MORNING AFTER BLUES

Bangkok Post - June 10, 2002
http://www.bangkokpost.com/en/Outlook/10Jun2002_out51.html
Morning-after blues
Excessive and incorrect use of an oral contraceptive designed for emergency use only is resulting in unwanted pregnancies - and worse
Story by KARNJARIYA SUKRUNG

Married and in their 30s, Noi (not her real name) and her husband are not prepared to expand their family. Condoms are out of the question, they say, and taking an oral contraceptive daily is inconvenient. College student Wilai (not her real name) has a boyfriend who refuses to use condoms; she wants a quick and effective way to prevent pregnancy. Not surprisingly, Noi, Wilai and many other sexually active Thai women have opted for the morning-after pill: Take two pills after sex and leave all pregnancy worries behind - or so they think. This attitude fits well with the modern, urban lifestyle where casual sex is no longer uncommon but pregnancy is often a no-no for social, economic or career reasons.

But a disturbing number of people who have recourse to the morning-after pill are totally in the dark about the dangers of this oral contraceptive containing a high dose of the steroid hormone progesterone. This ignorance has resulted in many Thai women taking the morning-after pill on a regular basis. But high doses of this powerful substance can cause side effects, health problems and, ironically, increase the risk of pregnancy. "The drug is not 100 percent pregnancy proof," said Nattaya Boonpakdee, programme assistant at the Population Council, an NGO working in the field of women's reproductive health. "There are also health risks for the woman. Most importantly, both men and women are putting themselves at greater risk of contracting Aids and other sexually transmitted diseases."

In recent years, regular users of the morning-after pill have been reporting unwanted pregnancies. One family-planning clinic in Bangkok sees four to five such cases a month. Nattaya has concluded that these failures stem from misunderstanding the nature and correct usage of the drug. Widespread misconceptions about the efficacy of the morning-after pill she attributes partly to the fact that it goes under a variety of colloquial names; it is also commonly termed a post-coital pill, a spermicide and a "temporary contraceptive". While "morning after" and "post-coital" suggest that it be taken the morning after sex, describing it as a "spermicide" indicates nothing more than its ability to kill sperm. And while there is a grain of truth in all these common terms, she pointed out that the confusion caused can easily lead to excessive use of this drug.

To avoid any misinterpretation, Nattaya thinks that it should henceforth be called the "emergency pill". "If we drop the other names and just stick to the term 'emergency pill', I believe that that will suggest its true purpose to the user _ that it is to be used only in an emergency and not on a regular basis as is often the case now," Nattaya said. "Many women take three pills in a single week. Obviously, those can't all be emergencies."

And what is most alarming is that such instances of excessive use are not exceptional - as evidenced by the records of various family-planning clinics around town. According to clinic worker Waranya Pitaktepsombat, it was not uncommon for women to take more than 10 pills a month despite the fact that the maximum recommended monthly dose is four tablets (two occasions of unprotected sex). Use of this pill, she insisted, should be limited to cases of sexual assaults, unplanned and unprotected sex, if a condom splits during intercourse or the woman has omitted to take an ordinary contraceptive for more than three days.

Designed to deter fertilised eggs from being implanted in the uterine wall, the morning-after pill can reduce the chance of pregnancy by only 75 to 85 percent while ordinary, low-dose oral contraceptives and condoms (if used properly) can diminish the risk by 99 percent.

According to Dr Niyada Kiatying-Angsulee from the Faculty of Pharmaceutical Sciences at Chulalongkorn University, the "emergency pill" available locally contains 0.75 microgrammes of the hormone, 50 times more than the ordinary oral contraceptive taken in 21-, 28- or 35-day courses. As a result, she said, many women who regularly take the morning-after pill report feeling ill - unsettled stomachs, vomiting and dizziness - almost immediately afterwards. Other possible side effects include delay in menstruation, occasional breakthrough bleeding, headaches and tiredness.

Symptoms such as chest pain, a persistent cough, migraine, numbness, blurred vision and difficulty in breathing may be signs of pregnancy, Niyada added. And women who take the morning-after pill unaware that they are already pregnant risk causing deformities in their babies, particularly to the reproductive organs.

Although no conclusive research has been conducted into the long-term effects of the morning-after pill, Dr Niyada said that some studies showed links between constant high levels of progesterone, due to extended use of the pill, and breast, ovarian and uterine cancer plus ectopic pregnancies.

Unfortunately, while many sexually active people abuse the morning-after pill, others who are in real need of it either have never heard of it or have no access to it. Nattaya from Population Control said she knew of many cases where doctors did not prescribe the pill to rape victims, forcing them to run the risk of an unwanted pregnancy. "Many women in real need of the emergency pill are not aware of its existence when they have unplanned or unprotected sex. They have to let nature take its course and then if they get pregnant, they often resort to abortion, which is pretty unnecessary if they'd had the right information in the first place." Pregnancies also result because women use the morning-after pill incorrectly.

It was first sold over the counter in Thailand some 15 years ago and became instantly popular. Going on advice from friends, many women would take a tablet one hour after sex but then omit to take the necessary second tablet. To remedy this widespread misuse, the Population Council and the Drug Study Group urged the FDA a few years ago to amend the instructions on the bottle to read: "the first dose may be taken up to 72 hours after unprotected sexual intercourse, with a second dose taken 12 hours later". The FDA agreed. Unfortunately, many users do not read the new instructions, carrying on with their old pattern of behaviour. And some pharmacists fail to emphasise the correct dose at the time of purchase.

Nor is the morning-after pill suitable for everyone. According to Dr Niyada, women with a history of jaundice, liver and gall bladder disease, and clogged arteries need to take especial care. "Normally, it is advised that first-time contraceptive users consult a physician to have a check-up for allergies and get their medical history looked into. Taking any sort of contraceptive, like any type of drug, involves risks. There are side effects which can affect each individual differently; some are mild, others very severe."

Of all the possible health risks, one of the worst scenarios is contracting Aids or another sexually transmitted disease."A woman taking the emergency pill is probably not insisting on the use of a condom and this practice is likely to be more common now among youngsters and married couples. This inevitably puts them at high risk of contracting sexual transmitted diseases. And, as statistics show, a high percentage of Aids victims contracted the virus from their [long-term] partners. Oral contraceptives cannot prevent diseases, but condoms can."

Sadly, women continue to have little say in whether or not their partner wears a condom. And several random studies have shown that men are the most frequent buyers of morning-after pills and that many learn about it from adverts in men's magazines. "They buy the pills for their girlfriends or wives," said Nattaya, "so that they don't have to wear condoms and feel they're at no risk of becoming a father afterwards. Some women I've spoken to said that they didn't even know what they were taking; that the guy just said it was a health supplement."

Although many feminists believe that the morning-after pill gives them more control over their own bodies, it would seem, judging from the few studies conducted so far, that it is actually being used by men to exploit women. "It is much easier for men to wear condoms," Dr Niyada concluded. "Not only are they safer, they also help a lot in preventing pregnancy if used properly. Forcing women to use oral contraceptives on a regular basis, especially these highly concentrated morning-after pills, is likely to put women's health at risk."