Aug 10, 2017

Dr. Jones: Uh-oh, now you have a family planning emergency. How much time do you have? This is Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today in The Scope studio, we're talking with family planning expert in emergency contraception. And what are the options and how do they work? Dr. Jennifer Kaiser is an OB/GYN at University of Utah Health and is currently in the family planning fellowship here. Welcome, and thanks for joining us and helping us out with this emergency on The Scope, Dr. Kaiser.

Dr. Kaiser: Thank you so much.

Dr. Jones: Well, when I was a young woman in the last century, we thought that a douche with Coca-Cola would work for emergency contraception. And douching with various chemicals after intercourse has been used for hundreds of years. Any truth to this ancient medical practice?

Dr. Kaiser: So there might be. I actually think one fascinating aspect of contraceptive care, both prophylactic, so using before intercourse or emergency using after, is how women have attempted to control their fertility for so long, for like you said . . .

Dr. Jones: Of thousands of years.

Dr. Kaiser: Of thousands of years. And in our modern era, though, we have plenty of options for birth control. And on the whole, women have really heard about all of these different options. In the past, this wasn't the case. Prior to the creation of the birth control pill in the 1960s, there really weren't any tried and true methods that were widely known. Women and their partners tried using home remedies that were passed on by word of mouth or methods they had read about in magazines. And douching, like you mentioned, was actually extremely popular as a means of preventing pregnancy following intercourse.

So in the 1800s, women could actually purchase special made syringes to douche with. They would use a wide variety of liquids for this, anywhere from cold water to tepid water, to hot water, boric acid, baking soda, and all sorts of astringents. And so we all know how acidic Coca-Cola is as we've seen people's YouTube videos of it dissolving all sorts of things. And it seems that douching with an acidic or basic compound is probably more effective than just water. So there is likely some truth to this, douching with either Coca-Cola or an astringent kind of liquid.

Sperm are very temperamental, and so they don't do well in a pH that's outside of the seven to eight range. So it may be very likely that the sperm were being killed with these kinds of treatments in the vagina or even the lower cervix. But that doesn't really cover the uterus or the fallopian tube where the sperm can get to in as little as 15 minutes. So if you're not right on top of it, it's really unlikely to work.

Dr. Jones: Oh, well, but let's move on to something that we know works a little bit better. So why do they call it emergency contraception? Why do we use that word?

Dr. Kaiser: Yeah. So in general, emergency contraception is so called because it describes the use of a contraceptive method in an emergent setting to prevent pregnancy. So that can be after unprotected intercourse, a rape, or after method failure. So somebody who was using a condom that broke or maybe they had some pills that they missed. This term has also dramatically changed over the past several centuries. In the 1800s, most contraceptive methods practiced were after intercourse with the notable exception of withdrawal or condoms. And so really, in the past, everything was emergency contraception.

The term post-coital contraception was used by scientists and physicians in the 1960s once the pill was created. And the popular media coined the term the "morning after pill" shortly after, which I'm sure is a familiar term to many listeners. But since the 1990s, the term emergency contraception was adopted to really emphasize that this shouldn't be an ongoing birth control method.

Dr. Jones: Right.

Dr. Kaiser: That it's for emergency use and then it also was used to correct misconceptions about when to take emergency contraception, the fact that it's not just limited to the morning after.

Dr. Jones: Right. But it is kind of urgent, and it's not likely to be available in an emergency room unless you're seeking health care in the ER. That's not the place you go for this unless you're already going there for, perhaps a rape or something violent, unfortunately, right? So what's available?

Dr. Kaiser: Yeah. So right now on the market, there are three current available forms of emergency contraception. There is Plan B, which is a synthetic progestin called levonorgestrel.

Dr. Jones: And it comes in other names too. There are a couple brands of this, yeah.

Dr. Kaiser: There's also Ella which is ulipristal, which is another progestin acting medication. And then there's also the copper IUD or para guard.

Dr. Jones: Okay. So let's pick Plan B or drugs like that. How does it work, and when is it too late for Plan B to work?

Dr. Kaiser: Yeah, those are great questions. So Plan B is an oral synthetic progestin called levonorgestrel. By taking this pill, the progestin in it blocks your body's ability to produce a surge of the hormone called LH or lutenizing hormone. By blocking the surge, ovulation is prevented so no egg is released, and thus fertilization and pregnancy are also prevented.

If it has been more than 72 hours from unprotected intercourse, there is less of a chance that Plan B will work. So in other words, it's best to take it within 72 hours, but it can be taken up to 120 hours from unprotected intercourse. But if you've already ovulated before taking Plan B, it's not going to work to prevent pregnancy.

Dr. Jones: Right. Okay. Well, can anybody take Plan B?

Dr. Kaiser: So the great news is that Plan B is now available over the counter at many pharmacies. There is no age limit as far as who can take or purchase Plan B over the counter at these pharmacies. And really, there's no reason why a woman can't take Plan B. The thought is that it's that there are no medical conditions that outweigh the benefits of taking and using emergency contraception.

Dr. Jones: Right.

Dr. Kaiser: The only aside to that is that there may be a little less efficacy if you weigh over 165 pounds.

Dr. Jones: Okay. Well, then let's talk about ulipristal or Ella.

Dr. Kaiser: Yeah. So ulipristal or Ella, also very similar to plan B in that this pill also interferes with the LH surge and prevents ovulation. But it also does this in a slightly different manner. So ulipristal actually blocks the progesterone receptor in the body which is associated with the LH surge and ovulation. So it mainly works through blocking the LH surge, but it may also postpone the release of the egg from the ovary.

So even if your body has already undergone the LH surge, it might be that Ella helps prevent the egg from being released from the ovary. And because of this and how it works in your body, Ella is actually effective for up to 120 hours from unprotected intercourse. The only downside to this one is that you need a prescription from a physician.

Dr. Jones: Now, neither of these, you know, once you take it, it isn't protecting you for days and days after. So you can say, "Well, I've taken it now and maybe it'll help me out. I just will have unprotected sex for the next week." It really doesn't work that way. In fact, that's often why people think it fails is because they kept having unprotected sex.

Dr. Kaiser: Exactly. So you know, like I mentioned, if you have taken it within the 72 hours for Plan B or the 120 hours for Ella, and your body has not ovulated yet, you are going to be protected from that one episode of unprotected sex. If you continue to have unprotected sex, like you said, Dr. Jones, for the remainder of the week, it's not going to work, you're going to need birth control for that.

Dr. Jones: Yeah. Because eventually you're probably going to ovulate, right?

Dr. Kaiser: Correct.

Dr. Jones: Okay. Well, what about the copper IUD? How does that work? And when is it too late?

Dr. Kaiser: Yeah. The copper IUD is actually a really exciting recent development in emergency contraception. So it combines the best of both worlds, like we're just talking about Plan B and Ella aren't going to protect you going forward. It's just for that one episode of unprotected intercourse. The great thing about the copper IUD is that it can give you really effective emergency contraception, and it gives women a long acting, highly effective method of birth control going forward. So this kind of method, once you get it, you can keep having all the unprotected intercourse that you want.

Dr. Jones: But it won't be unprotected anymore.

Dr. Kaiser: Right. Exactly, exactly. Now you have a great method. So we don't actually really know entirely how this works so well as emergency contraception, but we suspect it has to do with creating an inhospitable environment for sperm to prevent fertilization. But copper IUD may also impair implantation of a fertilized egg in the uterus. But again, we're not really entirely sure just how it works.

The great thing about the copper IUD as well is that it can be used for up to seven days following unprotected intercourse. So if a woman finds herself in need of emergency contraception and isn't interested in a pregnancy in the near future, the copper IUD is really a fantastic option.

Dr. Jones: Right. But it's not something you can get over the counter, and it's not something you can use yourself.

Dr. Kaiser: Correct.

Dr. Jones: You need to see someone who's good at putting in copper IUDs.

Dr. Kaiser: Right. So you would need to see a physician who would be able to place this IUD.

Dr. Jones: Or a nurse practitioner.

Dr. Kaiser: Or a nurse practitioner or a PA, whoever is available that has training, who can place one for you.

Dr. Jones: Right. Well, we don't want any woman to have a family planning emergency. We want everyone who isn't planning a pregnancy protected before they have sex. But you know, if stuff happens and now there are some options and some you can get online, check out our Scope podcast on emergency contraception over the internet. And thanks, Dr. Kaiser, for joining us. And thanks, everyone, for joining us on The Scope.

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