Thursday, December 08, 2005

as promised...

As I said in the Comments of Gina’s post on Target:

Ok guys, I am writing an entire post on this but let's be clear:

I hit MicroMedex (drug db) yesterday. The emergency contraception under scrutiny (not that I can find the policy outlined on Target's website) is NOT, repeat, NOT an abortifacient. IT DOES NOT CAUSE AN ABORTION. It prevents ovulation, meaning it may help prevent pregnancy JUST LIKE any other form of birth control prevents pregnancy. It CANNOT TERMINATE a pregnancy.

RU-486/mifepristone (or methotrexate) are used to cause a "medical" (as opposed to surgical) abortion.This is NOT the "morning-after pill." This is indeed an abortifacient and is approved by the FDA for such usage.

But the prescriptions under discussion in the Target case (also known as "the morning-after pill", admittedly confusingly so-called) are just normal everyday birth control pills.

SL, your friends who do not prescribe EC because they believe it causes an abortion are misinformed or are not being clear in their explanations. I respectfully would be interested in hearing their position on normal birth control methods and if they will indeed fill *those* prescriptions. And Gina, I would love to find out exactly what Target's policy is on both drugs, so if you find out more, please let me know.


After some extensive research here is what I emerged with.
I present what facts I can in the interest of helping you make up your own minds. (Please keep in mind that I am a medical librarian by training, forgive me if this is too technical. I think I made it pretty clear but please feel free to question or comment.)

In interest of full disclosure, it does seem to me that:
If you have taken or do take normal birth control pills, taking the “morning-after pill” should be morally acceptable to you, following a logical train of thought. Its actions are physically, mechanically, the same.

I am under the impression (but don’t know for sure and that is what I expressed above to Gina) that what is under debate is instead what I found to be called “emergency contraception” - the “morning after pill,” or Plan B. These are, chemically, levonorgestrel or norethindrone – the agents constituting typical birth control pills.

RU-486 IS NOT the “morning-after pill” and is indeed, straight-up, without argument, an abortifacient. It CAUSES an abortion to occur. I believe that this is not the drug under debate or being disputed in Target’s case. If/when I learn otherwise, you will be the first to know.

Here is the FDA info on emergency contraception:
(I don’t much care if it’s prescription or OTC; for the purposes of this post, the issue is its availability through pharmacies.)


Emergency contraception has been an off-label use of oral contraceptive pills since the 1960s…The mechanism of action may vary, depending on the day of the menstrual cycle on which treatment is started… If a woman becomes pregnant after using emergency contraception, she may be reassured about the lack of negative effects emergency contraception has on fetal development.
[Weismiller DG. Emergency contraception. American Family Physician. 2004 Aug 15; 70(4): 707-14.]


Now here is where the issue gets murky. Read carefully. There is much food for thought here, and I hope I covered everything fairly and even-handedly, to help you form your own informed opinion. Please let me know if you feel something needs to be clarified further.

( Gynecologists define the beginning of pregnancy as the implantation of a fertilized egg in the lining of a woman's uterus. Implantation begins five to seven days after fertilization (and is completed several days later). Emergency contraceptives work before implantation and not after a woman is already pregnant. Depending on the time during the menstrual cycle that they are taken, ECPs may inhibit or delay ovulation, inhibit tubal transport of the egg or sperm, interfere with fertilization, or alter the endometrium (the lining of the uterus), thereby inhibiting implantation of a fertilized egg.

( As a birth control agent, the Pill has three modes of operation: (1) it may suppress ovulation, (2) it may thicken the cervical mucous to block sperm passage, and/or (3) it may cause an abortion by making the uterine lining hostile to implantation. The original high-dose birth control pills had high rates of suppressing ovulation, but in an effort to reduce unwanted side-effects, manufacturers have reduced the dosage levels. As a result, the newer "low-dose" birth control pills are less effective at suppressing ovulation and more dependent on mode of operation number three: abortion by blockage of implantation. The "morning after pill" is a continuation of the trend toward more "birth control" through drug-induced abortion.


Birth control pills - I used brand names Micronor (progestin only) and Ortho-Novum 1/35 (progestin and estrogen) to search; these summaries include ALL estrogen and progesterone oral contraceptives (which contain in various dosages levonorgestrel (Plan B) and norethindrone)).

US PDI (Micronor):The low-dose progestins for contraception are used to prevent pregnancy. Other names for progestin-only oral contraceptives are minipills and progestin-only pills (POPs). Progestins can prevent fertilization by preventing a woman's egg from fully developing. Also, progestins cause changes at the opening of the uterus, such as thickening of the cervical mucus. This makes it hard for the partner's sperm to reach the egg. The fertilization of the woman's egg with her partner's sperm is less likely to occur while she is taking, receiving, or using a progestin, but it can occur. Even so, the progestins make it harder for the fertilized egg to become attached to the walls of the uterus, making it difficult to become pregnant.

US PDI (Ortho Novum):This medicine usually contains two types of hormones, estrogens and progestins and, when taken properly, prevents pregnancy. It works by stopping a woman's egg from fully developing each month. The egg can no longer accept a sperm and fertilization is prevented. Although oral contraceptives have other effects that help prevent a pregnancy from occurring, this is the main action.
Sometimes a woman's egg can still develop even though the medication is taken once each day, especially when more than 24 hours pass between two doses. In almost all cases when the medicine was taken properly and an egg develops, fertilization can still be stopped by oral contraceptives. This is because oral contraceptives also thicken cervical mucus at the opening of the uterus. This makes it hard for the partner's sperm to reach the egg. In addition, oral contraceptives change the uterus lining just enough so that an egg will not stop in the uterus to develop. All of these effects make it difficult to become pregnant when properly taking an oral contraceptive.

Clinical Pharmacology: Mechanism of Action: The primary contraceptive effect of progestins involves the suppression of the midcycle surge of LH. The exact mechanism of action, however, is unknown. At the cellular level, progestins diffuse freely into target cells and bind to the progesterone receptor. Target cells include the female reproductive tract, the mammary gland, the hypothalamus, and the pituitary. Once bound to the receptor, progestins slow the frequency of release of gonadotropin releasing hormone (GnRH) from the hypothalamus and blunt the pre-ovulatory LH surge, thereby preventing follicular maturation and ovulation. Overall, progestin-only contraceptives prevent ovulation in 70—80% of cycles, however, the clinical effectiveness ranges 96—98%. This suggests that additional mechanisms may be involved.[Emphasis mine – BB] Other actions of norethindrone include alterations in the endometrium that can impair implantation and an increase in cervical mucus viscosity which inhibits sperm migration into the uterus. The administration of norethindrone to women with adequate estrogen production transforms the uterus from a proliferative to a secretory phase.

US PDI (Levonorgestrel, aka Plan B): At the cellular level, levonorgestrel diffuses freely into target cells and binds to the progesterone receptor. Target cells include the female reproductive tract, the mammary gland, the hypothalamus, and the pituitary…. Levonorgestrel converts a proliferative endometrium into a secretory one in women with adequate estrogen replacement, reducing endometrial growth... Amenorrhea occurs in most women after more than 12 months of continuous transdermal estrogen-levonorgestrel application.


Now, here’s the drug info on what we commonly call RU-486, chemically known as mifeprestrome. This is NOT the medication typically prescribed as EC. This is CLEARLY an abortifacient. There is no argument about that.

Micromedex (Mifeprestrome/antiprogesterone):Mifepristone is indicated for use in the termination of pregnancy (through day 49 of pregnancy) and has no other approved indication for use during pregnancy…MECHANISM OF ACTION …The abortifacient action of mifepristone is thought to be mediated through antiprogesterone effects on endometrial progesterone receptors. When administered during the luteal phase, the antiprogesterone effects induce menses and permit the release of prostaglandins from the endometrium … If mifepristone is used before 56 days of amenorrhea, spontaneous abortion usually occurs and does not require surgical evacuation of the uterus for retained products of conception…
[In addition, FYI- BB] Emergency contraception - Postcoital contraception a) Both mifepristone 10 milligrams (mg) and 25 mg have been shown to be effective in preventing pregnancies up to 120 hours after unprotected sexual intercourse (Xiao et al, 2002).


I leave you with a quote from this article about the initial Target brouhaha,
In allowing workers to deny prescribed medications to customers based on religious beliefs, the chain joins a growing number of businesses that permit employees to trump national law, patients’ needs and doctors’ recommendations.


If you want my *detailed* opinion on all aspects of this issue, just email me. I am not being cagey, I am just trying to be even-handed and fair. I tried to use objective, clinical sources for my information. I hope I shed some light on the controversy.


Joke said...

I seriously appreciated the even-handedness and fairness in your post.

As far as I was able to find out at Target (I have a friend who works highish-uppish there) the policy is not to require an employee to do something that contravenes "deeply held moral/religious standards" (those are her words and not official policy) but to have personnel capable of providing the service/dispensing the product thereby serving the client. That is to say if Bob The Jewish Guy won't serve you a ham sandwich, they'll get Tom The Methodist Guy who will.

However, to someone who is a practicing Catholic, dispensing a product for the purposes of prevents implantation (remember, Catholic teaching is that life begins at conception) is equivalent to dispensing an abortifacient, which is equivalent to assisting/providing an abortion and therefore an excommunicable offense.

If I am misreading the information on the emergency contraception, please forgive me and, more importantly, please correct me. I have a strange fetish for being properly informed.

I expect our views on this (and lots more!) are diametrically apart, but I appreciate your tone and thoroughness in this post, and your goodness and decency as a human being in general.

And I am not opening my gift until Christmas.

Sarah Louise said...

What Joke said, mainly, although not completely. I am soooo glad

(exscuse the pause, I was watching Ellen's monologue about eating and I swallowed my cranberry juice wrongly)

that we have such a great bunch of folks here at "Behind the Stove." Merry Christmas, one and all!

grwepp: grinch went everywhere pink pink pink (had to add the third pink for effect)

Gina said...

Thanks for the info, Val. You loved having a reason to do some research, didn't you?

Joke's point about his Target friend and the ham sandwhich is okay, but . . . practically speaking, there is rarely more than one pharmacist working at a time. It's not like the scripts come in and Jack can say, "I'll take this one, Mary Margaret, because I know you don't want to fill it."

Can a tech do it? A student? I'm not sure whose responsibilty is what behind that high counter . . .

BabelBabe said...

i live to do research. good thing i finally figured this out and became a librarian (Poof! You're a librarian!)

here's what i find so interesting:

joke, your point about the RC church's teachings on conception is what makes the whole issue so controversial, as you pointed out. if everyone believed the implantation=pregnancy thing, there'd be no issue at all.

Joke said...

I'm not arguing what should be or not be, just explaining what is. In practical terms, Target is over a barrel, because the first time they compel someone to do this they will be slapped with a gazillion dollar lawsuit and one which they would have a difficult time winning and would be a pyrrhic victory even if they won.

Most Targets have 2-3 available at any given moment to fill prescriptions and so it would seem the real-world result should be not a very big deal.

But to take this one step further, what troubles me--and I realize it is only me--is the need/want to look for reasons to "take our business elsewhere."

We don't have to rummage very hard to find businesses who actively take positions with which we REALLY disagree. (At least *I* don't. Hell, I can rattle off at least 20 without having to have anything brought to my attention or doing the slightest research.)

But I made a choice not to go down that road because eventually I'd have to stitch my own shoes and forage for my own food. To say nothing of the fact that people are really entitled to their views and only in extreme cases should I withhold my consumer dollars. (Say, Citgo being used to funnel funds to FARC terrorists in Colombia.)

I think it indicative of an increasingly embittered national mindset to seek out reasons to be angry and punish those with whom we disagree. If we wish for others to change their mind about Subject X, it would seem to me the best course of action is to remain engaged and persuasive.

Your mileage may vary,

-J., who really does love you guys even if he is a raving Goldwater-ite

Sarah Louise said...

from Joke: But to take this one step further, what troubles me--and I realize it is only me--is the need/want to look for reasons to "take our business elsewhere."

Joke, you are so good at eloquently saying what I try to. I *have* stopped going to Citgo, but I pretty much refuse to refuse to shop at places because I disagree with their politics. I hate the idea of becoming a sub-culture. I want to be out there in the marketplace. As a Christian, I know a lot of people (some who are friends) who *are* entrenched in sub-cultures, don't listen to the radio or news or music unless it's on the Christian station, don't watch a lot of TV, won't read certain authors, etc. When Jesus said "I have come so they may live life more abundantly" (John 10:10) I don't think that's what he was talking about. Heck, I could do a whole post on this (hey, maybe I will.) And maybe I need to do more research on Goldwater, Joke.

Joke said...


If I were the sort of guy who defaced innocent automobiles with bumper stickers, I'd get one that read "Don't Blame Me, I Voted For Goldwater."

Which is a rhetorical, rather than factual statement, seeing as how I was 7 months at the time, rather under the minimum voting age.