Blog for Choice Day
Jan. 22nd, 2008 10:20 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
st_aurafinaI wanted to write about the morning-after pill, or emergency contraception as part of Blog For Choice Day. I'm not going to write about whether the use of emergency contraception constitutes the termination of pregnancy, beyond saying that I don't believe that it does. I do want to talk about what it's like to buy it, and what you can (or should) expect to experience when you ask for it in a pharmacy.
In Australia, it's available over the counter from pharmacies under the name Postinor or Levonelle. Legally it has to be sold under the supervision of a pharmacist and the pharmacist has the right to legally refuse the sale as well. I have never refused a sale, and I will never refuse a sale, unless it is medically unsafe for the patient to take the medication.
Postinor contains the drug levonorgestrel, a synthetic form of progesterone which is the hormone our bodies produce as part of our menstrual cycle, and to sustain pregnancy. We've been using these kinds of hormones as oral contraceptives in Australia since the sixties, in combination with synthetic oestrogens, and by themselves. Informally, doctors have been prescribing them as emergency contraceptives for just as long. When I first graduated and started working as a pharmacist, we would get prescriptions for the minipill where we would have to punch out a huge number of tablets (25, I think, from memory), which would have to be taken twelve hours apart. This is why I was surprised at the outrage when Postinor-2 was released - this is a medication that was already used for this purpose, albeit unofficially, and now patients would have only have to swallow one tablet, then another one twelve hours later. It made sense to me. In late 2004 Postinor became available for sale without a prescription, from pharmacies only. There was much debate. We were provided with educational material. I sold my first pack on the first working day of January 2005, to a seventeen year old.
This is how it is when you buy Postinor from my pharmacy: I have a list of questions that I ask you, to determine if it is safe for you to take the medication. If the pharmacy is not crowded, and I have reasonable assurance that your confidentiality is protected, we go through the list at my desk outside the dispensary. If more privacy is needed, we go to my office, where nobody can overhear us. You have the right to demand this level of privacy with any medical matter in a pharmacy; we are held to the same ethical requirements to protect your confidentiality as doctors are.
These are the questions I ask:
Is the Postinor for you?
I do not, under any circumstances, sell this medication to a third party. I will arrange a phone consultation, and allow another person to collect the Postinor, but we will have gone through the same procedure as if you had been standing in my pharmacy.
Why do you need to take it?
I need to know if you've forgotten to take your regular contraceptive, if this is a medication you take often, and most importantly, what your understanding is about the function of Postinor as emergency contraception. It's an open question - it allows me to assess the situation, to give you the chance to tell me if you have any concerns, if you've been assaulted and I need to refer you on to a doctor or involve the police. I am not a counsellor, and I don't have training for that kind of work, but I'm one of many people in the healthcare system that form part of the vanguard for early detection of sexual assault and molestation. If something makes me worry, I can question further. If I think you've been assaulted, I won't refuse to sell you the medication, but I will encourage you to speak to a doctor or to allow me to contact the police.
How long is it since you've had unprotected sex?
Postinor is around 99% effective when taken inside the first twenty four hours. This efficacy decreases as time goes on, until after 72 hours, when it is only 50% effective. If it's been more than three days, I will refer you to a doctor, and offer to make you an appointment at our local clinic. I will still sell you the medication, but I will explain that it's much less effective. So far, I've never sold it to anyone who waited more that 12 hours. There's a clear understanding in the community that the faster you act, the better the drug works.
Did you have unprotected sex at any other time since your last period?
Is there a chance that you might be pregnant?
As with any oral contraceptive, it's not recommended that you take it if you're pregnant.
Was your last period normal? Are they generally regular?
These are criteria that I use to eliminate the possibility that you have a condition that should be referred to a doctor, and to confirm that you're not pregnant. If you're not someone who can expect your period to come with any regularity, you will need to make other arrangements to make sure you're not pregnant.
Have you ever suffered from bowel disease, breast cancer or unexplained vaginal bleeding?
Bowel disease, like IBS or Crohn's disease will interfere with the absorption of Postinor and reduce how effective it is. Postinor, or any hormone treatment, is contraindicated in people who have breast cancer, unless there is a doctor overseeing the treatment. And unexplained vaginal bleeding is an indication of possible serious illness that may be complicated by taking Postinor. If you have any of these, it's not safe for me to sell you the medication.
Any vomiting or diarrhoea in the last twenty-four hours?
The vomiting is another check-point for me to confirm that you're not pregnant. Vomiting and diarrhoea may be an indication that you have some kind of stomach bug. This makes everything move swiftly though your gastro-intestinal tract, and that reduces the amount of time you have to absorb the Postinor into your system.
Any allergies?
I should ask this with every medication that I sell; in practice I check for the most common allergies.
At this point, I've asked all my questions, and I will tell you about the medication, and how to take it. It comes as a pack of two tablets. You take one immediately, and one in twelve hours. You should try to be as accurate as possible with this - even if it means getting up at four in the morning, because the sooner you take Postinor, the better the chances are of it working. If you throw up, or have diarrhoea in the next twenty four hours, it may not work, and you should see your doctor. Your period may be a little early, and it may be a little heavier; this is normal. You should see a doctor within a month of taking Postinor, but most especially if your period doesn't eventuate, and you should tell the doctor that you took emergency contraception. If you forgot to take your regular pill, you will need to use a barrier form of contraception for seven days before the pill is reliable again.
Then I take down your name and address - these go into my dispensing software, which is confidential. I don't have to record it, and you can ask me not to do that. I have a good reason for doing it: once you're out of the shop, and you've taken the pills and thrown away the box, you might not remember when exactly it was that you took it. I will keep that date on file for your reference for five years. I will not give that information to anyone other than you - legally I'm not allowed to. Ethically, I never would.
Once that's all done, I put a label on the box, put it in a bag with the list of questions and an information leaflet. On the information leaflet are phone numbers for my pharmacy, the doctor's clinic, Family Planning Victoria and CASA House, a rape crisis centre. I send you to the front counter to pay. Nobody can see what's in your bag - it's confidential. Postinor is not currently subsidised by our Pharmaceutical Benefits Scheme; you can expect to pay about $38 for it. It differs from pharmacy to pharmacy.
Last year I got a leaflet in the mail from a Pro-Life group, filled with misinformation about how Postinor works. It does not affect your fertility - they're still saying that about oral contraceptives in general, despite a lack of studies to support any such claim. One thing that they were very clear about was that it may cause a complication of pregnancy, and that is true.
This is really, really important: if the Postinor doesn't work, it may increase the chance of an ectopic pregnancy. That's a pregnancy where the embryo implants somewhere other than in the uterus; most commonly in the tubes that carry the egg from the ovaries to the uterus. An ectopic pregnancy is not a viable pregnancy. I always make sure that my patient understands this, because if there's any chance that they would want to carry through a pregnancy if the Postinor didn't work, I recommend that they don't take it.
That's all there is to it. When you walk out the door you should have an understanding of how the medication works, how likely it is to prevent pregnancy, what the complications may be, and what to do next. I inform you, and I allow you to make the decision. That's what choice is all about.
In Australia, it's available over the counter from pharmacies under the name Postinor or Levonelle. Legally it has to be sold under the supervision of a pharmacist and the pharmacist has the right to legally refuse the sale as well. I have never refused a sale, and I will never refuse a sale, unless it is medically unsafe for the patient to take the medication.
Postinor contains the drug levonorgestrel, a synthetic form of progesterone which is the hormone our bodies produce as part of our menstrual cycle, and to sustain pregnancy. We've been using these kinds of hormones as oral contraceptives in Australia since the sixties, in combination with synthetic oestrogens, and by themselves. Informally, doctors have been prescribing them as emergency contraceptives for just as long. When I first graduated and started working as a pharmacist, we would get prescriptions for the minipill where we would have to punch out a huge number of tablets (25, I think, from memory), which would have to be taken twelve hours apart. This is why I was surprised at the outrage when Postinor-2 was released - this is a medication that was already used for this purpose, albeit unofficially, and now patients would have only have to swallow one tablet, then another one twelve hours later. It made sense to me. In late 2004 Postinor became available for sale without a prescription, from pharmacies only. There was much debate. We were provided with educational material. I sold my first pack on the first working day of January 2005, to a seventeen year old.
This is how it is when you buy Postinor from my pharmacy: I have a list of questions that I ask you, to determine if it is safe for you to take the medication. If the pharmacy is not crowded, and I have reasonable assurance that your confidentiality is protected, we go through the list at my desk outside the dispensary. If more privacy is needed, we go to my office, where nobody can overhear us. You have the right to demand this level of privacy with any medical matter in a pharmacy; we are held to the same ethical requirements to protect your confidentiality as doctors are.
These are the questions I ask:
Is the Postinor for you?
I do not, under any circumstances, sell this medication to a third party. I will arrange a phone consultation, and allow another person to collect the Postinor, but we will have gone through the same procedure as if you had been standing in my pharmacy.
Why do you need to take it?
I need to know if you've forgotten to take your regular contraceptive, if this is a medication you take often, and most importantly, what your understanding is about the function of Postinor as emergency contraception. It's an open question - it allows me to assess the situation, to give you the chance to tell me if you have any concerns, if you've been assaulted and I need to refer you on to a doctor or involve the police. I am not a counsellor, and I don't have training for that kind of work, but I'm one of many people in the healthcare system that form part of the vanguard for early detection of sexual assault and molestation. If something makes me worry, I can question further. If I think you've been assaulted, I won't refuse to sell you the medication, but I will encourage you to speak to a doctor or to allow me to contact the police.
How long is it since you've had unprotected sex?
Postinor is around 99% effective when taken inside the first twenty four hours. This efficacy decreases as time goes on, until after 72 hours, when it is only 50% effective. If it's been more than three days, I will refer you to a doctor, and offer to make you an appointment at our local clinic. I will still sell you the medication, but I will explain that it's much less effective. So far, I've never sold it to anyone who waited more that 12 hours. There's a clear understanding in the community that the faster you act, the better the drug works.
Did you have unprotected sex at any other time since your last period?
Is there a chance that you might be pregnant?
As with any oral contraceptive, it's not recommended that you take it if you're pregnant.
Was your last period normal? Are they generally regular?
These are criteria that I use to eliminate the possibility that you have a condition that should be referred to a doctor, and to confirm that you're not pregnant. If you're not someone who can expect your period to come with any regularity, you will need to make other arrangements to make sure you're not pregnant.
Have you ever suffered from bowel disease, breast cancer or unexplained vaginal bleeding?
Bowel disease, like IBS or Crohn's disease will interfere with the absorption of Postinor and reduce how effective it is. Postinor, or any hormone treatment, is contraindicated in people who have breast cancer, unless there is a doctor overseeing the treatment. And unexplained vaginal bleeding is an indication of possible serious illness that may be complicated by taking Postinor. If you have any of these, it's not safe for me to sell you the medication.
Any vomiting or diarrhoea in the last twenty-four hours?
The vomiting is another check-point for me to confirm that you're not pregnant. Vomiting and diarrhoea may be an indication that you have some kind of stomach bug. This makes everything move swiftly though your gastro-intestinal tract, and that reduces the amount of time you have to absorb the Postinor into your system.
Any allergies?
I should ask this with every medication that I sell; in practice I check for the most common allergies.
At this point, I've asked all my questions, and I will tell you about the medication, and how to take it. It comes as a pack of two tablets. You take one immediately, and one in twelve hours. You should try to be as accurate as possible with this - even if it means getting up at four in the morning, because the sooner you take Postinor, the better the chances are of it working. If you throw up, or have diarrhoea in the next twenty four hours, it may not work, and you should see your doctor. Your period may be a little early, and it may be a little heavier; this is normal. You should see a doctor within a month of taking Postinor, but most especially if your period doesn't eventuate, and you should tell the doctor that you took emergency contraception. If you forgot to take your regular pill, you will need to use a barrier form of contraception for seven days before the pill is reliable again.
Then I take down your name and address - these go into my dispensing software, which is confidential. I don't have to record it, and you can ask me not to do that. I have a good reason for doing it: once you're out of the shop, and you've taken the pills and thrown away the box, you might not remember when exactly it was that you took it. I will keep that date on file for your reference for five years. I will not give that information to anyone other than you - legally I'm not allowed to. Ethically, I never would.
Once that's all done, I put a label on the box, put it in a bag with the list of questions and an information leaflet. On the information leaflet are phone numbers for my pharmacy, the doctor's clinic, Family Planning Victoria and CASA House, a rape crisis centre. I send you to the front counter to pay. Nobody can see what's in your bag - it's confidential. Postinor is not currently subsidised by our Pharmaceutical Benefits Scheme; you can expect to pay about $38 for it. It differs from pharmacy to pharmacy.
Last year I got a leaflet in the mail from a Pro-Life group, filled with misinformation about how Postinor works. It does not affect your fertility - they're still saying that about oral contraceptives in general, despite a lack of studies to support any such claim. One thing that they were very clear about was that it may cause a complication of pregnancy, and that is true.
This is really, really important: if the Postinor doesn't work, it may increase the chance of an ectopic pregnancy. That's a pregnancy where the embryo implants somewhere other than in the uterus; most commonly in the tubes that carry the egg from the ovaries to the uterus. An ectopic pregnancy is not a viable pregnancy. I always make sure that my patient understands this, because if there's any chance that they would want to carry through a pregnancy if the Postinor didn't work, I recommend that they don't take it.
That's all there is to it. When you walk out the door you should have an understanding of how the medication works, how likely it is to prevent pregnancy, what the complications may be, and what to do next. I inform you, and I allow you to make the decision. That's what choice is all about.
