1. Emergency contraception (MAP) without a medical prescription : luxury or necessity ? E. Aubény French Association for Contraception Paris - France

2. Currently two hormonal methods for emergency contraception (E.C.) E.C. (MAP) without a medical prescription : luxury or necessity ? Yuzpe method (EE + levonorgestrel) : less efficacy and medical contra-indications. It has been abandoned Levonorgestrel alone : more efficacy, no contra-indication : Reference as emergency contraception E. Aubény, French Association for Contraception

3. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? E. Aubény, French Association for Contraception

4. Emergency contraception is more efficient when taken very quickly after unprotected intercourse (WHO) E.C. (MAP) without a medical prescription : luxury or necessity ? Levonorgestrel E.C. % E.C. is a real emergency it must be used very quickly E. Aubény, French Association for Contraception

5. A doctor’s prescription E.C. (MAP) without a medical prescription : luxury or necessity ? 2 - Prevents women from using E.C. Women find this process too complicated for the prevention of an hypothetical pregnancy 1 - Delays the use of medication because of the waiting time for an appointment E. Aubény, French Association for Contraception

6. E.C. ( MAP) without a medical prescription : luxury or necessity ?  a doctor’s physical or gynaecological exam is not needed for E.C. It can be safely used without a medical prescription  has no contra-indication E. Aubény, French Association for Contraception Levonorgestrel E.C.

7. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? June 1999 the French health authorities by decree have allowed levonorgestrel E.C. without a medical prescription in pharmacies for everybody, including minors This decision was contested by Pro-Life organisations E. Aubény, French Association for Contraception Levonorgestrel E.C. without a medical prescription : December 2000 a law was passed to confirm this decision

8. Levonorgestrel E.C. sale without a medical prescription It is now authorised in many countries  Pharmacies Belgium Denmark Finland France Portugal U.K. Switzerland Slovenia Latvia Quebec South Africa  Drugstores Norway Sweden Levonorgestrel E.C. without a medical prescription : luxury or necessity ?. Europe

9. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? In some countries a medical prescription is needed There is no medical reason to deliver levonorgestrel E.C. on medical prescription (ESC Seminar, September 2003) There are only political reasons Levonorgestrel E.C. sale with a medical prescription E. Aubény, French Association for Contraception

10. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Results of 4 years of levonorgestrel E.C. without a medical prescription in France E. Aubény, French Association for Contraception

11. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Levonorgestrel E.C. can be bought without a medical prescription in pharmacies by everybody at a price of 7 euros whith a medical prescription in pharmacies at the price of 7 euros and it is reimbursed by social insurance at 65 % E. Aubény, French Association for Contraception

12. First hormonal contraceptive available without a prescription Women were informed about the availability of non-prescription E.C. by magazines, radio, newspapers and T.V. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Results Acceptability by women E. Aubény, French Association for Contraception

13. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience  Women use E.C. in a proper way, as E.C., not as a regular contraception (contraceptive pill sales keep on rising) E.C. meets a real need  85 000 women use it each month, more than 1 000 000 each year  Women have adopted this method by themselves 80 % without a medical prescription, 20 % with a medical prescription Results Acceptability by women E. Aubény, French Association for Contraception

14. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience In countries where levonorgestrel E.C. needs a medical prescription, women use it very little August 2002 users : Germany (with a medical prescription) : 9 000 Austria (with a medical prescription) :1 800 France, U.K. (without a medical prescription) : 85 000 Delivery of levonorgestrel E.C. without a medical prescription facilitates its use E. Aubény, French Association for Contraception Results Acceptability by women

15. Post-marketing surveillance has received no complaint No medical publication about complications No increase in ectopic pregnancies (French Drug Agency) Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Results Medical problems No medical problem for 4 years in France E. Aubény, French Association for Contraception

16. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience At the beginning, some of them  Felt that they had inadequate information about the drug  Had ethical doubts with the drug  Felt that it was too much responsibility Now, the majority is very pleased to have this responsibility and to be included in the contraception development Results Acceptability by pharmacists E. Aubény, French Association for Contraception

17. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Results Prevention of abortion In France, in 2000, for the first time, one year after the selling of levonorgestrel E.C.without a prescription, a slight decrease has been noticed in the number of abortions Coincidence or beneficial effect of this decision ? It is too early to arrive at a conclusion E. Aubény, French Association for Contraception

18. Four years later the authorisation to deliver levonorgestrel E.C. without a medical prescription appears in France to be a very good measure Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience E. Aubény, French Association for Contraception

19. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? French experience Two specific French dispositions for easy accessibility to emergency contraception for adolescents E. Aubény, French Association for Contraception

20. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Interest of E.C. for adolescents Stastistics show :  In France the average age of first sexual intercourse is 16 It is a fact : French adolescents are sexually active E. Aubény, French Association for Contraception French society has to help adolescents to protect against unwanted pregnancies and STD

21. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Interest of E.C. for adolescents When sexual activity starts at adolescence –Contraceptive information not always accurate (Ogino method, no risk the first time…) –Problems with contraceptive methods difficulties in using condoms properly forgotten birth control pills E. Aubény, French Association for Contraception Interest of post-sex contraception : emergency contraception

22. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Interest of E.C. for adolescents Adolescence is the age of - Crushes - Living in the present time - Intermittent intercourse - Intercourse more or less forced So unexpected, unprotected sex happens Interest of post-sex contraception : emergency contraception E. Aubény, French Association for Contraception

23. Interest of E.C. for adolescents Accessibility E. C., so useful for adolescents, to be used by them should be easily accessible Ease of use Rapidity of use How to make it very easily accessible ? E. Aubény, French Association for Contraception Levonorgestrel E.C. without a medical prescription : luxury or necessity ?

24. E. Aubény, French Association for Contraception Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Levonorgestrel E.C. free delivery in high schools by school nurses The nurse can deliver levonorgestrel E.C. only if it is impossible to have a quick appointment with a doctor or to go to a pharmacy First French disposition for easy accessibility for adolescents

25. For Nurses, Pupils, parents associations Public opinion in France The decision was more or less accepted Supports this practice (63% in favour) Levonorgestrel E.C. delivered by high school nurses At the beginning Levonorgestrel E.C. without a medical prescription : luxury or necessity ? E. Aubény, French Association for Contraception This decision was contested, but a law enforced it in December 2000

26. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Levonorgestrel E.C. free delivery by high school nurses Results September 2001/September 2002 : - 9 735 received it (preventing many unwanted pregnancies) - It allowed discussions between nurses and the students on contraception and on any sexual matter E. Aubény, French Association for Contraception

27. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Second French disposition for easy accessibility for adolescents : Levonorgestrel E.C. free delivery in pharmacies for minors The law passed in December 2000 came into effect in January 2002 E. Aubény, French Association for Contraception

28. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Levonorgestrel E.C. free delivery in pharmacies for minors Minors just have to ask for it : no identity control Pharmacists have - to councel minors - to give a leaflet about E.C. - to dispence E.C free.to minors. They are refunded by Health Insurance s Difficulties of implementation : pharmacists are afraid to speak with youngsters

29. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Unexpected beneficial consequences Unexpected beneficial consequences of 4 years of levonorgestrel E.C. of 4 years of levonorgestrel E.C. without a medical prescription without a medical prescription E. Aubény, French Association for Contraception

30. 1) Renewed interest in contraception particularly about non compliance with regular contraception  2 national campaigns in favour of contraception  Study on contraception failure and non compliance E. Aubény, French Association for Contraception Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Unexpected beneficial consequences of levonorgestrel E.C. without a medical prescription

31. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Unexpected beneficial consequences of levonorgestrel E.C. without a medical prescription 2) Involvement of new health professionals in contraception - Pharmacists - High school nurses They get interested in regular contraception. The majority is very pleased to have this responsibility and to be involved in the contraception development E. Aubény, French Association for Contraception

32. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Unexpected beneficial consequences of levonorgestrel E.C. without a medical prescription 3) Liberalization of regulation on contraceptive drugs  Before emergency contraception without a medical prescription, all contraceptive drugs needed a medical prescription  Now (by law) new contraceptive drugs with no known medical contra-indications will be sold without a medical prescription E. Aubény, French Association for Contraception

33. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? 4 years of French experience Unexpected beneficial consequences of levonorgestrel E.C without a medical prescription 4) Recognition of teenagers sexuality Levonorgestrel E.C. delivered by high school nurses and free in pharmacies for minors - opened the discussion about teenagers sexuality and contraception in the society - obliged to its recognition This recognition is the best way to prevent abortion and STD among adolescents E. Aubény, French Association for Contraception

34. Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Others’ experiences of levonorgestrel E.C. without a medical prescription : In U.K. in spite of a very high price (32 euros) each month 85 000 women use it : it meets a real need In Finland during the second trimester of 2002, the time when levonorgestrel E.C. without a medical prescription started, the minor abortion rate decreased by 30 % E. Aubény, French Association for Contraception

35. Levonorgestrel E.C. without a medical prescription : luxury or necessity ?Conclusion From 4 years of French experience of levonorgestrel E.C. without a medical prescription - is safe from a medical point of view - allows a large and safe use - is needed by women who use it properly and not as a regular contraception - is very useful for youngsters E. Aubény, French Association for Contraception

36. Conclusion Levonorgestrel E.C. without a medical prescription : luxury or necessity ? Conclusion Levonorgestrel E.C. without a medical prescription is essential for women It makes it possible for them It makes it possible for them to have a better protection to have a better protection E. Aubény, French Association for Contraception