The New Straits Times, October 22, 2000
By Prof Dzulkifli Abdul Razak
THIS year, the Pill turns 40. Prior to the 1960s, birth control pills were unheard of and women had to depend on many `natural' ways of birth control.
Some of these included very creative ways of jumping about after a sexual encounter in the attempt to hinder conception. Some practices were bizzare and clearly painful - not too different from the "perilous practices of 20th-century backstreet abortionists" noted Bernard Asbell, author of The Pill.
At times, plants were used as kneaded primitive barriers. Some were as simple as brewed teas or brewed portion of crushed willow leaves.
In the 11th-13th centuries, Indian women used more elaborate prescriptions of apalasa, fruits as well as flowers of the salmali tree, together with melted butter, to become `unfruitful'.
For centuries later, women were misled by the most learned of doctors who preached a method of timing intercourse with their menstrual cycles. How wrong they were!
The thought of a contraceptive "that could be swallowed like an aspirin", as envisioned by Margaret Sanger, founder of the International Planned Parenthood Foundation, has become a reality.
The Pill (spelt with a big P) is now very much a part of today's woman. Asbell wrote, "the Pill has been swallowed as a daily routine by more humans than perhaps any other prescribed medication".
Currently, various types of hormones are used as oral contraceptive pills, generally of two kinds: estrogen and a progestin. They are synthetic hormones taken orally each day to prevent ovulation.
These hormones trick the body into believing it has released an egg (ovulation), so no egg is freed by the ovaries. Thus, there is no egg to be fertilised and no chance of pregnancy.
Since the 1960s, an estimated 400 million unwanted pregnancies have been avoided with the Pill. Other methods include injectables and implants.
Viewed from another perspective, the Pill liberates women from being tied down by families when they are not prepared. Hence, the birth of feminism and the sexual revolution. Each is not without controversies fanned by anti-abortion and pro-life groups.
This debate comes alive again this month as a new abortion pill is approved for use by the US Food and Drug Administration. Like the Pill, this new version has garnred mixed reaction.
Some called it `an anti-human pesticide' or `the chemical coathanger'. Others regarded it as a `major milestone'.
What is this new pill? Better known by its code name RU-486, it first became available in France in 1988. It is named after the French company Roussel Uclaf, which developed the abortion pill back in 1980.
The `486' designation is the shortened version of the original 38486 compound number the pill was first assigned in the lab.
Although it gained popularity in Europe, anti-abortion advocates fought hard to keep it out of the US, where it was banned in 1989 by the Bush administration.
In 1993, President Bill Clinton began working to bring RU-486 to the US and trials began the following year.
This year, on Sept 28, FDA gave it seal of approval after an extensive review of its safety. Studies found it 92-95 per cent effective in causing abortion.
Mifepristone, the drug's chemical name is an artificial steroid that works as an anti-progestin by blocking the action of the hormone progestrone, which is essential for maintaining early stages of pregnancy.
Progesterone is naturally produced by the ovary and stimulates the proliferation of the uterine lining (endometrium) which nourishes foetal development.
Hence, by blocking progesterone it causes a small embryo to detach from the uterine lining and is purged out of the body along with the decayed uterine lining.
Pregnancy is brought to an end and the body initiates the menstrual process. It is also a major milestone in healthcare in that it will now allow researchers to explore a whole new class of anti-progesterone drugs.
Unlike most, it can be used only in the earliest days of pregnancy - within 49 days of the beginning of the last menstrual period.
The protocol consists of a two-medication regimen to bring on menses and induce an abortion more than 95 per cent of the time.
After taking the mifepristone pill, a second drug, misoprostol (a prostaglandin that causes the uterus to contract), is given two days later to expel the pregnancy.
This is vital since by itself, RU486 is not able to induce abortion good enough for general clinical use. As such, the pill-caused abortion requires at least three doctor visits over a two-week period to ensure accuracy.
The FDA restricts its use to doctors with certain training and mandates that detailed patient-information brochures, MedGuides, be given to every woman. The brochure explains who is eligible and what side-effects to expect.
To date, complications are said to be rare, yet nearly all women will experience some side-effects.
The most common side-effects of mifepristone are pain, bleeding, nausea, vomiting and diarrhoea, mild fever or chills and headaches and dizziness. But these side-effects tend to be minor and short-lived. Serious bleeding occurs in one per cent of women, although there have been no reports of deaths associated with the treatment.
The drug is distributed only to doctors trained to accurately diagnose the duration of pregnancy as its effectiveness reportedly begins to decline after 49 days of pregnancy.
It is also important to detect ectopic, or tubal, pregnancies, because those women cannot receive mifepristone.
Seemingly, the drug holds great promise as an emergency contraceptive, "a weekly or monthly contraceptive" and in the treatment of fibroids, endometriosis and certain cancers, such as meningiomas of the brain, prostate and breast, writes Dr Eric Shaff on Newsweek Web Exclusive (Oct 1).
Reportedly, however, evidence of its effectiveness in these applications is still limited.
Moreover, as Dr Shaff noted, "approximately five per cent of women using this method will need surgical completion to finish the process; one per cent for continuing pregnancies, two per cent for heavy or persistent bleeding and two per cent for an assortment of other medical and non-medical reasons".
In addition, not much is known about the long-term use of the drug. Some have already mentioned the psychological trauma of women seeing "pieces" of their aborted babies being expelled in everyday facilities like the toilet bowl, bathroom or shower.
As normally is the case, upon approval by the FDA, the drug will soon be on our shores.
One major hurdle to be overcome is to provide the public, especially women, with adequate information about expected benefits and side-effects.
Women must have access to information and be counseled in order to ensure that they receive the right advice to make the right choices.
Given the continuing debate surrounding the drug - on both medical and socio-ethical grounds - we can only hope that its acceptance be weighed with extra caution, not least its impact on the tradition and social norms of our country.
Recommended website on RU-486, http://www.ru486.org/
