Expert Commentary

Is the most effective emergency contraception easily obtained at US pharmacies?

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The availability of ulipristal acetate (Ella) for emergency contraception is limited (either immediately or via order placement), according to a national secret shopper telephone survey of 344 retail pharmacies in 10 major US cities. Only 10% of pharmacies (33 of 344) reported having ulipristal acetate immediately available, including 12% of chain pharmacies (28 of 233) and 5% of independent pharmacies (5 of 111).

Shigesato M, Elia J, Tschann M, et al. Pharmacy access to ulipristal acetate in major cities throughout the United States. Contraception. 2018;97(3):264–269.




Although it is available only by prescription, ulipristal acetate provides emergency contraception that is more effective than the emergency contraception provided by levonorgestrel (LNG), which is available without a prescription (TABLE). In addition, ulipristal acetate appears more effective than LNG in obese and overweight women.1,2 Package labeling for ulipristal acetate indicates that a single 30-mg tablet should be taken orally within 5 days of unprotected sex.

According to a survey of pharmacy availability of ulipristal acetate in Hawaii, 2.6% of retail pharmacies had the drug immediately available, compared with 82.4% for LNG, and 22.8% reported the ability to order it.3 To assess pharmacy availability of ulipristal acetate on a nationwide scale, Shigesato and colleagues conducted a national “secret shopper” telephone survey in 10 cities (each with a population of at least 500,000) in all major regions of the United States.

Details of the study

Independent pharmacies (defined as having fewer than 5 locations within the city) and chain pharmacies were included in the survey. The survey callers, representing themselves as uninsured 18-year-old women attempting to fill a prescription for ulipristal acetate, followed a semistructured questionnaire and recorded the responses. They asked about the immediate availability of ulipristal acetate and LNG, the pharmacy’s ability to order ulipristal acetate if not immediately available, out-of-pocket costs, instructions for use, and the differences between ulipristal acetate and LNG. Questions were directed to whichever pharmacy staff member answered the phone; callers did not specifically ask to speak to a pharmacist.

Of the 344 pharmacies included in this analysis, 10% (33) indicated that they could fill a prescription for ulipristal acetate immediately. While availability did not vary by region, there was a difference in immediate availability by city.

Almost three-quarters of pharmacies without immediate drug availability indicated that they could order ulipristal acetate, with a median predicted time for availability of 24 hours. Of the chain pharmacies, 81% (167 of 205) reported the ability to order ulipristal acetate, compared with 55% (57 of 106) of independent pharmacies.

When asked if ulipristal acetate was different from LNG, more than one-third of pharmacy personnel contacted stated either that there was no difference between ulipristal acetate and LNG or that they were not sure of a difference.

Study strengths and weaknesses

The authors noted that the secret shopper methodology, along with having callers speak to the pharmacy staff person who answered the call (rather than asking for the pharmacist), provided data that closely approximates real-world patient experiences.

Since more pharmacies than anticipated met exclusion criteria for the study, the estimate of ulipristal acetate immediate availability was less precise than the power analysis predicted. Further, results from the 10 large, geographically diverse cities may not be representative of all similarly sized cities nationally or all areas of the United States.

As the authors point out, a low prevalence of pharmacies stock ulipristal acetate, and more than 25% are not able to order this emergency contraception. This underscores the fact that access to the most effective oral emergency contraception is limited for US women. I agree with the authors’ speculation that access to ulipristal acetate may be even lower in rural areas. In many European countries, ulipristal acetate is available without a prescription. Clinicians caring for women who may benefit from emergency contraception, particularly those using short-acting or less effective contraceptives, may wish to prescribe ulipristal acetate in advance of need.
—Andrew M. Kaunitz, MD

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