The Morning-After Pill: Convenience and BPAS

On Friday the 23rd of October, the Independent reported that the British Pregnancy Advisory Service was calling for the reclassification of emergency hormonal contraception (EHC) as a general sales list medicine (GSL), rather than being restricted to pharmacy-only supply. This followed a mystery shopping exercise involving 34 pharmacies, ten of which were unable to provide confidential and Covid-secure consultations due to constraints imposed by the current crisis. Readers might be aware that the BPAS has a history of campaigning for the lowering of prices and reclassification of EHC as GSL, not being a stranger to charges of promoting emergency hormonal contraception itself.

The BPAS ambition, purpose and values are available on its website and, at the time of writing this post, were reflected as shown in the image below:

BPAS provides services centred on abortion, abortion care, pregnancy testing, contraception, miscarriage care, foetal anomaly care, STIs, vasectomy, erectyle dysfunction and fertility. Many of these are fully funded by the NHS and, as a charity, BPAS campaigns in lie with its values and receives charitable donations.

Looking back at the headline behind this discussion, BPAS is right to highlight the following challenges faced by women in relation to emergency contraception:

1. Lack of confidentiality in some locations
2. Inability to access the medication in those pharmacies where the pharmacists were either not trained or unable to supply due to personal beliefs.
3. Cost barriers where more expensive brands (above £26) were sold in comparison with more affordable generic brands that can cost as little as £3.
4. Delays in accessing EHC potentially leading to unwanted pregnancies.

BPAS also makes an interesting argument that the fact that both levonorgestrel and ulipristal have been safely used for many years is an argument in favour of reclassification as GSL. However, this does not necessarily follow from the evidence. The positive history of usage might simply be a reflection of the care that clinicians (doctors, pharmacists, nurses, family and sexual health practitioners etc) have exercised to ensure appropriate supply and counselling to recipients of EHC.

There remain some important clinical considerations that must be tackled before reclassification can be undertaken. These arise from the fact that EHC is not always suitable for those seeking it from pharmacies, doctors and sexual health clinics. This can be seen from a perusal of the Guideline for Emergency Contraception provided by the Faculty of Sexual and Reproductive Health. It is the duty of the clinician to know this guideline and ensure that any supply meets the standards therein.

As examples, within this guideline can be found the following situations when EHC may not be suitable.

1. Severe asthma controlled by oral glucocorticoids (relevant to ulipristal)
2. Hepatic impairment
3. Lactose intolerance
4. Breastfeeding (ulipristal – up to a week after taking the pill)
5. Within the first 21 days after giving birth
6. After the likely date of ovulation in any given cycle
7. When a woman is taking some enzyme-inducing drugs that might affect the metabolism and/or bioavailability of the drug
8. Women with malabsorption conditions that might mean that not enough of the drug is absorbed.

In addition to the above, the clinician is under obligation to cover the following as a minimum:

1. Consideration of the need for dose adjustments where body mass considerations are a factor (levonogestrel)
2. History of use of EHC
3. Ongoing contraception or hormonal treatment
4. The relative efficacy of ulipristal, levonogestrel and the Copper intra-uterine device (Cu-IUD)
5. The risks of ectopic pregnancy and what the woman should look out for.
6. How to take the medication to avoid side effects
7. What to do in the event of vomitting and how to minimise the risk.

Besides the clinical considerations, the emergency contraception consultation affords an opportunity for the clinician to provide added care for the client. This is especially important in safeguarding situations involving minors, instances of sexual assault, trafficking of women and where there is a risk of transmission of sexually-transmitted illnesses (STIs). Many EHC services run from pharmacies provide added free services such as pregnancy testing and referral to free chlamydia and STI-testing services.

In summary, while the reclassification of EHC as GSL might prove popular for the emancipated woman who values convenience; it could have the perverse effects of increasing inappropriate use; causing more unwanted pregnancies; greatly reducing the opportunities for intervention to protect vulnerable women and girls; increasing the risks of side effects and finally reducing access to a range of associated services that are tailored to benefit those seeking emergency contraception. BPAS would potentially benefit from some of these outcomes; but we would like to believe that this is not a consideration in its campaign to reclassify EHC as GSL.

In the meantime, some of the concerns around accessibility of emergency contraceptive services can be addressed by better signposting from pharmacies as well as commissioning of more providers of emergency contraceptiion services by municipal health and public health bodies.