Sometimes things seem a little clearer in the daylight the morning after – after a night of unprotected sex or ‘an accident.’ When that happens – and it often does – there’s a Plan B for the morning after, a plan that can help prevent a potential pregnancy and that many find at Syracuse University Health Services.

It’s quite a frequent stop for many SU women.

Syracuse University Health Services prescribes Plan B, ‘the morning-after pill,’ 40 to 70 times each week – that’s somewhere between 1,350 to 2,250 times a year – mostly to freshmen and sophomore women, according to estimates provided last fall by Kathy MacLachlan, a certified nurse practitioner in the women’s health department of Health Services. These numbers do not correspond to the precise number of women who visit Health Services, since some of them visit two times or more. Plan B is 89 percent effective at preventing pregnancy after unprotected sex if it is taken within 72 hours.

Some 10 to 15 doses of it are prescribed every Monday, Thursday, Friday and Saturday, MacLachlan said. Zero to five are prescribed on Tuesdays and Wednesdays, and zero to two are prescribed by phone on Sundays, when Health Services is closed. There are only two reasons why a woman would be refused Plan B, MacLachlan said: unexplained vaginal bleeding or if she’s already pregnant.

‘We do have days when there are zero (prescriptions written),’ MacLachlan said. ‘But not too many.’

Other universities were quick to provide the exact numbers of Plan B prescriptions they write – numbers routinely much lower than what SU prescribes. But Health Services Director James Jacobs declined to release specifics, saying patient confidentiality was tantamount.

Not every woman needs Plan B because she has been careless, MacLachlan said. In fact, probably six in 10 women request it just to be extra-cautious, she said; they may have concerns about a missed birth control pill or have doubts about condoms’ effectiveness. MacLachlan estimated another three in 10 women need Plan B because they did not use any contraception at all, were not consistent with it or used it incorrectly. One in 10 cases, she said, are related to alcohol consumption and have the potential for involving non-consensual sexual activity.

According to Plan B’s vendor, Health Services is the largest provider of it in the county, said Philip Ferro, a specialist in contraceptives and clinical professor of obstetrics and gynecology at the State University of New York Upstate Medical University.

SU’s estimate of the number of women who seek Plan B because they did not use contraception at all or because they weren’t cautious or were careless seems low, Ferro said, especially since most women do not use contraceptives the first time they have sex.

Plan B is a super-dose of progestin, which is the synthetic version of progesterone, the female hormone that prepares the uterus for pregnancy. Plan B works by preventing or changing when the egg is released from the ovary and by changing the lining of the uterus to make it more difficult for a fertilized egg to implant, Ferro said. It can also make the uterus less friendly to sperm cells.

While its effectiveness decreases if taken more than 72 hours after unprotected sex, it does not go to zero for weeks, Ferro said.

Recently, Plan B has been the center of great controversy, the roots of which go back to 2003, when Barr Laboratories, which produces the drug, applied to make it available over the counter so that pharmacists could dispense it. Currently, Plan B is only available by prescription from a doctor.

On Aug. 26, 2005, the Food and Drug Administration postponed a decision on the application, which would have made it available without prescription to women ages 17 and older. An independent FDA review board had recommended the pill for over-the-counter availability in December 2003, saying it was effective and caused no significant negative side effects.

Susan F. Wood, FDA assistant commissioner for women’s health and director of the Office of Women’s Health, resigned in frustration and protest five days after the postponement.

The postponement started a rule-making process, which began with a two-month period of public comment. This period ended on Nov. 1. The comments are now being reviewed before the application is altered and reviewed again by various levels of federal government and FDA officials.

‘The decision that came down was essentially a no without saying no by going into a rule-making period which is essentially a black box,’ said Wood, who estimates the rule-making process could last at least five years. ‘It’s putting it on the shelf forever.’

Proponents of Plan B say that making it available over the counter would lower the rate of abortions and unintended pregnancies, especially for teenagers. Critics disagree and say it would do neither. In fact, they argue it could increase sexually transmitted diseases by encouraging promiscuity and unsafe sex. They say Plan B is similar to abortion.

An unscientific survey of 463 women on the SU campus – conducted by a reporting class at the S.I. Newhouse School of Public Communications – suggested Plan B was very widely used and for many reasons, by students both reckless and cautious. Some 122 women surveyed, or approximately one in four, said they had used some form of emergency contraception at some point. The survey sampled women from residence halls, South Campus, off-campus and greek housing.

Of the women who had turned to emergency contraceptives, 43 percent said they had not used any birth control and 45 percent said the condom they used broke. Two of the women said the sex was non-consensual. One in three acknowledged alcohol or other drugs were in some way to blame for their need to turn to the morning-after option.

MacLachlan acknowledged traffic was heavy through Health Services.

‘We have no problem dispensing (our supply) within the shelf life,’ she said.

Plan B should not be used as a substitute for regular birth control, but it is a terrific after-the-fact option, said Marilyn Keefe, vice president of public policy at the National Family Planning and Reproductive Health Association.

‘It’s no secret that college students tend to have a great deal of unplanned, unprotected sexual activity, so it doesn’t surprise me that demand for emergency contraception is high at Syracuse,’ she said. ‘Emergency contraception is now regarded as an essential part of preventive health care that I would recommend every sexually active student keep in her nightstand or medicine cabinet … not as the first line of defense against unplanned pregnancy, but as a backup method.’

Joan DeWitt, a representative at the Plan B Information Center that is run by the drug’s maker, Barr Laboratories, said the number of prescriptions written each day at SU Health Services was not shocking.

‘That number seems like an awful lot,’ DeWitt said, ‘but it doesn’t surprise me.’ However, she added, ‘Women should be on a standard type of birth control instead of using Plan B all the time.’

A large percentage of emergency contraception prescriptions are written for women immediately after their first sexual encounter, when most women do not use contraception, Ferro said.

”It just happened.’ I’ve heard that phrase a million times in my career,’ Ferro said. ‘It didn’t just happen. It was building up and you just didn’t recognize the point of no return.’

The minimum estimated number of prescriptions written each week at Health Services matches what’s reported by Planned Parenthood of Syracuse, which prescribes about 40 pills a week, according to a Planned Parenthood nurse who would speak only on condition of anonymity, which is the organization’s policy.

The average customer at Planned Parenthood is high school or college age, 16 to 22 years old, she said.

Planned Parenthood charges $30 for Plan B; SU Health Services charges $32. The slightly lesser cost and somewhat greater confidentiality and anonymity may be reasons why some students prefer Planned Parenthood, the nurse said.

‘Maybe they think it’s more anonymous to go to Planned Parenthood,’ she said. ‘We don’t ask them for an address, phone number or anything. Just get their date of birth and their name.’

Sexual Assaults and Plan B

The questioning sometimes reveals a potential assault or rape, MacLachlan said, estimating that one out of every 10 Plan B requests is a product of questionable consent. If a patient says drugs or alcohol were involved, the case is treated as a potential rape.

‘The patient is not always sure that it was consensual or not, but in that case we kind of treat that as possible assault,’ MacLachlan said.

Janet Epstein, associate director of the Rape: Advocacy, Prevention and Education Center on campus, said she doubts many of those cases are actually rapes, since a person can have a few drinks but not actually be drunk.

‘If a woman is identifying it as consensual when alcohol was consumed,’ Epstein said, ‘you have to ask what is the relationship with the person who they had sexual contact with. There could clearly be consent before alcohol.’

Though the number of rapes is probably lower than a figure such as one in 10, some of the women who come in for Plan B have indeed been raped, she said.

‘There could be some,’ Epstein said, ‘some who are unclear – they might not have said no, but they didn’t say yes.’

The R.A.P.E. Center sees about 30 women a year, though only about half come in during the three-day peak effectiveness period for emergency contraceptives, Epstein said. During the 2004-2005 academic year, about half of these women said alcohol was involved in their rape, she said.

According to the Newhouse class survey, two women – or 1.6 percent of the 122 who reported using Plan B – said their sex was non-consensual.

The use of any sort of drug or alcohol distorts decision making, including decisions about sex, said Susan Scholl, director of SU’s Substance Abuse Prevention and Health Enhancement office. She said most of the students involved in SAPHE’s Options program, which educates them about the effects of drug and alcohol use, are men; the program does not include many women who complain about or discuss sexual behavior that occurred while they were intoxicated, she said.

A substitute for birth control

Sexual assaults aside, 90 percent of requests for Plan B at SU Health Services are due to broken condoms, missed birth control pills or no use of contraception at all, MacLachlan said. Approximately 30 percent of customers haven’t used any birth control, she said.

The numbers do not surprise Maureen Thompson, SU professor of nursing.

‘The (National Institutes of Health) reports that rates for women who opt not to use birth control have risen from 5.2 percent to 7.4 percent, thus increasing the risk for unintended pregnancy,’ Thompson said.

People in the United States are dangerously naive about contraception and sex, Ferro said. He said he once treated a young woman who became pregnant after her first sexual encounter. She had chosen not to use contraception because she said her high school health teacher told the class women do not get pregnant the first time.

‘It’s mind-boggling how unrealistic people are,’ he said.

Though the National Family Planning and Reproductive Health Association advocates family planning and healthcare services, the heart of its advocacy, Keefe said, focuses on improving access to birth control services.

‘I think broader availability of (emergency contraception) is a step in the right direction,’ Keefe said, ‘but the long-term goal would be for sexually active individuals to use more effective contraceptive options in advance of need.’

The most frequent complaint by women seeking Plan B at SU Health Services is a broken condom, MacLachlan said. In the reporting class’ survey, 63 percent of women said their partner regularly used a condom. The 45 percent who said they’d sought emergency contraception because the condom broke would not surprise some experts.

According to recent studies, most women and men do not know how to put a condom on correctly, and that severely decreases its effectiveness, said Nancy Jasper, a consultant for Barr Laboratories and an obstetrician in New York City.

The most common reasons condoms break is because they are either put on wrong and have no air space at the tip or the woman is not aroused enough and the friction causes the condom to break, Ferro said.

A 2002 study of heterosexual college men’s condom use, conducted by the American Sexually Transmitted Diseases Association, found 40 percent did not leave space at the tip and 30 percent put the condom on upside down. These errors, the study found, were associated with breakage and slippage.

Even if used correctly, condoms are only 90 percent effective, while birth-control pills are 99 percent effective, Ferro said.

MacLachlan estimated 15 to 20 percent of Plan B users become multiple-time consumers of the emergency contraceptive. Though there are no negative side effects to repeated use, MacLachlan and the other health professionals all said it is important to counsel repeat users on safer and more effective regular birth-control methods.

‘If I flip back and see they’ve been given Plan B two or three times this semester, and occasionally two or three times since their last menstrual cycle, we’ll have a lengthy discussion about getting a full exam,’ MacLachlan said. ‘There’s a difference between knowing (Plan B) is available and knowing what it’s intended for.’

The women who abuse emergency contraceptives are the minority, said Jasper, the Barr consultant.

‘It is the rare case of the woman who is using nothing and who is cavalier enough to say ‘I’ll just use emergency contraceptive,” she said, adding that she sees few multiple users. The higher number at SU, she said, may be attributed to college students’ attitudes toward sex.

 

Published on January 15, 2006 at 12:00 pm