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Lily Alexander is a public health practitioner with a reproductive health focus who’s based in Seattle, Wash. She currently runs a project, Miss Morning After, to improve teen access to emergency contraception in the Seattle metro area.

If you watched “Shrill,” you might’ve been shocked to learn that the over-the-counter form of the morning-after pill is less effective for women over 175 pounds. Annie, the Hulu series’s young, fat female protagonist played by Aidy Bryant, finds out she’s pregnant in the pilot episode. She’s flummoxed, because she took the morning-after pill in the wake of unprotected sex.

When Annie asks a pharmacist for an explanation, the woman replies, “The morning-after pill is only dosed for women 175 pounds and under.”

The average weight of a woman over 20 in the United States is 170.6 pounds, according to the most recent survey data from the Centers for Disease Control and Prevention.

“Shrill” provides one of the first television portrayals of fat women’s experience with the morning-after pill. What the show fails to mention is that there’s a form of emergency contraception known to be more effective for heavier women: Ella.

Unfortunately, since Ella’s approval by the Food and Drug Administration in 2010, it remains prescription only.

Differences between over-the-counter emergency contraceptives

For nearly a decade, there’s been growing evidence about the ineffectiveness of over-the-counter emergency contraception options for overweight women. While “Shrill” references women 175 pounds and over, some clinical trials have identified 165 pounds as the threshold for decreased effectiveness (which is even more alarming).

A 2011 study found that obese women — those with a body mass index of 30 and above — who had taken over-the-counter forms of the morning-after pill were more than three times more likely to get pregnant than non-obese women. More recent studies, like these from 2016 and 2017, have produced similar results.

These studies are well-known within the reproductive health community. Yet, disappointingly, it took a Hulu show for this information to reach the general public.

Unlike existing over-the-counter options, Ella (ulipristal acetate), is effective for women up to 195 pounds. Ella’s drug label says that it works up to five days after unprotected sex, whereas the label for current over-the-counter options — think Plan B One-Step, Take Action and My Way — says you have three days (but please note, any pill should be taken ASAP). The bottom line is this: For heavier women, Ella is more effective than Plan B at any point.

The additional time buffer that Ella provides could be critical for many women, who may need to jump through myriad geographic, logistical and social hurdles to get the morning-after pill. As a public health practitioner, I’ve heard from some women who said they had to visit three pharmacies before they were able to find the morning-after pill. Others recounted having to ask various friends for money to scrounge up the amount needed to cover the cost of emergency contraception. And some young women reported being told by pharmacy staff that they must be 18 to buy the pill, despite the fact that it is legally available at any age.

Barriers to access

Ella has a similar safety profile to existing over-the-counter morning-after pill options, and many other countries, including those in the European Union, have moved Ella to over-the-counter status.

But despite Ella’s advantages for heavier women, lengthier window of effectiveness and proven safety, the FDA requires a prescription for the drug. This is likely because Ella is newer to the market, and the FDA requires companies to take multiple steps to transition a drug from prescription to over the counter. But Ella’s prescription status poses a major barrier to American women; most people are not able to see a doctor within the short time frame in which the morning-after pill is effective.

According to Kelly Cleland, a researcher at Princeton University and the executive director of the American Society for Emergency Contraception, Ella’s limited availability is partially due to limited demand.

Plan B One-Step, known colloquially as Plan B, has been around much longer than Ella, Cleland says. The Plan B One-Step company has done extensive marketing, and they’ve been so successful that Plan B has become synonymous with emergency contraception.

“Plan B is over the counter, so people think about Plan B, they go to the pharmacy, they get it, and it’s over,” Cleland says. “Patients haven’t heard of Ella, so they don’t ask about it, so providers also don’t know about it and are not prescribing it. And pharmacies aren’t going to stock something that doctors don’t prescribe because it is expensive to stock drugs that may or may not sell.”

A 2018 study that surveyed pharmacies in 10 large U.S. cities found that fewer than 10 percent of pharmacies had Ella in stock.

So, if someone had unprotected sex on a Saturday night, and managed to get a last-minute appointment with a health-care provider on Monday, that person might still need to wait 24 hours for the pharmacy to fill a prescription for Ella, because the medication may not be in stock.

The route to greater availability, Cleland says, is by pushing for Ella to be available over the counter.

“Ella has been on the market for over eight years, and still no one is using it. Clearly its existence is not enough,” Cleland says. “Going over the counter is the only thing that is actually going to make this widely available, especially for women at higher weights.”

In the case of Plan B, the medication was approved by the FDA in 1999 and became available over the counter for those over 18 in 2006. (It took another seven years before Plan B was available to anyone of any age.)

It is time for us to stop prioritizing thinner bodies in our research, health services and policies and make Ella an over-the-counter medication. Women of all sizes should have safe and easy access to effective emergency contraception.

Millions of women — real-world Annies — are counting on us.

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