Emergency Contraception–Boon or Bane?
by Susan E. Wills, Esq.
Following the public debate on "emergency contraceptives" (ECs) is bound
to be confusing.
Are ECs really contraceptives–that is, do they prevent conception, as
supporters insist? Are they ineffective if a woman is already pregnant,
as they also claim? Or do they always or usually cause abortions, as
some pro-life groups say? And if so, why would legislators who usually
oppose abortion support ECs, and even vote to make them available
without a prescription?
Are emergency contraceptives as easy, safe, and effective as the
Before addressing such questions, it might be helpful to illustrate the
opposing perspectives on emergency contraceptives. One view is held by
reproductive "professionals" who promote them as a silver bullet
solution to unintended pregnancy; some women who have been on the
receiving end of this bullet have a different perspective.
The American College of Obstetricians and Gynecologists (ACOG) has long
advocated legal abortion, even partial-birth abortion. So it was no
surprise that in late April, newly-elected ACOG president Thomas F.
Purdon, MD, issued a "call to action" to ob-gyns, asking them to offer
"an advance prescription"of ECs to women during routine office visits.
No need to wait until the FDA permits over-the-counter sale, he
explained: "We need to pursue all avenues to increase women's awareness
of emergency contraception and their ability to get it within 72 hours"
(ACOG News Release, 4/30/01). He calls ECs "a last chance method of oral
contraception, which helps prevent abortion," and he hopes that one day
they will be "as common in most women's homes as a first aid kit."
Planned Parenthood boasts of being the largest supplier of ECs and says
they could "prevent 1.7 million unintended pregnancies and 800,000
abortions each year." It also says that women who have used ECs "report
high levels of satisfaction." But that's clearly not true of all women.
Postings on a "morning after pill" on-line support message board
(www.afterabortion.com) contradict the rosy picture of EC use as easy or
"L" describes "feeling agonizing remorse." She wrote to her doctor
several times, asking him to explain why he never told her it could
cause an abortion and to tell him what she had been going through since
learning, five years later, that she might have aborted her child. He
never replied. She also felt angry with her mother, who had taken her to
the doctor for morning-after pills but later refused to "pressure" the
doctor to explain why he hadn't warned her that the pills might cause an
abortion. On October 25, 2000, "L" posted this message: What I can say
with absolute certainty is that FOR ME the morning-after pill was a
totally negative experience which left me with lots of self-blame,
unanswered questions, mistrust in doctors and even loss of much of the
trust I had in my own mother.
"D" wrote on February 8, 2001: I just want to say ...
[BLEERRRRRGGGGGGHHHHHHH!!!] I'm sick. I'm sore. I'm a complete emotional
wreck. I'm scared. I'm now terrified about the prospect of having to
have sex again. I've got a pounding headache. I have spot
s in front of my eyes. I have 2 children under 5 that need looking after
Several women commiserate with "D," mentioning their own
experiences—being sick for three days or thinking they'd never stop
"Anonymous" wrote on March 8, 2001: i feel so many things, all so
conflicting, and i have so much fear and self-loathing, i need help. my
counselor today said he thinks i may be suffering from pas
[post-abortion syndrome], and i don't want to deal with this with him
because i want it to go away. he says i don't have to have had a
surgical abortion to feel like i caused that baby to die by my taking
those pills. i am so scared and confused. ...
This is supposed to be good for women? And it's going to prevent
What are "Emergency Contraceptives"?
The idea of "emergency contraceptives" arose decades ago as a high dose
of ordinary oral contraceptive pills. The idea was that women could use
these hours or days after "unprotected intercourse" or after their usual
contraceptive had failed to avert a pregnancy. The ACOG Practice
Bulletin (No. 25, March 2001) lists the following methods of emergency
contraception: "combination or progestin-only oral contraceptives,
danazol, synthetic estrogens and conjugated estrogens, antiprogestins
and the insertion of an intrauterine device [IUD]."
Combination oral contraceptives (COCs) typically contain a low daily
dose of a synthetic estrogen (ethinyl estradiol) and a low dose of
progestin (norgestrel or levonorgestrel). When used as a back-up for
missed or failed contraception, two doses of COCs, consisting of 2, 4 or
5 pills each, are taken 12 hours apart, beginning within 72 hours of
intercourse. This method, known as the "Yuzpe Regimen," was introduced
in 1974 and is the most commonly used. In 1998 the FDA approved the
first product specifically marketed for emergency contraception, the
"Preven" Emergency Contraceptive Kit. It contains 4 pills for the Yuzpe
regimen, a pregnancy test, and instructions.
Progestin-only oral contraceptives (e.g., Ovrette) contain a low dose of
norgestrel. For use as emergency contraception, one must take 20
Ovrette pills, followed by another 20 pills twelve hours later. In 1999,
the FDA approved "Plan B," an emergency contraception kit with two
high-dose pills of levonorgestrel each, equal to about one-third of the
amount one would take in a month.
The copper-releasing intrauterine device (IUD) can be used as "emergency
contraception" if inserted within five to seven days after intercourse.
With such use, "the IUD interferes primarily with the process of
implantation" thus ending the life of the week-old embryo. (Rosenfield,
A., "Emergency Contraception: A Modality Whose Time Has Come," Journal
of the American Medical Women's Association, vol.53, no.5, Sept. 1998,
How Emergency Contraceptives Work
This discussion will focus only on the two most widely used methods of
emergency contraception—COCs (Preven or "ordinary" COCs used according
to the Yuzpe regimen) and Plan B. First, it might be helpful to review
the normal fluctuations of a woman's reproductive hormones each month.
At the beginning of a woman's menstrual flow, the pituitary gland
produces a higher level of follicle stimulating hormone (FSH). The ovary
responds by ripening a follicle from which a maturing egg will be
released. The covering of the egg then produces estrogen which prompts
the lining of the uterus to proliferate. The rising estrogen level sets
off a sudden release of luteinizing hormone (LH) from the pituitary
gland. The LH "surge" causes the now mature egg to be released from the
ovarian follicle. This is ovulation. After ovulation, the lining of the
follicle begins to produce the hormone progesterone. Normally the
follicle's cells live for eleven to sixteen days, producing progesterone
and small amounts of estrogen. The progesterone causes the uterine
lining to thicken and produce a nutritious liquid so that if the egg
were fertilized, the week-old embryo can implant in it.
If conception does not occur, then eleven to sixteen days after
ovulation, levels of progesterone and estrogen drop and the next
menstrual period begins.
The human egg lives only for about 24 hours after its release. Sperm can
live for three days, and possibly even five days during the fertile
phase. A woman's "fertile phase" may therefore last at most from about
six calendar days prior to ovulation to the calendar day following
The main mechanisms of ECs are suppressing ovulation (by delaying or
suppressing FSH and LH), altering cervical mucus which slows sperm
transport, slowing transport of egg or embryo through the fallopian
tube, and changes to the uterine lining which make it thin and
atrophied, inhibiting implantation of the embryo. Researchers describe
three possible post-fertilization effects of hormonal contraceptives:
the slower transport of the embryo through the fallopian tube could
prevent the embryo from reaching the uterus to implant (resulting in
embryo loss or tubal pregnancy); changes in the uterine lining which
prevent implantation; changes in the uterine lining which are "not
sufficient to prevent implantation but unfavorable for maintenance of
the pregnancy" (Larimore, W. and Stanford, J., "Postfertilization
Effects of Oral Contraceptives and Their Relationship to Informed
Consent," Archives of Family Medicine, vol. 9, Feb 2000, 126-133).
Whether ECs prevent conception or act as an abortifacient depends on
when in the woman's fertility cycle intercourse occurs and ECs are used.
If taken before the beginning of the fertile phase, their only effect
would be to cause withdrawal bleeding completely out of phase with the
woman's ordinary cycle. (Klaus, "The Morning After Pill: Boon or
Boondoggle?," March 11, 2001).
If taken at the beginning of the fertile phase, "they may delay or
suppress the [LH] surge. ... If ovulation is delayed by more than 72
hours, it is possible that the sperm may not survive. If ovulation is
suppressed entirely, then there would be an out-of-phase bleed" (Ibid.).
Therefore, taken during this period of several days, COCs and progestin
would be somewhat more likely to prevent conception than to interfere
ECs taken after the LH surge cannot inhibit ovulation. If an egg has
been released in the preceding 24 hours, a sperm may penetrate the egg
within 15 to 30 minutes after intercourse, beginning the process of
fertilization. The new human embryo grows and develops over the next
three to five days while traveling down the fallopian tube to the uterus
to implant. The abnormally high level of synthetic progesterone present
in the ECs, however, alters the uterine lining, inhibiting or
preventing implantation. "This mode of action could explain the majority
of cases where pregnancies are prevented by the morning after pill"
(Grou, F. and Rodriguez, I. "The morning after pill, how long after?"
American Journal of Obstetrics and Gynecology (1994), vol. 171:
Finally, if ECs are taken in the late infertile phase, they would simply
cause premature menstrual bleeding.
For almost three weeks of the average cycle, then, ECs will neither
prevent conception nor cause an abortion because a woman is infertile.
During the remaining week or so, ECs are capable of both contraceptive
and abortifacient actions, the former action predominating in the
earlier days of the fertile phase and the latter action predominating
after the LH surge. Unless a woman charts her fertility (quite an easy
thing to do with methods developed for natural family planning) she
cannot be certain which action has "prevented pregnancy" when the pills
Issues of Informed Consent
Those who promote "emergency contraception" omit facts and publish
inaccuracies and half-truths, depriving women of their right to informed
consent. The foremost claim is that ECs do not cause abortion and have
"no effect on a pregnancy." To make this claim they have had to redefine
"pregnancy" as beginning after an embryo has implanted in the uterine
lining, and redefine "abortion" as terminating a "pregnancy."
Terminating a human being's life prior to successful implantation is not
counted. These word games are designed to obscure what ECs do, and to
prevent state abortion regulations from applying to the destruction of
embryos' lives by synthetic hormones. They also prevent conscientiously
objecting health care personnel–doctors, nurses and pharmacists–from
being able to cite state and federal "conscience clauses" on abortion in
their own defense.
For the same reason promoters of ECs refer to the implantation of a
"fertilized egg." At the age of 6-7 days when an embryo begins
implantation, it is not a "fertilized egg." It is an embryo in the
blastocyst stage. "The term embryo covers the several stages of early
development [single-celled zygote, multi-celled blastocyst, highly
differentiated embryo] from conception to the ninth or tenth week of
life" when all organs are present and the fetal stage begins.
(Considine, D. (ed.), Van Nostrand's Scientific Encyclopedia, 5th ed.
(1976), p. 943).
Women are also misled about the unpleasant side effects and health risks
of ECs. Promoters of ECs trivialize the physical, emotional and
psychological impact from using these drugs, assuming perhaps that any
amount of such harm to women is preferable to continuing a pregnancy. In
fact, ACOG seems willing to subject women to potential harm even when
the likelihood of pregnancy is nil. The ACOG Practice Bulletin describes
a candidate for emergency contraception as any woman of reproductive
age who has had "unprotected" intercourse in the previous 72 hours,
"independent of the time in the menstrual cycle" (emphasis added).
There are a number of common, relatively manageable, adverse reactions
to Preven and Plan B. Over 50% of women taking Preven experience nausea,
as do 23% of those taking Plan B. About 19% vomit after taking Preven,
compared to 5.6% of those taking Plan B. (WHO Department of Reproductive
Health and Research, "Improving Methods of Emergency Contraception,"
Progress in Human Reproduction Research, Bulletin No. 51, 1999). One out
of every five or six women may also experience headaches, abdominal
pain, menstrual irregularities, dizziness or fatigue.
But far more troubling is the long list of very serious
contraindications and warnings given to doctors. (See, e.g.,
"Prescribing Information" at www.preven.com.)
The risk of developing blood clots in the deep veins of the leg is three
to six times greater among users of COCs than for non-users. "Blood
clots that form in the leg can cause blockage of blood flow in the leg
veins [and] can travel to the lung, causing serious disability or death.
Rarely, clots occur in the blood vessels of the eye and may cause
blindness, double vision, or impaired vision." These risks are
substantially increased for women who smoke.
There is an increased risk of heart attack and stroke, both of which can
cause serious disability or death. Women who have had a heart attack,
and those with ischemic or valvular heart disease or very high blood
pressure are at even greater risk and should not use combination ECs.
Women are warned not to take combination ECs if they have diabetes with
blood vessel involvement, severe headaches including migraine, current
or past breast cancer, liver tumors or disease, or a known allergy to
any component in ECs. Schering Health Care, a manufacturer of COCs
marketed as ECs in England, provides the following warning to
There is a general opinion based on statistical evidence, that users of
combined oral contraceptives ... experience, more often than non-users,
venous thromboembolism, arterial thrombosis, including cerebral and
myocardial infarction, and subarachnoid hemorrhage. Full recovery from
such disorders does not always occur, and it should be realized that in a
few cases, they are fatal.
Because it can be difficult to schedule a medical appointment during the
72 hour window in which the initial dose must be taken, promoters of
ECs are lobbying the Food and Drug Administration and state legislatures
to authorize over-the-counter availability. Currently only Washington
state allows distribution by pharmacists. But a very public and busy
pharmacy counter is no place for a distraught and embarrassed teen or
woman to discuss her relevant medical and sexual history with a
pharmacist–absolutely essential given the serious contraindications of
the drugs. Nor will the average pharmacist have the time to explain all
that a woman needs to know to make an informed decision.
Failure to properly advise a patient of risks and options can be
actionable malpractice. And, although the National Federation of State
Medical Boards "explicitly" states that prescriptions without a doctor's
visit are "outside the bounds of professional conduct" except in the
case of refills, prescriptions for ECs can now be obtained through
several web sites operated in the U.S.
The availability of "emergency contraception" is not "the nation's best
kept secret" as promoters like to claim. The secret best kept from the
American public is that these drugs can cause abortions. The time for
covering up this unpleasant reality is long past.
Many Americans believe that if a woman is abortion-minded, it's better
to take the life of a week-old embryo than one at ten or 20 weeks. But
it's wrong to consider hormonally-induced abortion as a lesser evil than
later-term abortions, simply because the embryo has less resemblance to
what we think humans look like. In fact, we all once looked exactly
like a week-old embryo. The essence, the effect of both abortions is the
same: an individual is deprived of her entire earthly life span. She
will never be kissed or cuddled, never walk on a beach or ride a bike,
never sing in a choir or graduate from college, never fall in love,
raise kids, have a fulfilling career or leave the world a better place
for having lived here.
For Catholics the choice is clear. Natural family planning–fertility
awareness coupled with abstinence during the fertile phase–is the
healthy, risk-free and morally sound way for couples to plan the spacing
and number of their children. But all who believe in the sanctity of
human life–and all who oppose giving potentially dangerous drugs to
women with inadequate or extremely misleading information–can and should
oppose the growing use of emergency contraceptives.
is Assistant Director for Education & Outreach, United States
Catholic Bishops' Secretariat of Pro-Life Activities. For more information on the bishops’ pro-life activities, please visit www.usccb.org/prolife.
Copyright © 2001, United States Conference of Catholic Bishops, Inc.,
Washington, D.C. All rights reserved. Illustration by Dolores M. Daly.