The Morning-After Pill: How Can The New York Times Be So Sure?

Posted by Mark Abramowicz, M.D.

Oral emergency contraceptives (morning-after pills) have become political footballs because of a possible mechanism of action mentioned in their labeling. We last reviewed this subject in a January 10, 2011 Medical Letter article on Ella. The reason for bringing it up here and now is an article and subsequent editorial in The New York Times titled “Abortion Qualms on Morning-After Pill May Be Unfounded” (Pam Belluck, June 5, 2012) and “How Morning-After Pills Really Work” (editorial, June 8, 2012).

Both the progestin levonorgestrel (Plan B) and the progestin receptor modulator ulipristal (Ella) can delay ovulation, and that is thought to be their primary mechanism of action.The issue is whether they could also interfere with implantation of a fertilized ovum. If they did, some social conservatives would consider them abortifacients, even though the usual definition of an established pregnancy is that it begins with implantation. The labeling for these 2 agents varies slightly, but says in effect that their mechanism of action is probably delay of ovulation, but that they also cause endometrial changes that could interfere with implantation. The article in the Times says that “…an examination by The New York Times has found that the federally approved labels and medical Web sites do not reflect what the science shows.” In commenting on the FDA’s approval of the language in the levonorgestrel label, the editorial says: “There was no evidence to support that view at the time, and there is none to support it now.”

Both levonorgestrel and ulipristal cause changes in the endometrium. There is evidence that such changes could prevent pregnancy after fertilization, and there is no way to prove that they could not (see J. Trussell and B. Jordan, Contraception 2006; 74:87). Distorting the truth in an editorial is one thing. Distorting it in product labeling or in what we tell patients is another. I hope the FDA and all of us can stand our ground, even if that causes some difficulty for one party or the other in achieving their social goals.

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