If these are known, commons side effects, cite the patient data sheet, or medical journals, or something along those lines. And it still doesn't change the fact that it's written in a manner which seems entirely ignorant of what EC is, so it isn't apparent how it relates to this article, as it is written. Please defend your edit and your source, or consider major revisions. Thanks. See also WP:BRD and WP:EW. You shouldn't try to edit war to force new controversial, disputed content into an article, but try to work out a compromise or consensus for your proposal here first. Thanks.-Andrew c ^[talk] 13:57, 24 April 2010 (UTC)

Citation 100 Broken

I don't do enough on Wikipedia to have confidence in fixing this correctly. Hopefully someone else active here can take care of this. Link 100 is to a Forbes article that is no longer accessible on their website. It appears, though, that this same article is now available here: http://sexualhealth.e-healthsource.com/?p=news1&id=534950 Perhaps this cite could be updated?

Also, someone ought to add the new information about "ella" and "ellaOne" which the FDA is in the process of considering approving as an emergency contraceptive. Cngcng (talk) 19:57, 18 June 2010 (UTC)cngcng

I added some information about ella, a new citation and how it works.Nimravid (talk) 09:56, 16 March 2011 (UTC)

Many more citations added, updates to include new research

Since the mechanism of action was unknown for some of these in the few years old papers, there have been studies for some of these EC methods that clarify the mechanism of action. I added a lot of citations, and added information on how some of them work, moved some sentences around if needed from the addition, etc. There were some places waiting for citation that I updated.Nimravid (talk) 10:04, 16 March 2011 (UTC)

Thanks for the updates! Some revising of the introduction for clarification might help too. There's still ambiguity there around issues of pregnancy, conception, fertilization and implantation. It might be best to avoid the first two terms (as there's controversy to be had about whether pregnancy is rightly seen as beginning with fertilization or implantation) in favor of the latter two. I'll see if I can get to it after following up on your citations. Yndus (talk) 13:52, 30 June 2011 (UTC)

Ectopic pregnancy

In the 'Safety' sub-section, following a list of various organisations (AAP, ACOG, FDA, WHO, RCOG), there is currently mention of the conclusions of 'experts on emergency contraception' without reference to who these experts are. Should this be looked into? In addition, the conclusion of the above-mentioned organisations and experts is that 'there is no increase in the relative risk of ectopic pregnancy in women who become pregnant after using progestin-only ECPs'. I recently did some research on the possibility of a connection between emergency contraception and ectopic pregnancy, and found a couple of cases over the years where ectopic pregnancy occurred. I offer four references: Could these be used to show that ectopic pregnancy, in fact, a possibility for some women in some cases? Thanks. Nahbios (talk) 22:45, 8 September 2011 (UTC)nahbios

I'll take the silence as a cue to go ahead and add those references. If there's any problems, let me know. Thanks. Nahbios (talk) 15:08, 28 April 2012 (UTC)nahbios

No. Ectopic pregnancy is a possibility for anyone becoming pregnant. The question is not do ectopic pregnancies happen, but what is the rate with or without EC.

Several of the references you suggest are case reports, and therefore primary sources, and any inference we might draw from them would be original research (WP:OR). Only way would be if have a high quality review article or new consensus from a major organization, etc.

What type of articles are Jian, and Kozinszky? (The other two are clearly case reports.)

Sorry for the delayed response, I did not see this thread originally. Zodon (talk) 20:28, 28 April 2012 (UTC)

Given that the current content is supported by 10 very high quality references and several major health organizations, it would require a very good source with good evidence that it is not a fringe view. Zodon (talk) 20:40, 28 April 2012 (UTC)

The individual experts are in addition to the numerous major medical organizations. Who some of the experts are is plain from the references. James Trussell and DA Grimes are well known experts in contraception, see for instance Contraceptive Technology. There is nothing to "look into."

I assume you didn't see my response here before making the addition. Have reverted it. Since pregnancies happen after ECP, that ectopic pregnancies also happen is trivia. (Now if no ectopic pregnancies happened, that could be interesting.) Zodon (talk) 04:40, 30 April 2012 (UTC)

References

Plan B

This page got a spike of 6,000 hits on Thursday, and it was almost certainly because people are interested in Plan B because of the FDA's rejection of its OTC application.

I realize that Wikipedia is an international encyclopedia and has to cover a lot of ground, but I think we should cover the regulatory issues around Plan B in some detail and make it clearer to people who are looking for information about Plan B that this is the right place. --Nbauman (talk) 17:04, 11 December 2011 (UTC)

Introduction is too technical

WP is written for the ordinary reader. See WP:NOTPAPER. I think this introduction starts out by introducing too many complicated ideas that the ordinary reader is not likely to be familiar with.

Look at the introductions to the professionally-written web sites addressed to the ordinary reader:

Princeton:

Emergency contraception is birth control that prevents pregnancy after sex, which is why it is sometimes called "the morning after pill," "the day after pill," or "morning after contraception." You can use emergency contraception right away - or up to five days after sex - if you think your birth control failed, you didn't use contraception, or you were forced to have sex. [21]

Planned Parenthood:

Morning-After Pill (Emergency Contraception) at a Glance

Birth control you can use to prevent pregnancy up to five days (120 hours) after unprotected sex

Two kinds of emergency contraception — morning-after pill and IUD insertion

Safe and effective

Available at health centers and drugstores

Costs vary from $10 to $70 for the morning-after pill and up to $500 for IUD insertion [22]

Our introduction should be as simple as that.

Opinions? --Nbauman (talk) 06:14, 12 December 2011 (UTC)

Well I might agree but a lot of the language being used might be a bit too un-precise for some if it didnt come with explanations. For example looking at the discussions here and some of the references cited, it looks like some pro-life people are contesting defintions for "contraception", "implantation", and "pregnancy." I think it may be best to sacrifice brevity for precision, in this case, so people know exactly what the article is talking about. Absolutezero273 (talk) 21:06, 13 December 2011 (UTC)

Yes, but if your reader can't understand the introduction, he or she isn't likely to read the rest of it.

The introduction must be easy for an ordinary reader to understand. If your reader can't understand it, there's no point in writing it.

According to WP:MOS, WP:MEDMOS, and WP:NOTPAPER, you're writing for a general audience. You can't use terms that ordinary people won't understand, especially in the introduction. You can't use unfamiliar terms that require people to follow links.

Doctors have done studies of how well people understand medical information. When you use terms like "ovulation" and "fertilization", ordinary readers don't understand it. That's why Princeton and Planned Parenthood don't use words like that.

The pro-life people may contest the definitions. But that doesn't justify tortuous language that the reader can't understand. You can discuss the contested definitions further down, after the reader understands the basic ideas. --Nbauman (talk) 02:40, 15 December 2011 (UTC)

I completely agree with you and support a more concise intro that doesn't sacrifice clarity. I think the discussion of ovulation, fertilization, and implanation could occur further down in the article. The distinction of ECs and IUDs also doesn't really belong in the introduction.Absolutezero273 (talk) 03:16, 15 December 2011 (UTC)

In the same vein as this discussion, this statement seems odd and even somewhat snide:

'The phrase "morning-after pill" is a misnomer; ECPs are most effective when used shortly after intercourse.'

The phrase is presumably a popular nickname based on when people most commonly take it, not on perceptions of optimal effective usage. It might as well also say "'Plan B' is a misnomer because abstinence and condoms should be considered Plans A and B respectively". There's also the fact that while some article sources like Planned Parenthood do advise taking EPCs 'as soon as possible after unprotected sex', they mostly stress effectiveness timeframes such as '85% effective up to 5 days', with numbers falling off after that. This sentence could be interpreted as implying the next morning may be too late, which might be especially misleading for a reader in need of concise, reliable information quickly. AveVeritas (talk) 05:56, 13 April 2014 (UTC)

Regular birth control pills as EC

This caught my attention so I googled around and found this:

"Can I Use Regular Birth Control Pills as Emergency Contraception?
Yes, certain brands of birth control pills can be used in increased doses as emergency contraception. The Emergency Contraception Website has information about what brands of pills can be used and how to use them."
- http://www.plannedparenthood.org/health-topics/emergency-contraception-morning-after-pill-4363.asp

Following the link to http://ec.princeton.edu/questions/dose.html#dose seems to say that a wide variety of ordinary birth control pills can be used in two doses of 4, 5, or 6 pills each, 12 hours apart. That approach seems much less expensive than two generic levonorgestrel 0.75 mg tablets over the counter.

Is the Princeton site a reliable source? What are the disadvantages of this approach? The very recent reviews PMID 23050729 and PMID 22971457 both mention this approach in their abstracts, but I can't read their full text. This seems very significant to me. Liang Xie (talk) 22:08, 21 October 2012 (UTC)

Repeated addition of WP:SYNTHESIS about cancer

I reverted the following 5th repeated inappropriate addition of WP:SYNTHESIS about cancer to the "Safety" section of this article by Changerchangerchanger (contribs | talk):

The most prevalent type of emergency contraception in the United States (ie, Plan B) contains more than 75% of amount of levonorgestrel (ie. 1.5 mg) found in a entire month worth of some oral contraceptives (eg, Triphasil which contains 1.92 mg)). This may have carcinogenic implications in that the World Health Organization (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, 2007) has labelled oral contraceptives as a Group I carcinogen and a recent meta-analysis in the Mayo Clinic Proceedings (Mayo Clin Proc. 2006) have noted that ingestion of oral contraceptives at a young age increases the risk of premenopausal breast cancer by 44% (OR, 1.44; 95% CI, 1.28-1.62; 99% CI, 1.24-1.68)

1. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Combined estrogen-progestogen contraceptives and combined estrogen-progestogen menopausal therapy. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans 2007; 91:74–84.

2. Mayo Clin Proc. 2006;81(10):1290-1302

The cited sources (contradicted by many other authoritative reliable sources) are about ongoing daily use of combined oral contraceptive pills—not about one-time or occasional usage of progestin-only emergency contraceptives. BC07 (talk) 19:53, 18 November 2012 (UTC)

Is this really compliant with WP:MEDRS?

This source:
Durrance, Christine Piette (July 2013). "The effects of increased access to emergency contraception on sexually transmitted disease and abortion rates". Economic Inquiry 51 (3): 1682–1695. doi:10.1111/j.1465-7295.2012.00498.x
has been added to the article today, but I don't think it is compliant with WP:MEDRS - not only is it a primary source, it's also published in an economics journal. It's not listed in PubMed either. Is there a good (policy based) reason to have it in the article anyway? --Six words (talk) 11:57, 23 December 2013 (UTC)

No, it was not compliant with WP:MEDRS and there was not a good reason to have it in the article, so I removed it. BC07 (talk) 15:06, 24 December 2013 (UTC)

United States legal and ethical controversies

Moved the following stale, hodgepodge, play-by-play, U.S.-centric section started on 24 February 2006 by Chooserr (talk | contribs) to talk page:

United States legal and ethical controversies

A great deal of controversy accompanied the FDA approval of over-the-counter (OTC) access to Plan B. Supporters of over-the-counter access believe that easier access will reduce unintended pregnancy and abortion rates; some abortion opponents believe that EC itself is a form of abortion. The American Medical Association, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and other leading U.S. medical organizations all supported OTC access. An advisory committee to the FDA recommended that Plan B be made available over the counter in 2003. In 2004, the FDA refused the advisory board's recommendation and prohibited over-the-counter sale, citing insufficient evidence that ECPs could be used safely by adolescents without medical supervision. In 2005, Susan F. Wood, assistant FDA commissioner for women's health and director of the Office of Women's Health, resigned to protest the FDA's delay. Reproductive rights supporters accused the FDA of basing the decision on political pressure from the pro-life lobby. The Center for Reproductive Rights filed a lawsuit regarding the approval process, which had not been resolved as of December 2006. In the legal proceedings, two senior FDA officials alleged in depositions that the decision to reject the OTC application was made on political, rather than scientific, grounds to "appease the administration's constituents". In 2006, the FDA approved over-the-counter access to Plan B for women 18 years of age and older. In April 2009, the FDA followed the ruling of a New York Federal District Court and loosened the restrictions to allow Duramed Pharmaceuticals to provide Plan B without a prescription to 17-year-olds. However, as of June 2009, Duramed had not yet put a non-prescription Plan B product for 17-year-olds through FDA approval, a process that could take some time.

On April 5, 2013, Judge Edward R. Korman of the U.S. District Court for the Eastern District of New York ruled that "the government must make the most common morning-after pill available over the counter for all ages, instead of requiring a prescription for girls 16 and younger." Korman ordered the U.S. Food and Drug Administration to lift all age and prescription restrictions on Plan B One-Step and its generic counterparts within thirty days. In his opinion Korman wrote that "More than twelve years have passed since the citizen petition was filed and eight years since this lawsuit commenced. The F.D.A. has engaged in intolerable delays in processing the petition. Indeed, it could accurately be described as an administrative agency filibuster."

On April 30, 2013, the Obama administration U.S. Food and Drug Administration approved (with three-year marketing exclusivity) Teva Pharmaceutical Industries Plan B One-Step for sale without a prescription to anyone age 15 or over who can show proof of age such as a driver's license, birth certificate, or passport to a drug store retail clerk. Generic one-pill levonorgestrel emergency contraceptives and all two-pill levonorgestrel emergency contraceptives will remain restricted to sale from a pharmacist—without a prescription to anyone age 17 or over who can show proof of age.

On May 1, 2013, the Obama administration U.S. Department of Justice said it would appeal Judge Korman's decision and pending the appeal asked him to stay his order for the FDA to approve levonorgestrel emergency contraceptives for OTC sale without prescription or age restriction by May 6, 2013.

A Massachusetts law that went into effect on 14 December 2005 requires all hospitals in the state to provide emergency contraception to any "female rape victim of childbearing age" including Catholic Hospitals who oppose the provision of emergency contraception. In a letter criticizing the joint UN/WHO Inter-agency Field Manual on Reproductive Health in Refugee Situations, the Catholic Church explains its belief that emergency contraception, along with IUDs and hormonal contraception, cannot be considered "solely contraceptive because in the case of effective fertilization a chemical abortion would be carried out during the first days of pregnancy." The Catholic position on family planning is explained further in Ethical and Religious Directives for Catholic Health Care Services. Because of this expressed moral stance against emergency contraception, the Massachusetts Catholic Conference opposed this law, stating interference with religious freedom.

In isolated instances across the United States, pharmacists have refused to dispense emergency contraception even when presented with a legal prescription. In 2010, the Washington State Pharmacy Board decided that pharmacists do have a right to refuse to dispense emergency contraception. In addition, Wal-Mart, the nation's fifth-largest distributor of pharmaceuticals, refused to stock EC, beginning with Preven in 1999. However, Wal-Mart reversed this position when it was announced that stores would sell Plan B in March 2006.

The Congregation for the Doctrine of the Faith in the 2008 Instruction Dignitas Personae (Paragraph 23) stated that: "Alongside methods of preventing pregnancy which are, properly speaking, contraceptive, that is, which prevent conception following from a sexual act, there are other technical means which act after fertilization, when the embryo is already constituted, either before or after implantation in the uterine wall. Such methods are interceptive if they interfere with the embryo before implantation and contragestative if they cause the elimination of the embryo once implanted...Therefore, the use of means of interception and contragestation fall within the sin of abortion and are gravely immoral. Furthermore, when there is certainty that an abortion has resulted, there are serious penalties in canon law."

BC07 (talk) 12:54, 22 March 2014 (UTC)

Linacre Quarterly

Does not appear to be a have good impact factor. Thus I am not sure it supports

"Some scholars still insist that the abty-implantation effect is possible and aptients should be infomed about it."

[Per http://www.maneyonline.com/bibliometrics/lnq] Doc James (talk · contribs · email) 17:38, 3 February 2016 (UTC)

Per here it looks like it just started [23] Doc James (talk · contribs · email) 17:39, 3 February 2016 (UTC)

Trimmed it again. The fact that The_Linacre_Quarterly is associated with the Catholic church raises concerns IMO. Doc James (talk · contribs · email) 12:09, 14 February 2016 (UTC)

Not sure what this means exactly:

" If progestogen-only emergency contraceptive pills had post-fertilization effect,then they would lessen the number of normal pregnancies without influence on the number of ectopic pregnancies, but increasing the percentage of ectopic pregnancies up to maximum of the norm There were studies that showed the increase of percentage of ectopic pregnancies among women using LNG-EC amounted to compared to women who didn't use it. Thus, some scientits don't reject the possibility of anti-implantation effect of LNG-EC.,"

In fact the JAMA paper states " Both epidemiologic and clinical studies of Plan B's efficacy in relation to the timing of ovulation are inconsistent with the hypothesis that Plan B acts to prevent implantation."

Doc James (talk · contribs · email) 12:19, 14 February 2016 (UTC)

References

Terminology

Hi Doc James and UCDEBS, I noticed that the phrasing of the article for sexual assault section was changed from "rape victims" to "women who have been raped". The article also uses "women" for "women who had been sexually assaulted" and "women of child-bearing age". This seems to omit girls, however, who also can experience sexual assault and need emergency contraception. Should instances of "women" here (and perhaps other places in the article) be replaced by "women and girls"? Elysia (Wiki Ed) (talk) 19:59, 19 July 2019 (UTC)

I'd suggest simplifying to "individuals who have been raped" as unfortunately, women, girls, and those who may identify as trans-men at times may find the need to use emergency contraception after rape. As there are some who feel "survivor" is more empowering than "victim" probably a good idea to remove that word if we can--UCDEBS (talk) 20:28, 19 July 2019 (UTC)

Agree with User:UCDEBS "individuals or people who have been raped" is better. Doc James (talk · contribs · email) 00:16, 20 July 2019 (UTC)

Difference between emergency contraception and abortion

Rather than just stating that it's a type of birth control, the article should state the difference between emergency contraception and abortion. A lot of people who read this probably want to know that. —Lights and freedom (talk ~ contribs) 20:39, 25 April 2023 (UTC)