Emergency Contraception in Lebanon: The Morning-After Pill – The Scientific Reality

The picture making the social media rounds

This is a guest-post by Christian Sawma, a pharmacy student at the Lebanese American University, in reply to the Nasawiya post on the matter.

We need to start by differentiating between monthly contraception and emergency contraception. The monthly regimen consists of taking one pill per day, regardless of sexual encounters, in order to suppress the normal monthly period and ovulation; this regimen is used for sexually active women who are not wishing to get pregnant. On the other hand, the emergency contraception is used after an unprotected sexual intercourse in order to prevent pregnancy from happening.

The best choice of emergency contraception is a progestin only pill that increases the cervical mucus production and thickness; hence, inhibiting the sperm passage to the fallopian tubes. It is available as OTC (over-the-counter) in the United States and of course in Lebanon under the brand name of Norlevo (levonorgestrel 1.5 mg) – commonly known as the morning-after pill. The latter drug has no purpose other than emergency contraception; it cannot be used as normal monthly contraception.

Pills containing a combination of low concentration of estrogen and progesterone in one pill are used to suppress the ovulation and normal female cycle, therefore, they are used as a monthly contraceptive technique and prescribed as a once per day pill, taken at the same time every day for this purpose.

In contrast, before discovering the effectiveness of Norlevo (levonorgesrtrel 1.5 mg) as an emergency contraception technique, the regimen used was called Yuzpe (named after its founder Dr. Albert Yuzpe). It consisted of giving the combination of those low concentration estrogen and progesterone pills, discussed above, to inhibit pregnancy (before it happens) after an unprotected sexual intercourse, but they are given as multiple pills per day for the emergency contraception purpose. Now that Norlevo hasn’t been available on the Lebanese market since October 2011, the Yuzpe regimen can be used instead.

Estrogen is highly emetic (induces nausea and vomiting), and that is one of the main problems of this regimen: It consists of giving 2 or 4 tablets, of the monthly contraceptive pills, as soon as possible and repeat the same dose after 12 hours. The number of tablets to take is chosen according to the estrogen concentration in the tablets. For the 30 mcg ethinyl estradiol (EE), 4 tabs should be taken, and for the 50mcg EE, 2 tabs are advised. It is important to mention that the tablets of each dose should be taken all together and not separated.

This is a table that clarifies the aforementioned point:

Yuzpe (Microgynon 30) is effective in 75% of the cases, which is not a good statistical number, making it not a very good alternative to Norlevo. In addition, this regimen shouldn’t be followed without referring to your physician or a pharmacist and if vomiting occurs in less than 2 hours post dose, the dose should be repeated.

On the Lebanese market, a lot of brands containing 30 and 35 mcg EE are available. The one that contains levonorgestrel (Norlevo’s active ingredient) in an acceptable concentration for emergency contraception is Microgynon 30, and it is the best choice in Lebanon for a Yuzpe regimen. According to my knowledge, no 50 mcg EE is available in Lebanon for contraception.

In the case of Norlevo or combined oral contraceptive, the effectiveness is not studied beyond the 3 days period. Although the Yuzpe regimen can be given up to 5 days post intercourse, no safety and effectiveness has been proven. In addition, some studies have confirmed that beyond the initial 3 days, it’s neither safe nor effective to use Norlevo or Yuzpe (Microgynon 30).

Always refer to your physician or pharmacist before using a new drug especially if taking other drugs with it or if using it for its unlabeled use (such as in this case). In case of emergency contraception, it is important to refer to them in any case of bleeding or pregnancy post a dose of a progestin only pill, Yuzpe regimen or Ella pill, a new experimental FDA-approved drug that is not yet available in Lebanon.

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15 thoughts on “Emergency Contraception in Lebanon: The Morning-After Pill – The Scientific Reality

  1. When you write that, “Yuzpe (Microgynon 30) is effective in 75% of the cases, which is not a good statistical number, making it not a very good alternative to Norlevo”, i think we can agree that in this case its still better than no Norlevo and better than getting pregnant when you dont want to.

    Also when asking gynecologists and pharmacists, they all recommended 2 pills of Microgynon Q12hrs till you reach 8 pills, rather than 4 together. This may be because of the nausea effect. Do you know whether it diminishes effectiveness even if they are all taken within the correct timeframe?

    All in all though, Brilliant and thanks Christian Sawma!
    Im glad you went into the details of it because we need to focus on the fact that is only for emergencies and when the regular form of contraception fails.

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    • Hello Rola,
      unfortunately you will not find a clean cut answer for your questions. the Yuzpe regimen dated form the 70’s , so less and less clinical trials are made to confirm its effectiveness. In addition Norlevo effectiveness is up to 85 % with much less nausea and vomiting which makes it way more efficacious and practical. In addition, the discovery of Norlevo in the late 90’s and the Ella pill in the year 2010 will make the clinical trial go toward proving that those new regimens are much more safer than the old ones with much more efficacy.
      A relatively new study in 2003 made on Yuzpe is the one who proved the 75% effectiveness and they suggest that any modification with the regimen will further decrease its effectiveness. So for a maximum efficacy the women should stick with the time frame, dose recommended and the second dose. So when someone decides to modify the regimen for further compliance no backup studies can help him.
      Thank you for reading.

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  2. Well, the best thing to use would be a condom. If they’re afraid the condom breaks, why not use 2? One for her and one for him. Or two for him.

    The fact that there’s a discussion about emergency contraception is horrifying because it shows a lack of understanding in society when it comes to sex. Why would a woman have unprotected sex in the first place if she doesn’t want to get pregnant? If she and her boyfriend/one night stand person are that horny, pharmacies are everywhere and condoms are $1.

    If they are too lazy/in heat to go buy a condom, perhaps it’s a sign they shouldn’t be doing it in the first place.

    Just my 2 cents as Americans would say. Let the hate begin.

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    • Hello Elie,

      Your comment comes off as rather condescending, and also ill-informed. Condoms break, it’s a fact, so even if you are being careful, you might end up needing a morning-after pill. No need to judge people without knowing what their circumstances are. There will always be non-procreative sex happening, so as long as there are no 100%-sure contraception methods, there will be a need for emergency contraception. The fact that you think a discussion on emergency contraception is horrifying shows you perhaps don’t fully realize the realities of sex. Shit happens, and we need to have solutions for it. Needing the morning-after pill doesn’t mean you’re irresponsible or a “slut who deserves it.”

      Also, for the love of all things holy never wear two condoms at once! The friction will cause them to break. (http://www.health.arizona.edu/health_topics/sexual_health/usingtwocondoms.htm) So before you stop condemning people for needing emergency contraception, please don’t advocate things like this.

      Cordially,
      -C

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      • I was obviously being sarcastic when I said use two condoms.

        1) The probability of a condom breaking is 1 in 500, which is very low. A condom company does not dispense its product in the market if it doesn’t meet requirements. So if a condom breaks, it means they didn’t use it correctly.

        2) If a couple is worried about a condom breaking, they can always use spermicide with it. That should help with the problem they’re facing.

        3) Regardless of circumstances, unmarried people should always practice safe sex. Safe sex isn’t always about pregnancy. There’s a multitude of STDs that can be transmitted as well.

        4) I never used the terms “slut that deserves it” in my comment. I actually had to read it again to double check. And yeah, I think any talk about killing embryos is horrifying, even if they’re at a cell-level. Families are dying to have kids and “lucky” couples are killing theirs away.

        5) I am not preaching abstinence. But I’m saying that there are tons of couples out there who have premature sex without suffering from consequences. They must be doing something right. Those that are having trouble are ill-informed.

        Elie, seeing you’re in med school and all, have you considered blogging about this before?

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        • Apologies for misreading your sarcasm, although it’s not the clearest sentiment in the written form.

          Even if it is a 1/500 possibility of a condom breaking, this obviously does not mean it’s impossible. Of course there are instances when people use condoms incorrectly and they break, which is why there’s a need for a plan B in the first place. This is not just about people mindlessly copulating without protection, although there are undoubtedly people who do.

          I’m afraid our opinions diverge on your fourth point, but I don’t think we need to start the thousandth debate on the topic on the Internet.

          I agree with you that combining contraceptive/sexual protection methods is the best thing to do, but this also requires widespread, unbiased, complete sexual education addressing these topics. Unfortunately, this is not the case, either in Lebanon or a lot of places, including America. I feel wary blaming people for being ill-informed on the topic of sex, as there are numerous, contradictory sources on the topic, and depending on your upcoming, you might not have all the necessary information or have been raised with a proper understanding of how to protect yourself and your partner. In the meantime, I still believe that emergency methods of protection are going to remain necessary.

          Sincerely,
          -C

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  3. why we don’t have an alternative of norlevo in Lebanon , there is many morning after pills , why do we only have only norlevo ???
    I think it’s a very important subject, and we don;t need to judge the people nor their circumstances , and for these closed minded judgmental people out there what about women who been raped , why do they have to go through abortion ??? don;t every women need to have the choice ???
    why limit our choices ??? why this subject isn’t mentioned anywhere , are we ashamed to admit its importance ?? i myself wrote to the mtv about this subject and i hope many do so we can create some awareness about this subject , i pity the person who implied that only women are responsible about accidents , so much ignorance !!!

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  4. Though this an old thread I wanted to add that the copper IUD can also be used as emergency contraception (and is in fact the most effective of all EC methods) within 5 days after unprotected intercourse (a woman can then keep it as longterm contraception or not, either way in the long run it is beneficial and cost effective, costs much less than plan B). The problem of course can be finding a provider to insert it in a timely fashion and not be delayed by clinic wait times. There are many organizations that can provide it at little to no cost depending on financial vulnerability in Lebanon.

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