A simple way to find a simple answer to a simple question

R W M Chow 周偉文

A difference of opinion appeared at a typical luncheon meeting sponsored by a pharmaceutical company. A young doctor returning from overseas, a not-so-young general practitioner and a young drug representative new to the job met for the first time and were trying to make social conversation. The young doctor mentioned how a young lady requesting morning-after pills had misunderstood his instructions and took eight combined oral contraceptive pills as a single dose instead of four tablets to start with and four more twelve hours later. She developed severe vomiting afterwards. The more senior colleague questioned why he had used four tablets when two tablets at twelve hour interval would be quite sufficient. The young drug representative concurred and remarked that his married sister had obtained morning-after pills from the Family Planning Association before and she only needed to take a total of four tablets. Each of the two doctors believed he was right and the other was wrong. However, they could not put forward any strong argument except that they had remembered it that way. The poor drug representative went pale being caught in the middle and could not decide which side he should be on. Then the three noticed that the pharmaceutical company's Sales Manager, together with a group of other doctors were heading their way and were about to chip in. The morbid fear of making a fool of oneself in front of one's colleagues took over the three and the topic was quickly dropped. After all, medicine is such a broad and ever-changing subject, one cannot really be too sure about anything at times. By the time the luncheon meeting was over, the discussion was forgotten by all. How often do we let questions and answers pass us by? How often do we shy away from an opportunity to seek an answer for fear of embarrassment? How often do we take action to look up for an answer ourselves? If we start asking questions, we may get some answers.

I went on-line and used a standard search engine to search the Internet under "morning-after pills" and later "emergency contraception".

I learned the following about emergency contraception:

1. It is an effective means of contraception.¹
2. The original Yuzpe regime (0.1 mg Ethinylestradiol-EE + 0.5mg Levonorgestrol-LNG q12h) proposed in 1974 is the most widely studied method with clearly documented efficacy.¹ Now we have a standard!
3. Overseas recommendations on the Internet² as well as standard medical textbooks³ suggest giving 2 highdose pills (typically 0.05mg EE + 0.25 mg LNG) or 4 low-dose pills (typically 0.03 mg EE + 0.15 mg LNG) q12h
4. The Family Planning Association of Hong Kong homepage mentions giving 2 pills but the hormonal content of the pills is not disclosed.⁴

It then became clear that the young doctor was probably using low-dose pills (hence four tablets) while his friend was talking about using high-dose pills (hence two tablets). As I looked through the material I did some simple arithmetic and suddenly realized that if we give only two low-dose pills (typically 0.03mg EE + 0.015mg LNG) every twelve hours, we will be giving 0.06mg EE + 0.3mg LNG which is only 60% of the recommended Yuzpe Regime. The contraceptive efficacy of this low dose regime is not known. However, if we give four low-dose pills according to the overseas recommendation, we will overshoot and be giving 0.12mg EE + 0.6mg LNG which is 120% of the recommended regime. This is more than necessary and will possibly increase the likelihood of side effects such as vomiting, which, if it happens within two hours of pill administration, may indirectly reduce its efficacy.⁴ This may also bias the patient against the future use of this very effective contraceptive method for fear of side effects or experience of failure.

A reasonable compromise seems to be 3 low-dose pills twice daily. This way we give 0.09 mg EE + 0.45 mg LNG which is 90% of the Yuzpe regime. Taking into account individual variation in body weight, pharmacokinetics and pharmacodynamics, the 10% deficit is most likely immaterial in most cases. The theoretical reduction in efficacy may in fact be offset by reduction in side effects and greater patient acceptance. I sent my findings together with some useful material from the Family Planning Association homepage to my colleagues who received it quite well.

I am not recommending this regime to anyone. I am not even suggesting that conclusions should be drawn in such a cursory manner. If I had spent more time on the topic, I might have learnt a lot more than this and have come up with very different answers. More capable men and women than myself can lecture for hours on critical appraisal and research in general practice. I am only hoping to show that a sensible, preliminary answer can often be found without a lot of pain if our heart so desires. The example is described solely to illustrate its simplicity (hence the title) and the ease with which an answer can sometimes be found. The search, the analysis, together with the writing, was accomplished between seeing patients during a relatively quiet morning session. It was indeed quite an interesting exercise and a lot of fun. The only resources used were: a desktop computer with Internet access, standard medical textbooks, some spare time and common sense. What I do want to recommend is this: a spirit of inquiry.

Family Medicine has come a long way since its humble origin in general practice. It has spread like an epidemic and is now endemic in many parts of the world. It has become almost impossible to eradicate. Our Editor, Dr David Chao, asked in a previous editorial "How can we help?".⁵ I would like to ask the opposite question: How can we sabotage? How can we make Family Medicine go away like some annoying pests? An earthquake will not do it. A genetically engineered virus that selectively wipes out all the family physicians on this earth overnight will not do it. Because patients will demand it and doctors will certainly rediscover or reinvent it. However, the day we give up our right to ask questions, the day we stop asking who we are and what it is that we do, the day we stop looking for answers to our own unique problems, then and only then, will we see the demise of Family Medicine.

If we do have a question to ask, an issue we wish to clarify with our fellow practitioners or a point we would like to make, what options do we have? The Hong Kong College of Family Physicians has hosted a bulletin board for members at www.hkcfp.org.hk. At the time of writing, the number of topics on the board is the geometrically perfect zero! If any reader does not already know about it, this may be the perfect starting point to post questions that are encountered in one's practice, discuss the answers and share experiences and opinions. If we pool our experiences and talents together, everyone will benefit.

If we start asking questions, we may get some answers.