Crazy guilt over morning after pill

[Arania]

Hi, I am feeling very upset after taking the morning after pill and wondered about others’ perspective.

Background is I’ve desperately wanted to be a mum for years but had lots of physical health problems then my marriage ended in my late 30s. Despite that it was hard to give up on the dream of being a mother. Started dating someone new, stupidly managed to miss a few pills on different weeks last month. I then realise there is at least a small chance I could be pregnant and I begin to panic because whilst I do desperately want to be a mother, and I’m already in my late 30s, I had begun to realise that things were going to end with the person I was dating and that he maybe wasn’t a very nice guy. But most of all I panicked because when the reality of possibly being pregnant hit, I realised I was too unwell to care for a child especially as a single mother with an insufficient time supportive ex.

As a result of this panic I think about taking the morning after pill but am concerned about doing it because I have always been quite uncomfortable with the idea of ending a conception. I am very very very pro-abortion rights for women in general as it’s an entirely personal choice and completely subjective. But had always thought this was something I personally would find it difficult to deal with. obviously the morning after pill is not an abortion but my understanding is the research around its mechanism of action is uncertain and they can’t fully rule out that it prevents implantation of an early embryo. Whilst this is not technically a pregnancy, it is postconception so I personally am not comfortable with stopping this (I realise this is a fringe view and most people would be fine with it which I understand).

Eventually I become so panicked that I just take it. After a few days I became overcome with guilt.

Obviously the chance that I was even pregnant in the first place in my late 30s with a few missed pills more than seven days prior were pretty low, Probably under 1% percent. Yet this doesn’t seem to help, I am still overcome with remorse

Try not to worry, I felt similar when I took one but it was the right thing for me and seems the right thing for you. Don’t think of it as anything like an abortion because it really isn’t. I’m not clued up on how it works as such but I’m pretty sure it’s nothing like terminating. If there was anything there it wasn’t anything much, and I hope that doesn’t come across as harsh but rather comforting? I’m sure someone will have better advice, but try not to worry.

Thanks, very kind of you. I think the legal definition of pregnancy is it begins when a fertilised egg implants into the womb, but conception i.e. fertilisation of the egg happens before then. I just feel really guilty about the fact that I could have stopped implantation by taking the drug. It has to be something to do with wanting a child for so many years I guess, because so many women take this drug and are fine with it. I keep telling myself just how unlikely it was that I actually conceived, given I was on the combined pill, and that the primary mode of action of the drug is to stop ovulation and it probably only stops implanation in a minority of cases but....................the guilt is overwhelming. I even feel suicidal

The chances of the sperm fertilising the egg, it managing to inplant and start growing are very tiny. Chances are you didn’t have a fertilised egg in you. Easier said than done but try to let the guilt go. IF it even was fertilised it would of been one cell, two at the most and unlikely to of turned into a pregnancy. I’m sorry your struggling

Thanks that’s very kind of you. I keep telling myself to let the guilt go and I can’t

OP, the emergency pills (there are 2 versions) both work by delaying ovulation until sperm no longer viable to fertilise the egg. They therefore prevent fertilisation. They do not “terminate” a pregnancy.
Clearly this means that in some cases (when you’ve already ovulated) they don’t have an effect - but because the pregnancy rate after unprotected sex isn’t 100%, you wouldn’t have conceived regardless.

The emergency coil can work by killing sperm to prevent fertilisation, but will often work at the level you felt uncomfortable with - by preventing implantation of an already-fertilised egg. Likewise though, in many cases where an emergency coil is used, you may not have conceived anyway, so can never be sure whether the successful result was because of the intervention, or by chance.

I’m a consultant gynaecologist specialising in Contraception, if that helps.

Please don’t feel guilty - your worries in your original post are unfounded.

And yes, if you’d taken at least 7 consecutive day pills before missing any of the pills, it’s extremely unlikely you had ovulated at all.

You have another almost identical thread running, in which several posters have echoed what I have said above. HTH

Yes, it’s probably the upset causing obsessive concern

Grateful for your input as consultant gynaecologist.

It looked to me like on balance the body of published research supports levonelle working to stop ovulation but there are some conflicting papers and therefore a small chance it could also stop implantation in a minority of cases

In summary, given that I’d taken the pill on seven prior consecutive days, and that only a minority of the most recent published research supports an occasional anti implantation affect for levonelle, it is highly unlikely I stopped any implantation. It’s the fact I can’t be sure that’s getting to me

I did wonder if the conflicting papers were published by the anti-abortion contingent in the United States

There is no evidence to suggest that either of the FDA-approved emergency contraceptive options, levonorgestrel (LNG, such as Plan B One-Step, Take Action, Next Choice One Dose or My Way ) or ulipristal acetate (UPA, such as ella) works after an egg is fertilized. In two recent studies of the levonorgestrel regimen, women who presented for EC (Emergency Contraception) were monitored to identify their menstrual cycle day and ascertain which women took EC before ovulation, and which took it after. Among women taking LNG before ovulation, there were no pregnancies. Among those who took it on the day of ovulation or after, there were about the number of pregnancies that would be expected with no use of EC; if LNG were effective at preventing implantation, it would most certainly be more effective when taken after ovulation. A recent study of UPA EC showed that when UPA was used before ovulation, the number of pregnancies that occured was significantly lower than would be expected without EC, while when it was used after ovulation, the pregnancy rate was what would be expected without EC.

ec.princeton.edu/questions/ecwork.html

To summarise, the emergency contraceptive pills prevent ovulation rather than implantation.

Thank you very much. That’s actually some of the information that prompted me to decide to take the levonelle morning after pill in the first place. Later I read contradictory papers and became more concerned. But that’s the nature of published research, often there’s conflict

Quince, one thing that interests me is it seems generally to be accepted that the combined pill and progestogen only pill will occasionally prevent implantation if they fail to prevent ovulation, due to their thinning effects on the endometrium. Why then would the large dose of Progestogen in the levonelle MAP not effect the endometrium enough to sometimes affect implantation? Does it not have enough time to do so, being a one off large dose?

one thing that interests me is it seems generally to be accepted that the combined pill and progestogen only pill will occasionally prevent implantation if they fail to prevent ovulation, due to their thinning effects on the endometrium

So why doesn't taking a regular contraceptive pill bother you in the same way as taking the MAP?

I completely understand your guilt. I had unprotected sex with someone I was only seeing for a few days, so I took the morning after pill and even while I was taking it I felt guilt...I'm now 36 weeks pregnant. My point is if it was meant to be it would've been. I suspect you wasn't even pregnant in the first place. The morning after pill only stops your egg being released, if it's already been released and fertilised, there's nothing the morning after pill could do. It's not an abortion pill. Go easy on yourself :)

I think you need to ditch the guilt. You were on the pill -taking the morning after pill really isn't any different. It's really not. You're preventing a pregnancy, not ending one. Seriously, put it behind you and instead focus on what comes next.

You still have a window of opportunity to have a baby. Decide if you want one or not &
If you do HOW you're going to make that happen.

Otherwise you'll find yourself HAVING to accept it's not going to happen for you and that, my friend, is utterly shit. Utterly, utterly shit.

Hi Broohaha - it's because I did not know the combined pill had that effect until this happened and I began to research it. I keep trying to find a way to ditch the guilt like - "come on the combined pill would have been more likely to affect the endometrium (and implantation) than the Levonelle MAP". But I don't feel guilt about taking the combined pill because I had no idea it could (rarely) affect implantation, so I don't see myself as culpable. However I do feel guilty about taking the MAP because I DID know that it was possible it might just affect the endometrium and implantation (even if the newer research suggests the primary effect is to stop ovulation).

I'm aware I may have a bit of a problem with guilt in general and I think that's linked to so many years of wanting a baby.

k1- congrats!

LLLL- You are SO right, this is me desperately trying to find a way to ditch the guilt cos if I don't get my head together soon, that's it for my chances of having a kid. At the moment I'm so upset there's no way I'm well enough to try to meet someone!

The panic over my physical health that prompted me to take the MAP has probably already told me I'm too ill to manage have a baby and the grief of that is probably getting mixed up in the grief of this. Weirdly the guilt is actually worse.

Hi OP - the POP thins the endometrium as a regular method, and takes a few days to have full effect. However the main effect is on thickening the cervical mucus and (with desogestrel POP) to mostly prevent ovulation.

You seem to be tying yourself up in knots about something that there is NO evidence medically occurs. As has been pointed out above - even if you disbelieve this and consider it's possible, then the same could be said of your regular COC....

In my experience (and this seems to be case from what you've said), those women who experience significant guilt or regret after a TOP actually are grieving for what they perceive as the loss of a chance of a child.

Ring I your late 30's does not hugely reduce your chances of future pregnancies - so would advise you to maybe consider counselling from the TOO service - all offer this - and to start to plan how and when you would like to be pregnant again.
Good luck.

Sorry - Being, not ring
TOP service

Hi quince, thank you, that does help rather. I understand now that despite the large dose of P in the MAP it may not have sufficient time to thin or otherwise affect the endometrium. The half life isn’t super long

I used to work in science and haven’t been able to help but torture myself by reading the literature. I did notice there were a number of review and data papers arguing in favour of a post fertilisation affect.

www.ncbi.nlm.nih.gov/pmc/articles/PMC5102184/

Yes, you are right, there is absolutely no doubt that the hugely excessive painful guilt is about wanting a child very much for years. I’m 39. I had heard this can happen after abortion in women in their later 30s and even though this is not what I have had, there is something like that going on.The dilemma for me was lots of physical health problems and some depression, and that’s what prompted me to take the MA pill in a panic in the first place, along with the unsuitable short term relationship man. This has actually greatly worsened the depression, ridiculously, rather as abortion can in a few women.

I assume that TOP is the termination of pregnancy service – do you think that they would offer that to somebody who had only taken the morning after pill?

There

www.ncbi.nlm.nih.gov/pmc/articles/PMC5102184/

pubmed.ncbi.nlm.nih.gov/20399948/

The thing I don’t understand is this one is one of the two main studies cited in favour of the mechanism of action being the delaying of ovulation.

However, most of the women in the study did have follicular rupture on ultrasound. The authors actually do not claim the medication inhibits or delays ovulation, instead they are quite careful in their wording and simply state that their results have shown that the medication only acts before ovulation and not after

Abstract from another paper re levonelle and follicular rupture

Forty eight LNG-treated (1.5 mg) cycles, 31 LNG (1.5 mg) + meloxicam (15 mg), 34 UPA (30 mg) cycles and 50 placebo cycles were compared. Follicle rupture was delayed for at least 5 days in 14.6%, 38.7%, 58.8% and 4% of the LNG-, LNG+meloxicam-, UPA- and placebo-treated cycles, respectively. UPA was more effective than LNG and placebo in inhibiting follicular rupture (p=.0001), while LNG, when administered at this time of the cycle, was not different than placebo. The addition of meloxicam improved the efficacy of LNG in preventing follicular rupture (p=.0292 vs. LNG; p=.0001 vs. placebo; non-significant vs. UPA). UPA was effective in preventing rupture in the 5 days following treatment, even when administered at the time of the luteinizing hormone (LH) surge (UPA 79%, LNG 14% and placebo 10%). None of the treatments were effective when administered on the day of the LH peak. The median time from treatment to rupture was 6 days during the ulipristal cycles and 2 days in the placebo and LNG/LNG+meloxicam cycles (p=.0015).

Although no EC treatment is 100% effective in inhibiting follicular rupture when administered in the late follicular phase, UPA is the most effective treatment, delaying ovulation for at least 5 days in 59% of the cycles. LNG is not different from placebo in inhibiting follicular rupture at this advanced phase of the cycle. No treatment was effective in postponing rupture when administered on the day of LH peak.

From the frequently cited Noe paper

“ 3.3. Detection of FR and luteal phase in women at risk of pregnancy
In the 87 women treated before ovulation, FR was confirmed in 62 by means of TVU and elevated P level (n=39), or TUV only (n=18), or by luteal phase values of P only (n=5).
In 57 cases (66%) of the 87 preovulatory treated women, FR was detected during the 5 days of follow-up after LNG- EC intake; half of them had a follicle size N18 mm on the day of treatment. In 15 women (17%), FR was not detected during follow-up; in most of them, follicle size was b18 mm on the day of treatment. In the other 15 (17%), FR could not be determined because the women did not attend the follow- up visits (Table 2).”

From the Noe paper:

“Our finding that FR occurs after administration of LNG-EC is in line with those reported by Croxatto et al. [6]. In that study, the purpose was to examine the effect of LNG-EC on follicles at different stages of development, using follicular diameter as proxy for follicular develop- ment. It was observed that FR was suppressed in a high proportion when treatment was administered to women with follicles with a diameter of b18 mm. In the current study, FRs occurred in some two thirds of women taking LNG-EC preovulatory; this suggests that other mechanism than suppression of ovulation prevents pregnancy in these women. We postulate that increased cervical mucus viscosity caused by LNG impedes the migration of sperm from their reservoir in cervical crypts to the Fallopian tubes; therefore the time elapsing between LNG-EC intake and ovulation would be crucial. Such an effect on sperm migration of lower doses of LNG has been reported by Kesserü et al. [7]. Evaluating cervical mucus properties at different times after LNG-EC administration in women close to FR would clarify this mechanism of pregnancy prevention.
In conclusion, this study shows that LNG-EC is very effective in preventing pregnancy when it is administered before ovulation, but it is ineffective in preventing pregnancy once fertilization has occurred”

So a lot of the work that cites this paper says that levonorgestrel suppresses ovulation but the authors themselves say it does not do that for most women who take it before ovulation. As for Delay of ovulation, I don’t think they make comment as to when these follicular ruptures occurred

I feel a bit confused like there is something I’m missing

I think, OP, that you need to make a conscious decision to stop obsessing over this. Take a big breath and close the box that holds this worry. It's clear that no amount of external reassurance is going to help you because you're actively searching for information to fuel the worry. Stop it.

I think you’re probably right BHH..But in the normal run of things I really like facts and make a habit of analysing academic research claims for anything I’m interested in. It turns out in this circumstance that is not a good thing. I don’t understand why it is so often stated that levonelle can inhibit or even delay ovulation when – as far as I can see – all that has been conclusively proven is the drug only really works before ovulation