MOA of Ella

[Guest guest]

Dear Colleagues,

I was reading the opinion article in the December Green Journal (Obstetrics &

Gynecology), which happens to be about Ella. The author Mark Nichols, clearly a

fan of Ella, talks about the supposed MOAs of the drug. I will summarize it,

but also paste the original text below. In sum, he says it's likely that Ella

may interfere with implantation, but if that troubles your patients, just remind

them that we don't know all of the true MOAs of OCPs, and that they also likely

interfere with implantation. !!! As if that should " put your patient to ease! "

I was also shocked to see him so casually state that OCPs may have an

implantation effect. Although I am fully convinced they do, most of the medical

literature refers to that as the third and " hypothetical but unlikely "

mechanism.

In a way, I was happy to see him admit that. On the other hand, I was terrified

he could do so in such a callous manner.

Excerpt from the original text:

" What is the MOA of ulipristal acetate [Ella] as an emergency contraceptive?

Ulipristal acetate appears to precent pregnancy by blocking or delaying the

luteinizing hormone surge and follicular rupture when ingested before ovulation.

There may also be a delay in maturation of the endometrium, which may interfere

with implantation. Its is believed that the primary mechamism of ulipristal

acetate is the blocking or delaying of ovulation. However, somem patients and

providers may be opposed to the use of ulipristal acetate due to the possible

inhibition of implaintation. In this context, it may be helpful to review the

uncertainty of the mechanism of action of other commonly used medications, such

as OCPs. Given that ovulation sometimes occurs despite consistent use of oral

contraceptives, it is likely that some embryos are unable to implant because of

the endometrial effects among oral contraceptive users.

What should the provider do who is unwilling to provide emergency contracetion

that might affect implantation? The ethical dilemma of conscientious refusal

has been addressed by an ACOG Committee Opinion (# 385, 2007). It states that

providers have a duty to refer patients ina timely manner if they cannot

provide, in conscience, the services their patients request. In the context of

emergency contraception, provision of accurate information and referral for

patients well before the possibility of unprotected intercourse is important. "

(Nichols, M. Ulispristal Acetate: a nocel molecule and 5-day emergency

contraceptive. Obstet Gynecol 2010;116:1252-3)

Thoughts?

Rehmann, DO

PGY2, Sisters of Chartity Hospital

Buffalo, NY