DES used as a postcoital contraceptive ; for abortion purpose
1976 Study Abstract
Despite growing controversy surrounding its use as a “morning after pill,” diethylstilbestrol (DES) is prescribed liberally for rape victims. Guidelines for its use in these patients is lacking. Of 150 consecutive rape victims treated at a university medical center, 63 (42 percent) received prescriptions for DES. Of the 55 (87 percent) on whom follow-up was obtained, in 40 (73 percent) there were substantial side effects—nausea or vomiting, or both. At least six (11 percent) did not complete therapy because of these side effects.
The authors offer guidelines for use of DES for rape victims and a plan for patient education and follow-up.
There has been growing interest in the medical community in improving the health care of rape victims. A chief medical concern during emergency treatment of these patients is prevention of pregnancy. This is usually accomplished in susceptible patients by the prescribing of high doses of diethylstilbestrol (DES), a synthetic estrogen commonly used as a “morning after pill.”
However, recent concern about the use of this drug has been voiced from many quarters-the health profession, lay groups, and government. This concern springs from the results of recently published research implicating DES with subsequent vaginal tumors in female offspring of mothers who took the medication during pregnancy.
The Food and Drug Administration has consequently called for more stringent criteria for use of DES, including the recommendation that should a patient taking DES subsequently discover herself to be pregnant, pregnancy termination be strongly considered.
Historically, rape victims served as the original experimental group in whom DES was tested as a postcoital contraceptive. With tightening controls and narrower indications for use of DES, the Food and Drug Administration (FDA) and congressional critics may in the near future allow its liberal use only in such extreme circumstances as rape, leaving rape victims one of the few groups for whom DES is routinely prescribed.
In light of this growing concern about the use of DES, a careful clinical review of experience with this drug in the emergency management of rape victims is in order.
For the past 12 months the Department of Family, Community. and Emergency Medicine of the University of New Mexico School of Medicine has developed a program to improve the crisis and follow-up health care of rape victims and their families at the Bernalillo County Medical Center (BCMC) in Albuquerque.
Under the new program, when a rape victim comes to the emergency room, a member of the department’s Rape Contact Team, on 24-hour call, is immediately notified. The team member comes to the emergency room and counsels the victim, preparing her for medical examination by a gynecologist and possible questioning by police. The team member stays with the victim throughout the emergency room experience. Follow-up appointments to the Family Practice Clinic are made within two to three days to assess emotional progress, physical status and compliance with medication regimens. If victims fail to keep appointments they are either given new appointments or an attempt is made to establish contact by telephone or home visit.
Gynecologic examination of rape victims in the emergency room is carried out by gynecology residents rotating through the inpatient obstetrical service. During the time covered by this article no firm criteria guided the resident’s prescribing of DES for victims of rape. Major side effects (nausea, vomiting, altered menses) and potential hazards (if pregnant) of DES therapy were generally described to each patient to whom the medication was offered. The patient herself made the final decision concerning its use. When prescribed, the dose of DES was 25 mg given orally twice a day for five days. In most instances an antiemetic medication, prochlorperazine (Compazine®) or trimethobenzamide (Tigan®), was prescribed prophylactically to diminish nausea.
Rape Contact Team members kept careful records of 150 consecutive rape victims treated at the BCMC. Doctors’ prescribing patterns for DES and patients’ compliance with and reaction to the prescribed drug were recorded. Since most of the patients received the full extent of their follow-up care within a week after initial emergency room contact, data on long-term reactions to DES in this population are scant and not reported here.
Of the 150 rape victims seen, 87 (58 percent) did not receive (DES). The reasons are listed in Table 1.
Of the 63 victims (42 percent) for whom DES was prescribed, follow-up information on patient compliance and drug side effects was obtained in 55 (87 percent) (Table 2). In 40 of these victims (73 percent) there were substantial side effects from DES therapy. In six ( 11 percent) reactions of such severity occurred that the course of DES could not be completed despite the addition of antiemetic medication. Most patients who experienced nausea noted its tendency to subside spontaneously by the second or third day, frequently disappearing completely.
In two patients receiving prochlorperazine as a prophylactic against nausea, severe dystonic reactions developed necessitating both emergency treatment of the reaction and cessation of administration of the antiemetic drug.
Kuchera reported the incidence of side effects in a sample of 1,000 women receiving DES as a postcoital contraceptive (few rape victims were included) to be 55 percent. These side effects consisted almost exclusively of nausea and vomiting. Such side effects occurred in a substantially higher proportion (73 percent) of rape victims receiving DES in our study.
It is tempting to speculate that the emotional upset of sexual assault magnifies the side effects of DES. However, Hall, reporting on experience with the use of DES in 71 women at a college health clinic (presumably few of the patients being rape victims), noted that in 71 percent nausea vomiting or both developed, a rate similar to our own. Spontaneous subsidence of nausea over several days has been well documented. This fact should be noted for each patient receiving DES.
An important outcome not reported in either of the above studies is the rate of failure to complete the full course of treatment with DES because of these side effects. Our services uncovered the fact that at least 11 percent of patients did not complete DES prophylaxis. This rate must be considered by physicians when recommending this medication.
The physical and emotional trauma of rape is so severe that health workers try to alleviate suffering by all possible means. This attitude has tended to favor a more liberal use of DES for rape victims in the belief that the discomfort of nausea and vomiting is a lesser evil than suffering the risk of an unwanted pregnancy and abortion.
Almost all victims taking DES voiced a strong desire to rid themselves of the physical and emotional vestiges of the sexual assault. They considered pregnancy prevention very important. In many cases, fear of pregnancy was the main reason for their seeking medical attention.
However, on follow-up visits, many victims and their health providers found that the victim’s prolonged nausea and vomiting drastically interfered with their ability to return to normal function and greatly compounded their already severe emotional distress, complicating the treatment effort.
Conclusion and Recommendations
There is no absolute indication for use of DES as a postcoital contraceptive in the emergency management of a rape victim. The decision to employ this drug must be made after allowing the patient to weigh the risk of pregnancy and abortion against the likelihood of DES side effects. The physician’s role is to offer options.
In light of the above findings we offer the following recommendations:
- DES should be offered as an option to every fertile, unprotected female rape victim if she is seen within 72 hours of the assault, if the assailant’s penis penetrated her vaginally and if she is in the intermenstrual phase of her cycle. Though failure to find motile sperm in the vaginal aspirate or noting that the patient is near to her menses diminishes the risk of pregnancy, this risk is not eliminated. The patient should be allowed to weigh these risks and come to her own decision about taking DES.
- Every rape victim for whom DES is prescribed should receive a simply written handout describing the drug, how it is taken, the likelihood of side effects and the potential dangers to the unborn fetus. A sample currently in use at the BCMC emergency room is provided. It should be noted that while the FDA has ordered that each prescription of DES be accompanied by a patient booklet setting out warnings and instructions in greater detail, such booklets have not yet been developed.
- Each rape victim receiving DES should be contacted within 48 to 72 hours of beginning the medication to assess the presence and degree of side effects, the impact of DES on daily activities and feelings about continuing the medication.
- If an antiemetic is prescribed prophylactically with DES, use of prochlorperazine should be avoided because of its relatively high rate of side effects.
The physician should offer the patient clearly understood, realistic alternatives and early, supportive, follow-up care. Doctor-patient rapport will be enhanced in this way and, should side effects to DES occur, knowledge of their presence will be shared with the physician, leaving the patient less frightened, upset and alone.
- THE WESTERN JOURNAL OF MEDICINE, DIETHYLSTILBESTROL AND RAPE VICTIMS, NCBI PubMed PMC1237330, 1976 Oct.
- Information sheet for rape victims about diethylstilbestrol (DES) featured image THE WESTERN JOURNAL OF MEDICINE.