Emergency contraception
» Proceed with great care
/ Antiemetics are impractical
Proceed with great care
From Dr P. J. Brown, FRPharmS
I must take issue with some of the remarks made in your editorial
“Hot potato” dealing with the matter of emergency hormonal
contraception (PJ, March 3, p269).
First, you dismiss as “side issues” concerns about the
supply of EHC which include conscientious objection to the whole
principle. I am sure that those pharmacists who hold such views
would not regard them as side issues. Those who hold the view that
chemical abortion is wrong do so very sincerely and should not be
marginalised. Since when, in a free country where free speech is
encouraged, has discussing moral issues become unacceptable?
Second, you say that the main reason for the introduction of emergency
contraception is to tackle the high rate of teenage pregnancy prevalent
in the UK. Although this may be the case, I believe that, however
good its intentions, it is another misguided Government policy.
Do policy makers really believe that teenage girls will go to their
local pharmacy to ask for such a product? In many cases, these children
express amazement at the state in which they find themselves. It
is important to remember that the teenage girls for whom the emergency
contraception is intended are actually frightened children who need
the support of their families and the confidentiality of the doctor's
surgery. If these are not available, the next best place is probably
their schools where, at least, they are known and, it is to be hoped,
understood. The open pharmacy is not the place for this kind of
business to be transacted.
You did not raise the matter of safety in your editorial and this
is my third concern. It seems that the safety of emergency contraception
has yet to be studied extensively. Yet, there are no requirements
for pharmacists to keep records of the over-the-counter purchases
and there is no follow-up. It must be remembered that we are providing
girls, who may not have taken oral contraceptives, with a large
dose of a progestogen, with all its immunosuppressive properties.
Some gynaecologists are concerned that this immunosuppression could
occur at a time when sexually transmitted infections could be present
with very serious consequences. I understand that one such case
may have occurred and is currently being followed up and could result
in a yellow card warning being sent to the Committee on Safety of
Medicines.
If pharmacists are to be involved in the provision of emergency
contraception to girls and young women, they must approach it from
a strictly medical point of view, and not see themselves as being
players in a social experiment aimed at ridding society of an ill,
as your editorial suggests. Although there is a strong case to be
made for pharmacists to become involved in the treatment of minor
illnesses, I do not think that morning after contraception comes
into this bracket, and hence that pharmacists must proceed with
great care.
Philip Brown
Kingston-upon-Thames, Surrey
Antiemetics are impractical
From Mr N. Shah, MRPharmS
With reference to the vomiting experienced with progestogen only
emergency hormonal contraception, the “Information guide on
emergency hormonal contraception” produced by the Centre for
Pharmacy Postgraduate Education states that “consideration
should be given to whether an antiemetic might be useful”.
However, in the absence of a licensed over-the-counter antiemetic,
this consideration, in my view, would not be manageable.
Nitin Shah
London SW6
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Dr PETER WILSON (director, Centre for Pharmacy Postgraduate Education)
replies:
The full text from our information guide is as follows — “If
a woman has taken EHC in the past and has had a problem with vomiting,
consideration should be given to whether an antiemetic might be
useful. Where previous use has been of Schering PC4 the likelihood
of vomiting will be much lower with Levonelle. The clinical trial
results with Levonelle-2 suggest that vomiting is only likely to
be a problem in 5–6 per cent of women with Levonelle. Family planning
doctors often prescribe domperidone where an antiemetic is needed.
However there is not a currently licensed OTC indication for domperidone.”
If a woman requesting emergency hormonal contraception from a pharmacy
has had problems with vomiting in the past then it would be appropriate
to consider referral to her GP or a family planning clinic so that
the provision of EHC can include the management of possible vomiting.
If this proves impractical, eg, because of the delay it may cause,
the pharmacist needs to consider how to meet the best interests
of the woman. There are at least three options: supply EHC, supply
EHC with an over the counter antiemetic, or suggest that the woman
could attend a family planning clinic within five days of unprotected
sex to have an IUD fitted. It would help in decision making if the
pharmacist is aware of how EHC-induced vomiting is managed by family
planning practitioners locally. Which, if any, of these options
is chosen would depend on the circumstances and the pharmacist’s
professional judgment.
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The
Pharmaceutical Journal Vol 266 No 7139 p356-359