American Journal of Obstetrics and Gynecology (2004) 190, S30e8
James Trussell, PhD,a,* Charlotte Ellertson, PhD,b Felicia Stewart, MD,cElizabeth G. Raymond, MD, MPH,d Tara Shochet, MPHe
Woodrow Wilson School of Public and International Aﬀairs, Oﬃce of Population Research, Princeton University,Princeton, NJa; Ibis Reproductive Health, Cambridge, Massb; University of California San Francisco, Center forReproductive Health Research & Policy, San Francisco, Calif c; Biomedical Affairs Division, Family HealthInternational, Research Triangle Park, NCd; Population Studies Center, University of Michigan, Ann Arbor, Miche
Received for publication September 11, 2003; accepted January 27, 2004
Emergency contraception is an underused therapeutic option for women in the event of unpro-
tected sexual intercourse. Available postcoital contraceptives include emergency contraceptive
pills (ECPs) both with and without estrogen, and copper-bearing intrauterine devices. Each
method has its individual eﬃcacy, safety, and side eﬀect proﬁle. Most patients will experience pre-vention of pregnancy, providing they follow the treatment regimen carefully. There are concernsthat women who use ECPs may become lax with their regular birth control methods; however,reported evidence indicates that making ECPs more readily available would ultimately reducethe incidence of unintended pregnancies. In addition, it is typically conscientious contraceptiveusers who are most likely to seek emergency treatment. Patient education is paramount in the re-duction of unintended pregnancies and there are numerous medical resources available to womento assist them in this endeavor. Finally, ECPs are associated with ﬁnancial and psychologic ad-vantages that beneﬁt both the individual patient and society at large.
Ó 2004 Elsevier Inc. All rights reserved.
Half of all pregnancies in the United States are unin-
by providing a bridge to use of an ongoing contraceptive
tended; there were 3.0 million in 1994 alone, the last year
method. Although emergency contraceptives do not
for which data are available.Emergency contraception,
protect against sexually transmitted infection, they do
which prevents pregnancy after unprotected sexual in-
offer reassurance to the 7.9 million women who rely on
tercourse, has the potential to reduce signiﬁcantly the in-
condoms for protection against pregnancyin case of con-
cidence of unintended pregnancy and the consequent
dom slippage or breakage. Emergency contraceptives
need for abortion.Emergency contraception is espe-
available in the United States include combined oral con-
cially important for outreach to the 3.1 million women
traceptive tablets, levonorgestrel-only contraceptive tab-
at risk of pregnancy but not using a regular method
lets, and the copper-T intrauterine device (IUD).
The authors have no personal ﬁnancial interest whatsoever in the
commercial success or failure of emergency contraception.
This article is part of a supplement sponsored by Ortho-McNeil
Combined emergency contraceptive pills (ECPs) are
ordinary birth control pills containing the hormones
* Reprint requests: James Trussell, PhD, Princeton University,
estrogen and progestin. Although this therapy is com-
Ofﬁce of Population Research, 21 Prospect Ave, Princeton, NJ 08544.
monly known as the morning-after pill, the term is
0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
Twenty-one OCs that can be used for emergency contraception in the United States*
* Plan-B and Preven are the only dedicated products specifically marketed for emergency contraception. Ovral, Ogestrel, Alesse, Levlite, Aviane,
Lessina, Nordette, Levlen, Levora, Portia, Seasonale, Lo/Ovral, Low-Ogestrel, Cryselle, Triphasil, Tri-Levlen, Trivora, and Enpresse have been declared safeand effective for use as ECPs by the US Food and Drug Administration.26 Outside the United States, more than 20 emergency contraceptive products arespecifically packages, labeled, and marketed. For example, Gedeon Richter and HRA Pharma are marketing in many countries the levonorgestrel-onlyproducts Postionor-2 and Norlevo, respectively, each consisting of a 2-pill strip with each pill containing 0.75 mg levonorgestrel. Norlevo becameavailable OTC without a prescription in Norway in October 2000 and in Sweden in late 2001.
y The treatment schedule is 1 dose within 120 hours after unprotected intercourse, and another dose 12 hours later. However, recent research has
found that both doses of Plan B or Ovrette can be taken at the same time.
z The progestin in Ovral, Ogestrel, Lo/Ovral, Low-Ogestrel, Cryselle, and Ovrette is norgestrel, which contains 2 isomers, only 1 of which
(levonorgestrel) is bioactive; the amount of norgestrel in each tablet is twice the amount of levonorgestrel.
misleading; ECPs may be initiated sooner than the morn-
that 25% of women using ECPs will become pregnant.
ing afterdimmediately after unprotected intercoursedor
Rather, if 100 women had unprotected intercourse once
laterdfor at least 72 hours after unprotected intercourse.
during the second or third week of their cycle, about 8
The hormones that have been studied exclusively in clini-
would become pregnant; after treatment with ECPs, only
cal trials of ECPs are the estrogen ethinyl estradiol and the
2 would become pregnant, a 75% reduction. The cur-
progestin levonorgestrel or norgestrel (which contains 2
rent treatment schedule is 1 dose within 72 hours after
isomers, only 1 of whichdlevonorgestreldis bioactive).
unprotected intercourse, and a second dose 12 hours
These are found in 18 brands of combined oral contracep-
after the ﬁrst dose. A large study by the World Health
tives available in the United States as well as in 1 specially
Organization (WHO) found that effectiveness declined
packaged ECP product (This combination of
signiﬁcantly with increasing delay between unprotected
active ingredients used in this way is also sometimes called
intercourse and the initiation of treatThis
the Yuzpe method, after the Canadian physician who ﬁrst
ﬁnding suggests that ECPs should be taken as soon after
described the regimen. Newer research has investigated
unprotected intercourse as is practical. When taking the
the safety and efﬁcacy of formulations containing ethinyl
second dose 12 hours later would be difﬁcult, however,
estradiol and the progestin norethindrone; results indi-
the timing of the second dose might be altered; for ex-
cate efﬁcacy, but probably less than the Yuzpe or levonor-
ample, a woman who took her ﬁrst dose at 3 PM imme-
gestrel-only regimens (described later).
diately after discovery of a burst condom might delaytaking the second dose until 7 AM. The goal should be
to make the therapy as user-friendly as possiblNew research does indicate, however, that the second
The use of combined ECPs reduces the risk of preg-
dose appears to increase efﬁcacy of the therapy and so
nancy by about 75%.This statement does not mean
It is biologically implausible that efﬁcacy would
There have been no conclusive studies of births to
abruptly plummet to zero after 72 hourMoreover,
women who were already pregnant when they took
new research directly investigating the effectiveness
combined ECPs or after failure of combined ECPs.
beyond 72 hours suggests that combined ECPs are just
However, 2 observations provide reassurance for any
as effective when taken 73 to 120 hours after unprotected
concern about birth First, in the event of treat-
intercourse as when taken in the ﬁrst 72 hour
ment failure, ECPs are taken long before organogenesis
Therefore, clinical protocols that deny treatment beyond
starts so they should not have a teratogenic effect. Sec-
72 hours seem excessively restrictive, particularly if the
ond, studies that have examined births to women who
alternative of emergency insertion of a copper IUD is
inadvertently continued to take combined oral con-
not immediately available or appropriate.
traceptives (including high-dose formulations) withoutknowing they were pregnant have found no increased
risk of birth defects.The FDA removed warningsabout adverse effects of combined oral contraceptives on
About 50% of women who take combined ECPs expe-
the fetus from the package insert several years ago.
rience nausea and 20% vomitIf vomiting occurs within2 hours after taking a dose, some clinicians recommend re-
peating that dose. The results of one study suggest thatECPs containing levonorgestrel have an incidence of side
Several clinical studies have shown that combined ECPs
effects substantially lower than do ECPs containing nor-
can inhibit or delay ovulation.This is an important
gestrel(see last column in for information on pro-
mechanism of action and may explain ECP effectiveness
gestins in ECPs). The nonprescription antinausea medicine
when used during the ﬁrst half of the menstrual cycle,
meclizine has been demonstrated to reduce the risk of nau-
before ovulation has occurred. Some studies have shown
sea by 27% and vomiting by 64% when two 25-mg tablets
histologic or biochemical alterations in the endometrium
are taken 1 hour before combined ECPs, but the risk of
after treatment with the regimen, leading to the conclu-
drowsiness was doubled (to about 30%).Antinausea
sion that combined ECPs may act by impairing endome-
medicines are not routinely offered in the United States.
trial receptivity to implantation of a fertilized egg.
Many providers recommend instead that women reduce
However, other studies have found no such effects on the
the risk of nausea by taking ECPs with food, although re-
endometrium.Additional possible mechanisms in-
search suggests that doing so is ineffective.
clude interference with corpus luteum function, thicken-ing of the cervical mucus resulting in trapping of sperm,
alterations in the tubal transport of sperm, egg, or em-bryo, and direct inhibition of fertilization.No clin-
Almost all women can safely use combined ECPs. Ac-
ical data exist regarding the last 3 of these possibilities.
cording to the WHO, the only absolute contraindication
Nevertheless, statistical evidence on the effectiveness of
to use of combined ECPs is conﬁrmed pregnancy, sim-
combined ECPs suggests that there must be a mechanism
ply because ECPs will not work if a woman is preg-
of action other than delaying or preventing ovulation.
naTreatment may also not be appropriate for
ECPs do not interrupt an established pregnancy, deﬁned
those who have an active migraine with marked neuro-
by the National Institutes of Health/FDAand the
logic symptoms or crescendo migraine.Given the very
American College of Obstetricians and Gynecologists
short duration of exposure and low total hormone con-
tent, however, combined ECP treatment can be consid-
an informed choice, women must know that combined
ered safe for women who would ordinarily be cautioned
ECPsdlike all regular hormonal contraceptives such
against use of combined oral contraceptives for ongoing
as the birth control pill, the patch Evra, the vaginal ring
contraception. Although no changes in clotting factors
NuvaRing, the injectable Lunelle, and the injectable De-
have been detected after combined ECP treatment,
po-Provera (Pharmacia Corporation, Peapack, NJ),
progestin-only ECPs or insertion of a copper IUD
and even breastfeedingdmay prevent pregnancy by
may be preferable to use of combined ECPs for a woman
delaying or inhibiting ovulation, inhibiting fertilization,
who has a history of stroke or blood clots in the lungs or
or inhibiting implantation of a fertilized egg.
legs and wants emergency contraception. All 3 of theseconditions (pregnancy, migraine, or history of throm-
boembolism) are identiﬁed through medical historyscreening, so women requesting combined ECPs can
Progestin-only ECPs contain no estrogen. Only the pro-
be evaluated via telephone, without need for an ofﬁce
gestin levonorgestrel has been studied for freestanding
visit, pelvic examination, or laboratory tests. Planned
use as an emergency contraceptive. The treatment sched-
Parenthood Federation of America now allows afﬁliates
ule is one 0.75 mg dose within 72 hours after unpro-
tected intercourse, and a second 0.75 mg dose 12
hours after the ﬁrst dose. The only practical progestin-
obstacle to more widespread use of emergency contra-
only product available in the United States is Plan-B
ception in the United States until the fall of 1998, when
(Barr Pharmaceuticals Woodcliff Lake, NJ), approved
Preven (Gyne´tics Inc, Somerville, NJ) was approved.
by the FDA as an ECP in July 1999 (). One tablet
More recently, a second specially packaged emergency
is required for each dose. Aside from Plan-B, the only
progestin-only formulation available in the United
approved a year later. Although availability of these
States is the birth control minipill Ovrette (which con-
products has helped, the 2 pharmaceutical companies
tains 0.075 mg norgestrel) (Wyeth Pharmaceutical, Col-
originally distributing them were very small and were
legeville, Pa). Twenty Ovrette tablets are needed for each
not able to promote the products on the same scale as
dose. The levonorgestrel regimen appears to be as or
most contraceptives. For this reason, and because the
more effective than the Yuzpe regimen, and deﬁnitely
dedicated products can cost more, off-label use of regu-
has a signiﬁcantly lower incidence of nausea and vomit-
lar ongoing oral contraceptive brands remains popular.
ingaccording to a randomized controlled trial con-
Although the FDA has not speciﬁcally approved reg-
ducted by WHO, progestin-only ECPs reduce the risk
ular combined or progestin-only birth control pills or
of pregnancy by 88% and are associated with an inci-
copper-bearing IUDs for emergency contraception, pro-
dence of nausea 50% lower and an incidence of vomit-
viding these products for this indication off-label is com-
ing 70% lower than that for combined ECPs. Like
pletely legal. Once a medication or device has been
combined ECPs, progestin-only ECPs are more effective
tested and approved for one use, it is a legal and medi-
the sooner after unprotected intercourse treatment is ini-
cally accepted practice to prescribe it for other appropri-
tiated.The most recent trials found that treatment
ate For example, many women take birth control
is effective when initiated up to 5 days after unprotected
pills not to prevent pregnancy, but to regulate their men-
intercourseand that a single dose of 1.5 mg is as effec-
strual periods, to decrease menstrual cramping, or to
tive as two 0.75 mg doses 12 hours apart.Early
prevent the recurrence of ovarian cysts, and these uses
treatment may inhibit or delay ovulation or interfere
are perfectly legal. The FDA’s reproductive health drugs
with sperm migration and function at all levels of the
advisory committee reviewed research concerning ECP
treatment in 1996 and concluded that existing data were
sufﬁcient to document the safety and efﬁcacy of this reg-imen, and the agency then took the unusual action of
Copper-bearing IUDs can be inserted up to the time of
publishing in the Federal Register a notice declaring
pregnancy. Thus, if a woman had unprotected inter-
‘‘The Food and Drug Administration (FDA) is an-
course 3 days before ovulation occurred in that cycle,
nouncing that the Commissioner of Food and Drugs
the IUD could prevent pregnancy if inserted up to 10
(the Commissioner) has concluded that certain com-
days after intercourse. Because of the difﬁculty in deter-
bined oral contraceptives containing ethinyl estradiol
mining the day of ovulation, however, many protocols
and norgestrel or levonorgestrel are safe and effective
allow insertion up to only 5 days after unprotected inter-
for use as postcoital emergency contraception.
course. Emergency insertion of a copper-bearing IUD is
Commissioner bases this conclusion on FDA’s review
signiﬁcantly more effective than use of ECPs, reducing
of the published literature concerning this use, FDA’s
the risk of pregnancy after unprotected intercourse by
knowledge of the safety of combined oral contraceptives
more than 99%.Such a degree of effectiveness implies
as currently labeled, and on the unanimous conclusion
that emergency insertion of a copper-bearing IUD must
that these regimens are safe and effective made by the
be able to prevent pregnancy after fertilization. A cop-
agency’s Advisory Committee for Reproductive Health
per-bearing IUD can also be left in place to provide ef-
Drugs at its June 18, 1996 meeting.’’
fective ongoing contraception for up to 10 years. But
Even though some doctors have been prescribing
IUDs are not ideal for all women. Women at risk of sex-
emergency contraceptives since the 1970s, no company
ually transmitted infections (STIs) may not be good can-
already marketing oral contraceptives or IUDs for on-
didates for IUDs; insertion of the IUD in these women
going contraception has applied to the FDA to market
can lead to pelvic infection, which can cause infertility if
these products for emergency use. Although consider-
untreated. Women not exposed to STIs have little risk of
able international research attests to the safety and efﬁ-
pelvic infection after IUD insertion.
cacy of emergency contraceptives, manufacturers cannotalso promote these products for postcoital use until they
seek and gain formal FDA approval for this speciﬁc
purpose. Without commercial marketing or advertis-ing, it is not surprising that physicians prescribe emer-
The lack of a product speciﬁcally packaged, labeled, and
gency contraceptives infrequently and rarely provide
marketed as an emergency contraceptive was a major
information about emergency contraception to women
during routine visits. As a consequence, very few women
completely conﬁdential, available 24 hours a day in En-
know that emergency contraception is available, effec-
glish and Spanish, and offer names and telephone num-
tive, and safe.A college campus survey found that
bers of providers of emergency contraception located
while nearly all students were aware of ECPs and knew
near the caller’s area. Public service announcements for
they were available at the college health centerdbecause
print, radio, television, and outdoor venues advertising
of an effective publicity campaigndfew knew that com-
the Hotline ran in several cities in 1997 and 1998. These
bined ECPs were ordinary oral contraceptives, and
were the ﬁrst advertisements about contraception to be
many could not distinguish ECPs from mifepristone,
a medication taken to induce abortion after pregnancyhas been con
One objection to making ECPs more widely available
is the concern that women who know they can use ECPs
may become less diligent with their ongoing contracep-tive method. However, if used as an ongoing method,
Several service delivery innovations involving emergency
ECP therapy would be far less effective than most other
contraception would help to reduce the number of unin-
contraceptive methods: if the typical woman used com-
tended pregnancies. Perhaps the greatest impact would
bined ECPs for a year; her risk of pregnancy would ex-
result from making ECPs available over-the-counter
ceed 35% and if she used progestin-only ECPs, she
(OTC) without prescription. There are no medical rea-
would still have a 20% chance of pregnancy. Therefore,
sons why ECPs should remain prescription-only products
continued use would not be a rational choice. Moreover,
in the United StateThe ACOG recently recom-
1 in 2 women experiences nausea and 1 in 5 women vom-
mended that emergency contraceptive pills be available
its after taking combined ECPs. If antinausea medicines
OTC in the United States,and the Center for Repro-
are used with combined ECPs or if progestin-only ECPs
ductive Law and Policy has ﬁled a petition with the FDA
are used, the incidence of nausea and vomiting would be
signed by more than seventy organizations supporting
reduced signiﬁcantly, but not eliminated.This risk is
the method’s OTC availability.ECPs are available
likely to dissuade such users from having unprotected
OTC in Norway (2000) and Sweden (2001). In December,
intercourse often. Reported evidence demonstrates that
2003, an FDA advisory committee voted 23 to 4 to sup-
making ECPs more widely available does not increase
port a switch for plan B from Rx to OTC.
risk taking but instead reduces the incidence of unin-
A second-best alternative is enabling women to ob-
tain ECPs directly from a pharmacy without having to
diligent about ongoing contraceptive use are those most
see a physician, as is possible in Alaska, California,
likely to seek emergency treatmentFor example, a re-
Hawaii, New Mexico, Washington State,Albania,
cent study considering the effect of advance ECP provi-
Belgium, Benin, Cameroon, some provinces in Cana-
sion on regular methods of birth control, women aged
Congo, Denmark, Estonia, Finland, France,
16 to 24 receiving emergency contraception supplies in
Gabon, Guinea, Guinea-Bissau, India, Israel, Ivory
advance were 3 times as likely to use ECPs when needed
Coast, Latvia, Madagascar, Mali, Mauritania, Mauri-
but did not report higher frequencies of unprotected
tius, Namibia, New Zealand, Nigeria, Portugal, Senegal,
sex.Another study demonstrated that educating teens
South Africa, Sri Lanka, Switzerland, Tunisia, Uganda,
about ECPs does not increase their sexual activity levels
or use of emergency contraception but increases their
A third-best alternative is screening by telephone
knowledge about proper administration of the drugs.
or Web site, after which a prescription is called to the
And ﬁnally, even if ECP availability did adversely affect
woman’s pharmacy of choice; several Planned Parent-
regular contraceptive use, women are entitled to know
hoods offer this service (see Appendix).
Another important step is changing provider prac-
To help educate women and men about emergency
tices so that women seen by primary and reproductive
contraception, the Association of Reproductive Health
health care clinicians would be routinely informed about
Professionals in Washington and the Ofﬁce of Population
emergency contraception before the need arises; cur-
Research at Princeton University sponsor the toll-free
rently only 25% of gynecologists and 14% of general
practice physicians routinely counsel women in advance
LATE) and the Emergency Contraception Web site
about emergency contraception.The recent clinical
(http://not-2-late.com). Since it was launched on Febru-
practice bulletin issued by the ACOGshould help
ary 14, 1996, the Hotline has received more than
450,000 calls. More detailed information is available on
include a monograph of legal issues for health care pro-
the Emergency Contraception Web site, which has re-
viders of ECPs produced by the Center for Reproduc-
ceived approximately 2,100,000 hits since it was launched
tive Law and Policyand a provider packet developed
in October 1994. Both the Hotline and the Web site are
by the Program for Appropriate Technology in Health
and endorsed by many medical organizations (including
more widely available in the United States is 1 of the
the American Medical Association, the ACOG, and
most important steps that can be taken to reduce the in-
Planned Parenthood Federation of America). Infor-
cidence of unintended pregnancy and the consequent
mation could be provided to women (and men!) in a
need for abortion.It was estimated that as many
culturally sensitive mannerduring counseling or by
as 51,000 abortions were averted by use of ECPs in
posters, brochures, audio or videocassettes, or wallet
cards. Access would be enhanced if clinicians advertisedemergency contraception services and if ECPs were pre-scribed by telephone without the need for an ofﬁce visit.
A more proactive step would be to prescribe or dispenseECPs to women in advance so the therapy would be im-mediately accessible if the need arises.
Availability would also be enhanced if one of the
large pharmaceutical companies active in marketing
- Only 25% routinely discuss emergency contra-
other contraceptives to the medical community gained
FDA approval for and then actively promoted emer-
- 80% prescribed ECPs last year (61% of whom
- Only 14% routinely discuss emergency contra-
- 36% prescribed ECPs last year (83% of whom
Emergency contraception is nearly always cost-effective.
Use of combined or progestin-only ECPs reduces expen-
ditures on medical care by preventing unintended preg-
nancies, which are very costly. Insertion of a copper-T
- 68% know there is something a woman can do in
IUD is not cost saving in the United States when used
the next few days after unprotected sex to prevent
solely as an emergency contraceptive. Unlike the other
2 alternatives, however, insertion of a copper-bearingIUD can provide continuous contraceptive protectionfor up to 10 years thereafter, producing savings if used
as an ongoing method of contraception for as little as4 months after emergency insertion.Hormonal emer-
Ensure that all ofﬁce staff (especially those answer-
gency contraceptives are cost-effective regardless of
ing the telephone) know that you provide emergency
whether they are provided when the emergency arises
or provided beforehand as a routine preventive mea-
Routinely discuss emergency contraception with
Not only would making emergency contraception
Do not require a pelvic exam before prescribing
more widely available save medical care dollars, but also
additional social cost savings would result. These in-
clude not only the monetary costs of unwanted pregnan-
Provide ECPs in advance to clients or give
cies and births but also the considerable psychologic
prescriptions in advance that can be ﬁlled when
costs of unintended pregnancy. Moreover, the average
medical care cost of unintended births is likely to be
Discuss antinausea medicines with clients
greater than the average cost of all births.
Extend 72-hour window when prescribing ECPs Join the directory of providers listed on the
Emergency Contraception Web site and the Emer-
Advertise the availability of emergency contracep-
One of every 2 women aged 15 to 44 in the United States
has experienced at least 1 unintended pregnancy.Unin-tended pregnancy is a major public health problem that
affects not only the individuals directly involved but alsosociety.Emergency contraception, whether combined
Emergency Contraception Web site: http://not-2-
estrogen-progestin, progestin-alone, or copper-bearing
IUDs, are effective, safe, simple, and readily feasible in
Emergency Contraception Hotline: 1-888-NOT-2-
the United States. Making emergency contraceptives
ARHP EC Train-the-Trainer PowerPoint slide set:
Prescription: 1 promethazine hydrochloride (Phe-
nergan) 25-mg tablet or suppository 30 minutes to 1
Emergency Contraceptive Pills: Common Legal
hour before each ECP dose; repeat as needed every 8
Questions about Prescribing, Dispensing, Repack-
aging, and Advertising. New York: The Center forReproductive Law and Policy; 1999. To order, call
Emergency Contraception: Resources for Providers.
1. Henshaw SK. Unintended pregnancy in the United States. Fam
Seattle (WA): Program for Appropriate Technology
2. Trussell J, Stewart F, Guest F, Hatcher RA. Emergency
in Health; 1997. To order, call 1-800-669-0156.
contraceptive pills: a simple proposal to reduce unintended
Emergency Contraception: Client Materials for
pregnancies. Fam Plann Perspect 1992;24:269-73.
Diverse Audiences. Seattle (WA): Program for
3. Abma JC, Chandra A, Mosher WD, Peterson LS, Piccinino LJ.
Appropriate Technology in Health; 1998. To order,
Fertility, family planning, and women’s health: new data from the1995 National Survey of Family Growth. Vital Health Stat 23
call 1-206-285-3500 or e-mail firstname.lastname@example.org.
Emergency Oral Contraception. ACOG Practice
4. Van Look PFA, Stewart F. Emergency contraception. In: Hatcher
Bulletin. Number 25. Washington (DC): The Col-
RA, Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al,
lege; 2001. To order, call 508-750-8400.
editors. Contraceptive technology. 17th rev ed. New York: Ardent
Emergency Contraception: Is the Secret Getting
5. Glasier A. Emergency postcoital contraception. N Engl J Med
Out? Menlo Park (CA): The Henry J. Kaiser Family
Foundation; 1997. To order, call 1-800-656-4533
6. Hatcher RA, Trussell J, Stewart F, Howells S, Russell CR, Kowal
D. Emergency contraception: the nation’s best kept secret. Decatur(GA): Bridging the Gap Communications; 1995.
7. Trussell J, Koenig J, Ellertson C, Stewart F. Preventing unintended
Planned Parenthood state hotlines and Web sites
pregnancy: the cost-effectiveness of three methods of emergencycontraception. Am J Public Health 1997;87:932-7.
8. Ellertson C, Webb A, Blanchard K, Bigrigg A, Haskell S, Shochet
T, Trussell J. Modifying the Yuzpe regimen of emergency
contraception: a multicenter randomized controlled trial. Obstet
9. Trussell J, Ellertson C, Stewart F. The effectiveness of the Yuzpe
regimen of emergency contraception. Fam Plann Perspect 1996;28:
10. Trussell J, Rodriguez G, Ellertson C. New estimates of the
effectiveness of the Yuzpe regimen of emergency contraception.
11. Trussell J, Rodriguez G, Ellertson C. Updated estimates of the
effectiveness of the Yuzpe regimen of emergency contraception.
12. Task Force on Postovulatory Methods of Fertility Regulation.
Randomised controlled trial of levonorgestrel versus the Yuzpe
OTC: 2 meclizine hydrochloride (Dramamine II,
regimen of combined oral contraceptives for emergency contra-ception. Lancet 1998;352:428-33.
Bonine) 25-mg tablets 1 hour before the ﬁrst ECP
13. Piaggio G, von Hertzen H, Grimes DA, Van Look PFA. Timing of
emergency contraception with levonorgestrel or the Yuzpe
OTC: 1 to 2 diphenhydramine hydrochloride (Be-
nadryl) 25-mg tablets 1 hour before each ECP dose;
14. Webb A. Emergency contraception. Fertil Control Rev 1995;4:3-7.
15. Grou F, Rodrigues I. The morning-after pilldhow long after? Am
OTC: 1 to 2 dimenhydrinate (Dramamine) 50-mg
16. Ellertson C, Evans M, Ferden S, Leadbetter C, Spears A,
tablets or 4 to 8 teaspoons dramamine liquid 30
Johnstone K, et al. Extending the time limit for starting the Yuzpe
minutes to 1 hour before each ECP dose; repeat as
regimen of emergency contraception to 120 hours. Obstet Gynecol
OTC: 1 cyclizine hydrochloride (Marezine) 50-mg
17. Rodrigues I, Grou F, Joly J. Effectiveness of emergency
contraception pills between 72 and 120 hours after unprotected
tablet 30 minutes before each ECP dose; repeat as
sexual intercourse. Am J Obstet Gynecol 2001;184:531-7.
18. Sanchez-Borrego R, Balasch J. Ethinyl oestradiol plus dl-
Prescription: 2 meclizine hydrochloride (Antivert)
norgestrel or levonorgestrel in the Yuzpe method for post-coital
25-mg tablets 1 hour before the ﬁrst ECP dose
contraception: results of an observational study. Hum Reprod
Prescription: 1 trimethobenzamide hydrochloride
19. Raymond EG, Creinin MD, Barnhart KT, Lovvorn AE, Rountree
(Tigan) 250-mg tablet or 200-mg suppository 1 hour
W, Trussell J. Meclizine for prevention of nausea associated with
before each ECP dose; repeat as needed every 6 to 8
emergency contraceptive pills: a randomized trial. Obstet Gynecol
20. Improving access to quality care in family planning. Geneva:
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SAFETY DATA SHEET ___________________________________________________________________________________ 1. IDENTIFICATION OF THE SUBSTANCE/PREPARATION AND COMPANY: _______________________________________________________________________________ SUPPLIER’S NAME PRODUCT NAME: EMERGENCY TEL. NO . PRODUCT CODE: MANUFACTURER: _____________________________________________
The Caffeine Problem Introduction In this lesson, we explore the dynamics of caffeine in the body through the use of exponential functions. Various foods and drinks popular around the world contain caffeine. Caffeine is an alkaloid compound that comes from plants, including coffee, tea, kola nuts, mate, cacao and guarana. Many people drink caffeine drinks because they like the taste of the