When 26-year-old curve model Lucy Bennett broke a pandemic-imposed dry spell in her sex life, she was pretty delighted. But any initial excitement turned to anxiety when a mishap with the condom meant she might be in danger of becoming pregnant, something she very much did not want to do. As someone who has previously had an abortion, Lucy was adamant that she not take any chances.
“I track my ovulation on an app and noticed I may be in my fertile window,” she tells me over coffee in east London where she lives. “When you’ve been burned once, you just know it’s not worth the risk.”
Lucy had taken the morning after pill (emergency contraception) a couple of times before so knew that she needed to get to a pharmacy as soon as possible to maximise her chances of it working. “The pharmacist took me into a little side room and asked me a bunch of questions,” she says, “like ‘When did you have sex? How many times?’ So I told him only once was potentially unprotected.” It’s worth noting at this point that the pharmacist didn’t ask Lucy when her last period was, which would have determined whether the morning after pill would work for her or whether she should have got the copper coil instead, which is a more effective and less time-sensitive emergency contraceptive.
Then he asked Lucy her weight. “I wasn’t fully sure to be honest,” she says, but she guessed around 90kg. It was then that the pharmacist told her something she’d never heard before: that women and people who menstruate who weigh over 70kg should take a double dose.
“He quite literally said, ‘Well you’re obviously too big’,” she recalls. Lucy was surprised, having never heard this before, and said she would take some time to think about it. But the pharmacist was persistent. “He told me that literally every minute that goes by, the pill is going to become less effective,” she tells me. “He said, ‘You need to take this as soon as possible’.”
Alarmed, Lucy took the two pills and went home.
Almost instantly she says she felt off. “The next day, I started to feel a shift in my mood,” she says, “I was feeling quite drab and lethargic.” Lucy busied herself with work but a week or so later she was overcome with “the worst thrush” of her life. As had worked for her in past cases, she took the over-the-counter pessary and used a topical cream but this time it didn’t work. “It had literally no effect whatsoever,” she says, and “things got worse.”
A week later she rang the GP because her labia were “red raw and bleeding” and she was in the midst of an “incredibly heavy and painful period” that would last nine days in total and prevent her from working. The GP told her it was “possibly a side effect of the medication” and prescribed her antibiotics but also asked her to go and get checked out at a sexual health centre, which she did.
It was at the sexual health centre that a nurse told Lucy that the double dose may have been the issue. “She was shocked, but not surprised,” Lucy tells me. “She quite quickly said I should have only had one dose of the morning after pill and that double dosing was quite a ‘prehistoric way of thinking’.” The nurse told Lucy that you shouldn’t take two pills if you’re above a certain size and that the evidence for giving two was lacking. “I don’t know if that was just her opinion,” says Lucy, “but she was very firm that the next time somebody tells me to take two to just take one and to say that you’ve been advised otherwise.”
Who’s right? Should Lucy have been double dosed on emergency contraception?
The guidance from the Faculty of Sexual and Reproductive Healthcare (FSRH) backs the pharmacy’s decision to give Lucy two doses of levonorgestrel (commonly sold under the brand name Levonelle). “The bulk of study evidence suggests that pregnancy rates after taking levonorgestrel oral emergency contraception increase sharply with increasing weight over 70kg or a BMI over 26,” Dr Sarah Hardman, co-director of the Clinical Effectiveness Unit of the FSRH, tells Refinery29. “The guideline development group for the 2017 FSRH Guideline on Emergency Contraception looked at this evidence in detail,” she continues. “While acknowledging that the evidence is limited, they considered that, as we know from studies that a 3g dose of levonorgestrel (ie. a double dose) is well tolerated, and there are not safety concerns about its use, it made sense to offer the double dose to heavier/higher BMI individuals as it could potentially increase effectiveness and help to reduce risk of pregnancy.”
There is limited and inconclusive data on the effect of high body weight/high BMI on the contraceptive efficacy.
bayer, manufacturer of Levonelle
The NHS website confirms this. On efficacy of both Levonelle and ellaOne (another brand name for the drug known as ulipristal acetate, which works slightly differently from levonorgestrel) it reads: “The effectiveness of both Levonelle or ellaOne may be reduced if a woman has a high body mass index (BMI). This makes it harder to provide a more precise estimate for either pill.” Nonetheless, double dosing is only recommended with levonorgestrel. As for ellaOne, National Institute for Health and Care Excellence (NICE) guidelines state that it may be more effective for those with higher BMIs. “If the patient’s body-weight is greater than 70 kg […] it is recommended that either [ellaOne] or a double dose of levonorgestrel is given […] it is unknown which is more effective.”
When Lucy shared her story on her social media account, tens of people got in touch to say they had experienced similar side effects after being double dosed. One of those was Kelly*, a 32-year-old from Manchester, who says she took three pills after being advised by a pharmacist to do so. “I was told in the pharmacy that they only had one pill available and to go somewhere else for the next dose which I needed because my BMI was too high,” she explains over email. “I went to the pharmacy on the way back from work the day after and was provided with two more pills.” And though she thought it seemed strange, she chose to trust the advice she was given as she had also had to have a termination in the past after contraception failed. “I was so scared.”
Soon Kelly felt “really ill, dizzy and sick” and her “periods got really bad and heavy”. She was told by the second pharmacist that this could happen because she’d taken three pills (a very high dose) and that the pharmacy should have given her two maximum or told her to go somewhere else. “The symptoms lasted around a week,” she tells me, “but I’ve only just managed to regulate my periods again, almost a year later.” Izzie,* who weighs 80kg, had a similar experience. “It took four weeks ’til I was totally back to normal I think,” she says. “I was getting terrible pains in my stomach and my hormones were all over the place.”
In all three cases, medical professionals and pharmacists seemed to have conflicting opinions over whether double dosing levonorgestrel was the correct thing to do. Despite what Lucy says she was told, when I contacted the sexual health centre she visited, a representative said they couldn’t comment on individual cases and quoted the FSRH guidelines that support double dosing. This environment of confusion is reflected in some of the comments under Lucy’s post on the issue on TikTok from people who have a high BMI but have never been told to double dose, suggesting implementation of the guidance is patchy. “I’ve had the MAP [morning after pill] a few times and I’m obese now,” says one user, “but was still given one.” Another said: “Whaaat? I’ve never had to take two. I’m bigger too.” What is the truth? Should all high BMI people who need emergency contraception need twice the dose? And are there instances when they shouldn’t?
@lucybennettmodel I was overdosed the morning after pill because of my size 👆 #fyp #morningafterpill #birthcontrol #foryou #feminist #women #curvywomen ♬ original sound – Celeste Alaniz
One of the biggest issues is that the upper limit for taking one dose as per the FSRH guidelines is 70kg, which is just below the average weight of a woman in the UK (70.2kg), according to the Office for National Statistics (ONS). According to the NHS in 2019, the average BMI of a woman in the UK is 27.6. That we are all heavier than our grandparents isn’t news but against this backdrop it is easy to wonder whether the dosing of these pills is outdated. This is especially true if you consider that when buying emergency contraception in a pharmacy (which is already expensive), two pills often means paying twice. And if the majority of women should be taking an increased dose, wouldn’t it be simpler for pharmaceutical companies to adjust the strength of the pill or to provide a new version for those with a higher BMI rather than doubling the basic dose?
I put this question to Bayer, the manufacturer of Levonelle, but they declined to answer that specific question. Veronica Yao, communications business partner at Bayer, pointed me towards the Summary of Product Characteristics (SmPC), which states that “there is limited and inconclusive data on the effect of high body weight/high BMI on the contraceptive efficacy.” She also told me that “there is no recommendation in the SmPC regarding a change of dose with regards to BMI,” which contradicts the FSRH guidance. Headaches, dizziness, gastrointestinal disorders, nausea, abdominal pain lower, diarrhoea, vomiting and irregular menstruation are listed among the most common side effects (≥ 1/10) of a single dose. Bayer encourages people who have adverse side effects to report them, and acknowledges situations in which non-hormonal emergency contraception (such as a copper IUD) might be the best option.
You can also report adverse reactions to medicine directly to the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) via their yellow card scheme.
I also asked ellOne’s manufacturer whether their pill should be double dosed. They said:
“Please reference the ellaOne SmPC which has a table showing the effect of BMI on the efficacy of ellaOne (pregnancy rates). At no level of BMI does ellaOne become ineffective. There is no specific weight at which ellaOne becomes ineffective within the scope of the clinical study data reviewed and so our position is that ellaOne remains effective for all eligible women regardless of BMI or weight, and we would not recommend a doubling of the dose in any circumstance. Double dosing of EHC [emergency hormonal contraception] is off-label use and is technically a misuse/overdose.”
The last part of ellaOne’s response is crucial. For their part, “double dosing” of any emergency contraception is a “misuse” or “overdose”.
It’s unclear what the experience is of all those people who double dose, owing to a lack of data on the subject, but it is worth noting that, anecdotally, many people will experience limited or no side effects. “The pills didn’t make me feel ill in the short term,” Jane* tells me on Twitter, although she says that the shame of being told she was “too big for the pill” made her feel bad about herself. “Could they not just invent a different pill for those of us who weigh more to take?” she asks.
If you are concerned then it is always a good idea to consult a medical professional before taking anything as there are other options you can explore, such as the insertion of a copper IUD, which is 99.9% effective if inserted within five days of unprotected sex.
Ultimately, reading these women’s experiences feels like another area of healthcare where gaps in data mean that people in larger bodies are left with little information about what to expect when undergoing certain treatments. A lack of consensus among medical professionals about correct use of this drug is clearly also causing concern for bigger bodied women about what exactly they should be doing. “It all seems so wrong,” says Kelly. “Medical staff should know and should be advising consistently.”
What is clear is that the manufacturers of both Levonelle and ellaOne do not endorse double dosing. Added to that, much more data on safe use for higher BMI women is needed. In its absence, anecdotal evidence will be relied upon, which is neither comprehensive nor objective enough to paint a clear enough picture for us to feel safe or adequately informed.
A desire to fill this information gap is precisely what motivated Lucy to share her story. “I don’t want to deter people from taking the extra dose if it will prevent them from falling pregnant,” she says. Her goal, she says, is to ensure that any consent given during what for many women can be an acutely stressful time is more informed.
“No one told me this could happen and when it did I felt so scared and overwhelmed by what was happening to my body,” she says. “I don’t want anyone else to experience that.”
*Name changed to protect identity
If you have any concerns about emergency contraception you should contact your GP immediately.
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