Caitlin Gallagher
March 22, 2019 7:44 am

Nearly everyone who binge-watched all six episodes of Shrill when it premiered on Hulu on March 15th fell in love with Aidy Bryant’s Annie, the show’s body-confident star. But they also were left with a lot of questions about the morning-after pill.

[Spoilers for Shrill ahead!]

In one episode of the show, Annie picks up the morning-after pill after an unprotected encounter with her boyfriend, but finds herself pregnant not too long after. Turns out, some emergency contraception (EC) brands like Plan B (called “Step Two” on the show) aren’t always effective for women who weigh more than 175 pounds—which is true for Annie. If that scene left you wondering, What the hell ELSE don’t I know about the morning-after pill?!, you’re not alone. That’s why HG spoke with two gynecologists—Dr. Jennifer Conti and Dr. Jennifer Wider—to get the low-down on EC.

How does the pill work? What hormones does it contain and how do they stop pregnancy?

Dr. Wider: The morning-after pill comes in a one-dose option and is effective if taken within 72 hours of unprotected sex. It contains a synthetic version of the hormone progestin, which works to inhibit the body from releasing an egg (or ovulation). The synthetic hormone can also change the consistency of the cervical mucus to make it harder for sperm to find the egg. Also, the hormone can alter the lining of the uterus, making it difficult to implant if there happens to be a fertilized egg.

How is emergency contraception different from abortion?

Dr. Conti: I want to be super clear here—emergency contraception is NOT the abortion pill. In fact, the two medications work in completely opposite ways. Emergency contraception like Plan B is the hormone progestin, while mifepristone (commonly called “the abortion pill”) is an antiprogestin and actually blocks the hormone from working.

What’s the timeframe that the morning-after pill is effective? Is it more effective the earlier you take it?

Dr. Conti: The sooner EC pills are taken after unprotected sex, the better they work.

Dr. Wider: Plan B, or the morning-after pill, is effective if taken within 72 hours, but is most effective if taken within 24 hours after unprotected sex.

Should you only take the morning-after pill when you are ovulating? Is it okay to take when you aren’t ovulating?

Dr. Wider: Most people do not know the exact timing of ovulation, so it’s best to take the pill as soon as possible after unprotected sex. While the timing of your menstrual cycle may impact how well emergency contraception works, it’s best to speak to your doctor if you have questions because certain types of emergency contraception have different timing suggestions.

Dr. Conti: It’s okay to take EC any time in your cycle and within the three- to five-day window after unprotected sex (depending on the type of EC). Plan B works more effectively if taken before ovulation, but we can’t expect people to know when exactly that is, so the safest rule of thumb is just take it right away regardless of where you think you are in your cycle and then take a pregnancy test two weeks later to confirm it worked.

How should a woman expect to feel after taking emergency contraception?

Dr. Conti: You might notice some irregular spotting outside of your normal cycle, and maybe a little nausea, but otherwise, there really aren’t many side effects.

Dr. Wider: This one is a tough question because everyone is different, so there is no set way a woman will feel. Some of the more common symptoms include upset stomach, lightheadedness, dizziness, and tender breasts. But some women don’t notice anything at all. The next period you get may be irregular—the timing may be off and the flow may be heavier or lighter. But again, it can vary person to person.

Can you have unprotected sex after you take emergency contraception?

Dr. Wider: The pill is most effective after you’ve had unprotected sex. It will not work as well after another encounter. Although the chances are probably lower, it isn’t worth the risk. Sperm can survive for up to five days in a woman’s body, and if you have unprotected sex again, you may not be covered. Your doctor would likely recommend taking it again.

What are the health risks of taking emergency contraception? Do the benefits outweigh the risks?

Dr. Wider: The morning-after pill is very safe and more than mild side effects are rare. If needed, women should feel comfortable that the risk profile is extremely low.

Dr. Conti: There aren’t any known health risks to taking these pills. They’re incredibly safe overall.

Do I need a prescription to get emergency contraception?

Dr. Conti: Some yes, some no. You don’t need a prescription to get Plan B [if you are over 17], but you do need a prescription to get Ella, which is the newest EC med on the block. Ella (ulipristal acetate) is an emergency contraceptive pill that works in a slightly different way than Plan B but that has the same end goal.

So is the morning-after pill really only dosed for women who weigh 175 pounds or less?

The Centers for Disease Control (CDC) reported that the average weight for U.S. women over the age of 20 was 170.6 pounds in 2015-2016, so what’s the deal with EC?

Dr. Wider: It wasn’t specifically designed to only work in women under 175 pounds [but] unfortunately, there aren’t a ton of studies exploring this. But there are a few significant ones, and it’s important to take note (especially if you’re [over 175 pounds]). In a 2016 study in the journal Contraception, the researchers set out to look at the safety and effectiveness of emergency contraception in obese women. They reviewed all prior studies and came to the conclusion that there was some evidence that emergency contraceptive pills were less effective in overweight/obese women and they may have an increased likelihood of pregnancy when compared with women who were underweight and normal weights.

Providers should counsel all women at risk for unintended pregnancy, including those with obesity, about the effectiveness of the full range of emergency contraception options in order for them to understand their options, to receive advanced supplies of emergency contraception as needed, and to understand how to access an emergency copper intrauterine device if desired.

What can women who weigh more than 175 pounds do in the case of unprotected sex?

Dr. Wider: Some women may not realize this, but you can get a copper IUD placed within five days of having unprotected sex. This method is highly effective [at preventing pregnancy] and does not seem to have any weight limit restriction.

Dr. Conti: One of the best options for emergency contraception for people of all sizes is the copper IUD. It’s amazing because it’s effective when inserted up to five days post-unprotected sex, and protects you going forward for an additional 12 years. We don’t talk enough about how effective the copper IUD is for emergency contraception. It has no weight limit.

What about Ella?

Dr. Conti: One of the biggest advantages of Ella over Plan B is that it has a less stringent weight limit for when it’s effective. Plan B is less effective (read: don’t bank on it to reliably work) if you weigh over 165 pounds, and Ella is less effective if you weigh over 195 pounds.

Dr. Wider: According to limited research studies, it is supposed to be more effective in women who have higher BMIs, but more studies are needed. You can take it within five days of unprotected sex, but unlike the other ones, it does NOT get less effective the later you take it. Ella is also different because it does not contain hormones—it contains ulipristal acetate, which is a non-hormonal drug that blocks the hormones that are vital for contraception.

Does it make sense to keep emergency contraception in my medicine cabinet/on hand?

Dr. Conti: Absolutely! I always tell anyone taking hormonal birth control to keep some on hand just in case they miss a dose.

What else should women know about the morning-after pill that isn’t common knowledge/commonly discussed? Are there other limitations?

Dr. Wider: If you throw up after taking the pill (within one hour of taking it) most health care providers will recommend taking it again.

Another thing Shrill might have you wondering is if there’s a limit to how much emergency contraception you can take. After all, the female pharmacist on the show says, “It’s supposed to be for emergencies only.” But Dr. Conti said there’s no limit to how much a person can take within their lifetime. So while you probably shouldn’t use it as your only regular birth control, don’t stress if you’ve taken it multiple times, like Annie.

Dr. Conti also noted that you can take EC even if you’re already on another form of hormonal contraception—like if you take the birth control pill but haven’t been taking it diligently and are concerned you might be at risk for pregnancy after unprotected sex.

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