Emergency contraception (MAP) without a medical prescription : luxury or necessity ?

1. Emergency contraception (MAP) without a medical prescription : luxury or necessity ? E. Aubény French Association for ContraceptionParis - France

2. Yuzpe method (EE + levonorgestrel) : less efficacy and medical contra-indications. It has been abandoned Levonorgestrel alone : more efficacy, no contra-indication : Reference as emergency contraception E.C. (MAP) without a medical prescription : luxury or necessity ? Currently two hormonal methods for emergency contraception (E.C.) E. Aubény, French Association for Contraception

3. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? E. Aubény, French Association for Contraception

4. % E.C. (MAP) without a medical prescription :luxury or necessity ?Levonorgestrel E.C. Emergency contraception is more efficient when takenvery quicklyafter unprotected intercourse (WHO) E.C. is a real emergency it must be used very quickly E. Aubény, FrenchAssociation for Contraception

5. E.C. (MAP) without a medical prescription :luxury or necessity ? A doctor’s prescription 1 - Delays the use of medicationbecause of the waiting time for an appointment 2 - Prevents women from using E.C. Women find this process too complicated for the prevention of an hypothetical pregnancy E. Aubény, FrenchAssociation for Contraception

6. It can be safely used without a medical prescription E.C. (MAP) without a medical prescription : luxury or necessity ? a doctor’s physical or gynaecological exam is not needed for E.C. Levonorgestrel E.C. has no contra-indication E. Aubény, FrenchAssociation for Contraception

7. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Levonorgestrel E.C.without a medical prescription : • June 1999theFrench health authorities by decree have allowed levonorgestrel E.C.without a medical prescriptionin pharmacies for everybody, including minors This decision was contested by Pro-Life organisations December 2000 a law was passed to confirm this decision E. Aubény, FrenchAssociation for Contraception

8. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? . Levonorgestrel E.C.sale without a medical prescription It isnow authorised in many countries  Pharmacies Belgium Denmark Finland France Portugal U.K. Switzerland Slovenia Latvia Quebec South Africa  Drugstores Norway Sweden Europe

9. Levonorgestrel E.C.sale with a medical prescription Levonorgestrel E.C. without a medical prescription :luxury or necessity ? In some countries a medical prescription is needed There is no medical reason to deliver levonorgestrel E.C. on medical prescription (ESC Seminar, September 2003) There are only political reasons E. Aubény, FrenchAssociation for Contraception

10. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Results of 4 years of levonorgestrel E.C. without a medical prescription in France E. Aubény, FrenchAssociation for Contraception

11. Levonorgestrel E.C. without a medical prescription : luxury or necessity ?4 years of French experience Levonorgestrel E.C. can be bought • without a medical prescriptionin pharmacies by everybody at a price of 7 euros • whith a medical prescriptionin pharmacies at the price of 7 euros and it is reimbursed by social insurance at 65 % E. Aubény, FrenchAssociation for Contraception

12. Levonorgestrel E.C. without a medical prescription :luxury or necessity ?4 years of French experience Results Acceptability by women • First hormonal contraceptive available without a prescription • Women were informed about the availability of non-prescription E.C. by magazines, radio, newspapers and T.V. • E. Aubény, French Association for Contraception

13. Levonorgestrel E.C. without a medical prescription :luxury or necessity ?4 years of French experience Results Acceptability by women Women use E.C. in a proper way, as E.C., not as a regular contraception (contraceptive pill sales keep on rising) E.C. meets a real need • 85 000 women use iteach month, more than 1 000 000 each year • Women have adopted this method by themselves80 % without a medical prescription, 20 % with a medical prescription E. Aubény, French Association for Contraception

14. Levonorgestrel E.C. without a medical prescription : luxury or necessity ?4 years of French experience Results Acceptability by women In countries where levonorgestrel E.C. needs a medical prescription, women use it very little August 2002 users : Germany (with a medical prescription) : 9 000 Austria (with a medical prescription) :1 800 France, U.K. (without a medical prescription) : 85 000 Delivery of levonorgestrel E.C. without a medical prescription facilitates its use E. Aubény, FrenchAssociation for Contraception

15. Levonorgestrel E.C. without a medical prescription :luxury or necessity ?4 years of French experience ResultsMedical problems • Post-marketing surveillance has receivedno complaint • No medical publication about complications • No increase in ectopic pregnancies (French Drug Agency) Nomedical problem for 4 years in France E. Aubény, FrenchAssociation for Contraception

16. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Results Acceptabilityby pharmacists At the beginning, some of them Felt that they had inadequate information about the drug  Had ethical doubts with the drug  Felt that it was too much responsibility Now,the majority is very pleased to have this responsibility and to be included in the contraception development E. Aubény, FrenchAssociation for Contraception

17. Levonorgestrel E.C. without a medical prescription :luxury or necessity ?4 years of French experience ResultsPrevention of abortion In France, in 2000, for the first time, one year after the selling of levonorgestrel E.C.without a prescription, a slight decrease has been noticed in the number of abortions Coincidence or beneficial effect of this decision ? It is too early to arrive at a conclusion E. Aubény, French Association for Contraception

18. Levonorgestrel E.C.without a medical prescription : luxury or necessity ?4 years of French experience Four years later the authorisation to deliver levonorgestrel E.C. without a medical prescription appears in France to be a very good measure E. Aubény, French Association for Contraception

19. Levonorgestrel E.C.without a medical prescription : luxury or necessity ?French experience Twospecific French dispositions for easy accessibility to emergency contraception for adolescents E. Aubény, French Association for Contraception

20. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Interest of E.C. for adolescents Stastistics show :  In France the average age of first sexual intercourse is 16 It is a fact : French adolescents are sexually active French society has to help adolescents to protect against unwanted pregnancies and STD E. Aubény, French Association for Contraception

21. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Interest of E.C. for adolescents When sexual activity starts at adolescence • Contraceptive information not always accurate (Ogino method, no risk the first time…) • Problems with contraceptive methods • difficulties in using condoms properly • forgotten birth control pills E. Aubény, French Association for Contraception • Interest of post-sex contraception : • emergency contraception

22. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Interest of E.C. for adolescentsAdolescence is the age of - Crushes - Living in the present time - Intermittent intercourse - Intercourse more or less forced So unexpected, unprotected sex happens • Interest of post-sex contraception : emergency contraception • E. Aubény, French Association for Contraception

23. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Interest of E.C.for adolescentsAccessibility E. C., so useful for adolescents,to be used by them should be easily accessible • Ease of use • Rapidity of use How to make it very easily accessible ? E. Aubény, French Association for Contraception

24. E. Aubény, French Association for Contraception Levonorgestrel E.C. without a medical prescription : luxury or necessity ? First French disposition for easy accessibility for adolescents • Levonorgestrel E.C. free delivery • in high schools by school nurses • The nurse can deliver levonorgestrel E.C. • only if it is impossible to have a quick appointment with a doctor or to go to a pharmacy

25. ForNurses,Pupils, parents associations Public opinion in France Supports this practice(63% in favour) The decisionwas more or less accepted Levonorgestrel E.C.without a medical prescription : luxury or necessity ? Levonorgestrel E.C. delivered by high school nurses At the beginning This decision was contested, but a law enforced it in December 2000 E. Aubény, French Association for Contraception

26. Levonorgestrel E.C. without a medical prescription :luxury or necessity ? Levonorgestrel E.C. free delivery by high school nurses Results September 2001/September 2002 : - 9 735 received it (preventing many unwanted pregnancies) - Itallowed discussionsbetween nurses and the studentson contraception and on any sexual matter E. Aubény, French Association for Contraception

27. Levonorgestrel E.C.without a medical prescription :luxury or necessity ? Second French disposition for easy accessibility for adolescents : Levonorgestrel E.C.free delivery in pharmacies for minors The law passedin December 2000 came into effect in January 2002 E. Aubény, French Association for Contraception

28. Levonorgestrel E.C. without a medical prescription :luxury or necessity ? Levonorgestrel E.C. free delivery in pharmacies for minors • Minors just have to ask for it : no identity control • Pharmacists have - to councel minors - to give a leaflet about E.C. - to dispence E.C free.to minors. They are refunded by Health Insurance s Difficulties of implementation : pharmacists are afraid to speak with youngsters

29. Levonorgestrel E.C.without a medical prescription : luxury or necessity ?4 years of French experience Unexpected beneficial consequences of 4 years of levonorgestrel E.C. without a medical prescription E. Aubény, French Association for Contraception E. Aubény, French Association for Contraception

30. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experienceUnexpectedbeneficial consequences of levonorgestrel E.C. without a medical prescription 1) Renewed interest in contraception particularly about non compliance with regular contraception 2 national campaigns in favour of contraception Study on contraception failure and non compliance E. Aubény, French Association for Contraception

31. Levonorgestrel E.C. without a medical prescription : luxury or necessity ?4 years of French experienceUnexpectedbeneficial consequences of levonorgestrel E.C.without a medical prescription 2) Involvementofnew healthprofessionals in contraception - Pharmacists - High school nurses They get interestedin regular contraception. The majority is very pleased to have this responsibility and to be involved in the contraception development E. Aubény, French Association for Contraception

32. Levonorgestrel E.C.without a medical prescription : luxury or necessity ?4 years of French experienceUnexpectedbeneficial consequences of levonorgestrel E.C. without a medical prescription 3) Liberalization of regulation on contraceptive drugs Before emergency contraception without a medical prescription, all contraceptive drugs needed a medical prescription Now (by law) new contraceptive drugs with no known medical contra-indications will be sold without a medical prescription E. Aubény, French Association for Contraception

33. Levonorgestrel E.C. without a medical prescription : luxury or necessity ?4 years of French experienceUnexpectedbeneficial consequences of levonorgestrel E.C without a medical prescription Levonorgestrel E.C. delivered by high schoolnurses and free in pharmacies for minors - opened the discussion about teenagers sexuality and contraception in the society - obliged to its recognition This recognition is the best way to prevent abortion and STD among adolescents E. Aubény, French Association for Contraception 4) Recognitionofteenagers sexuality

34. Levonorgestrel E.C.without a medical prescription : luxury or necessity ? Others’ experiences of levonorgestrel E.C. without a medical prescription : • In U.K. in spite of a very high price (32 euros) each month 85 000 women use it : it meets a real need • In Finland during the second trimester of 2002, the time when levonorgestrel E.C. without a medical prescription started, the minor abortion rate decreased by 30 % E. Aubény, French Association for Contraception

35. Levonorgestrel E.C.without a medical prescription : luxury or necessity ? Conclusion From 4 years of French experience oflevonorgestrel E.C. without a medical prescription - is safe from a medical point of view - allows a large and safe use - is needed by women who use it properly and not as a regular contraception - is very useful for youngsters E. Aubény, French Association for Contraception

36. Levonorgestrel E.C.without a medical prescription : luxury or necessity ?Conclusion Levonorgestrel E.C.without a medical prescription is essential for women It makes it possible for them to have a better protection E. Aubény, French Association for Contraception