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Am Fam Physician. 2007;75(5):624

to the editor: In the July 1, 2006, issue of American Family Physician, Drs. Lesnewski and Prine state that the “quick start” method of initiating oral hormonal contraception can be used for women who have had unprotected intercourse within five days of the office visit, after appropriate counseling.1 In counseling such patients, physicians should be aware that women seeking contraception may be opposed to a method that has the theoretical potential to impede implantation of a fertilized ovum.

Although easier access to health care is a worthy goal, physicians should be careful about “over-the-phone” requests for contraception. An office visit is more conducive to the type of patient assessment and education that is often necessary before contraceptives are prescribed. For example, a woman who is the victim of abuse or incest would be more likely to seek help in the setting of a private, secure office visit than during a phone call, perhaps coerced by the perpetrator, to request emergency contraception. Family physicians need to empower women by providing them with the information and support they need to make decisions that may have a profound impact on their lives.

in reply: Dr. Pisaniello points out that physicians and patients may have moral or religious concerns about the “quick start” method of initiating oral contraception because of the theoretical risk of post-fertilization effects. Women who have had unprotected intercourse within five days of an office visit can take emergency contraception that day and begin their new contraceptive the following day. Levonorgestrel emergency contraception prevents pregnancy primarily by inhibiting ovulation, with some additional effects on sperm motility and cervical mucus.1,2 Research on progestin-only emergency contraception has not demonstrated any post-fertilization mechanism of action. This information should allay patients' concerns about preventing implantation of a fertilized ovum.

The quick start algorithm generally requires an office visit. To prescribe a new hormonal contraceptive method between menses, physicians must take a full patient history, including medical history, concurrent medications, sexual practices, and social issues. All of these areas impact the patient's choice of contraceptive. I agree that office visits present a crucial opportunity to screen for abuse and to optimize health in many other ways. However, patients who need emergency contraception episodically (because a condom broke or a pack of birth control pills was misplaced) must have easy access, unimpeded by a requirement to schedule an office visit. Our wish to identify potential cases of abuse should not prevent teenagers or women from accessing emergency contraception during the brief window of this medication's highest effectiveness.

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