Letters to the Editor
Emergency Contraception: A Potential Solution
editor's note: The following was originally published in Diary From a Week in Practice in the February 15, 2004, issue of American Family Physician: KS felt that she had failed this 16-year-old young woman, who had just discovered that she was pregnant. The teenager had been in the office twice during the previous year, each time for a mild upper respiratory infection. Both times she admitted to being sexually active. KS had counseled her about birth control methods, including condoms, which have the added benefit of preventing sexually transmitted diseases. On the previous visit, she had written a prescription for birth control pills, although the patient now admitted she had never filled it. At the time, her parents did not know that she was sexually active. KS had volunteered to talk to the girl's mother, but the young woman had refused. "Now my mother knows," she admitted ruefully. KS wondered sadly what more she could have done.1
to the editor: The doctor in this vignette1 could have done more. Emergency contraception (EC) could have been an answer for this teenager. Health care professionals who work with women concerning reproductive issues need to educate their patients that they have an option for preventing pregnancy if a condom breaks or if they have unprotected intercourse for any reason. Physicians can provide prescriptions or actual tablets that constitute emergency contraception whenever regular oral contraception or condoms are dispensed.
At our office, we have developed preprinted prescription pads for the three most common types of emergency contraception available to our patients: levonorgestrel (Plan B), the Yuzpe regimen (Preven), and Lo/Ovral. (It should be noted that Preven is no longer manufactured, but is available while supplies last.2) These prescription pads are kept in the usual places, including next to the boxes of condoms that we distribute, with a sign that reads: "Giving Condoms? Think EC!" to prompt staff to remember. Our nurses are trained in an emergency contraception telephone protocol, enabling them to gather an appropriate history and to order prescriptions with physician approval when indicated.
The use of emergency contraception in adolescent populations may be one reason for the recent decline in births to teen mothers.3 In general, users of emergency contraception are not substituting this for regular contraception.4 In some states, pharmacists dispense emergency contraception packs directly to patients.5 Although the U.S. Food and Drug Administration recently has rejected over-the-counter approval of emergency contraception, the arguments for its safety were not in question; the decision was widely thought to be based on political considerations.
Emergency contraception is safe and effective. Family physicians who provide contraception always should include discussion of the use of emergency contraception with patients who are or could potentially become sexually active.
REFERENCES
1. Soch K. [Diary from a Week in Practice]. Am Fam Physician 2004;69:849-50.
2. Preven Online Care Center. Accessed online April 19, 2005, at: http://www.preven.com.
3. U.S. Teenage Pregnancy Statistics/Overall trends, trends by race and ethnicity and state-by-state information. Alan Guttmacher Institute. New York, February 19, 2004. Accessed online August 11, 2005, at: http://www.agi-usa.org/pubs/state_pregnancy_trends.pdf.
4. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17:87-96.
5. Sommers SD, Chaiyakunapruk N, Gardner JS, Winkler J. The emergency contraception collaborative prescribing experience in Washington State. J Am Pharm Assoc 2001;41:60-6.
Case Report: Use of Prazosin for Treatment of Posttraumatic Stress Disorder
to the editor: Nearly two full years after the events of September 11, 2001, I was consulted at a rural community mental health center on a 38-year-old male former emergency relief worker who was present for the clean-up after the collapse of the Twin Towers in New York City. He continued to experience severe sleep disturbance despite multiple medication trials including a selective serotonin reuptake inhibitor (SSRI), a mood stabilizer, and an atypical antipsychotic. Many of his other symptoms of posttraumatic stress disorder (PTSD), including "wild nightmares," irritability, and reexperiencing scents and colors, had waned over two years, during which he also had undergone therapy to include Eye Movement Desensitization Response (EMDR). Other than an exhausted appearance, he had a normal mental status examination.
As presented so clearly by Dr. Grinage in the American Family Physician article, "Diagnosis and Management of Posttraumatic Stress Disorder,"1 PTSD is a compelling disorder that can severely disrupt a person's premorbid lifestyle with intrusive thoughts, nightmares, sleep disturbance, irritability, and a plethora of other potentially disabling effects. One report2 demonstrated relief of nightmares in two veterans who were being treated with prazosin (Minipress) for benign prostatic hypertrophy. Subsequently, this was repeated successfully for five civilian trauma victims in another study3 and replicated in a placebo-controlled trial4 in 10 additional veterans. As noted by Raskind and colleagues,2 prazosin is a centrally active alpha1-adrenergic antagonist that should reduce excessive brain noradrenergic activity. The use of prazosin is likely to be familiar to family physicians given its past popularity in the treatment of patients with hypertension.
After warning the patient about the potentially significant first-dose effect of orthostatic hypotension, a trial of prazosin was initiated at 1 mg before bedtime. At follow-up, he reported excellent sleep, with no nightmares since the third week of the trial. He had experienced one minor spell of lightheadedness and some mild morning grogginess. He appeared well rested and in good condition. No dose escalation was required.
Prazosin should be considered in the treatment of the otherwise healthy patient with PTSD, if other standard treatments such as cognitive therapy and SSRIs have failed to relieve the sleep disturbance.
REFERENCES
1. Grinage BD. Diagnosis and management of post-traumatic stress disorder. Am Fam Physician 2003;68:2401-8.
2. Raskind MA, Dobie DJ, Kanter ED, Petrie EC, Thompson CE, Peskind ER. The alpha1-adrenergic antagonist prazosin ameliorates combat trauma nightmares in veterans with posttraumatic stress disorder: a report of 4 cases. J Clin Psychiatry 2000;61:129-33.
3. Talyor F, Raskind MA. The alpha1-antagonist prazosin improves sleep and nightmares in civilian trauma posttraumatic stress disorder. J Clin Psychopharmacol 2002;22:82-5.
4. Raskind MA, Peskind ER, Kanter ED, Petrie EC, Radant A, Thompson CE, et al. Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin. Am J Psychiatry 2003;160:371-3.
The article "Evaluation of Palpable Breast Masses" (May 1, 2005, page 1731) contained an error in Figure 2, the diagnostic algorithm for the management of women with palpable breast masses. Under "Cyst," the arrow from "No residual mass" should have led to "Repeat clinical breast examination in 4 to 6 weeks," and the arrow from "Residual mass or bloody fluid," should have led to "Is patient 40 years or older." The online version of this article has been updated, and the corrected algorithm appears below.
Management of Women with Palpable Breast Masses
Figure 2. Diagnostic algorithm for patients with palpable breast masses.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.
Please include your complete address, telephone number, fax number, and e-mail address. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count.
Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
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