Should the Pill be offered over the counter?

    Correction appended

    Your alarm clock goes off. It’s 6 p.m. — time to take your birth control pill. You shuffle over to your desk and pull open a drawer, only to find that your packet of Yaz is completely empty. Worse yet, your prescription is out and you’ll have to make a doctor’s appointment to renew it. Damn, you knew there was something you forgot to do this week. If only birth control was as easy to pick up as Advil and Tylenol.

    Sound familiar? Chances are many Northwestern women have experienced similar situations. Weinberg freshman Lindsey Kreutzer knows the feeling well. Her health insurance plan only allows her to receive one packet of the Pill at a time, which means that at the end of every month she needs to head back to CVS in time to refill.

    “It makes me really nervous,” said Kreutzer, who is well aware of the necessity of taking the Pill consistently.

    The Pill is the most widely used form of contraception among unmarried, college-educated women in their teens and twenties, according to the Guttmacher Institute, a group that uses research, policy analysis and education to improve sexual and reproductive health.

    “We don’t make men get prostate exams before they buy condoms.”
    -Dan Grossman, OB/GYN and senior associate at Ibis Reproductive Health

    However, difficulties procuring the Pill often cause lapses in use, which can result in unplanned pregnancy. Half of all women at risk of unintended pregnancy are not fully protected because they don’t use a contraceptive, use it inconsistently or incorrectly or have gaps in use of one month or longer, according to a study done by the Guttmacher Institute in 2004.

    When asked why they failed to use contraceptives properly, the most commonly identified reason among at-risk women was problems accessing or using their contraceptive. This is causing women’s health advocates and gynecologists throughout the country to work to increase the accessibility of the Pill, with some even campaigning for oral contraceptives to be offered over-the-counter.

    The dream of popping over to a local CVS to pick up birth control pills without a prescription may someday become reality, but we’re still far from that point. Currently, no applications for over-the-counter oral contraceptives are filed with the Food and Drug Administration, according to Sneha Barot, senior public policy associate at the Guttmacher Institute. In the meantime, plenty of research is being conducted and efforts are being made to de-link birth control pill prescriptions and vaginal exams in order to make birth control easier.

    “We don’t make men get prostate exams before they buy condoms,” said Dan Grossman, OB/GYN and senior associate at Ibis Reproductive Health, of the vaginal exams that doctors often require before issuing a birth control prescription.

    A long fight
    The battle for contraceptive availability in the United States has been long and hard-fought. The taboo surrounding birth control dates back to 1873 when Congress passed the anti-obscenity Comstock Act.

    This law lumped the distribution of birth control into the same category as the distribution of pornography, creating a taboo around contraceptives that lasted long after the ban of birth control was declared unconstitutional in 1936.

    It may be largely because of this sense of taboo, rather than medical evidence, that birth control pills are only offered through a prescription today, according to Barot.

    “Basically, the medical community became a gatekeeper to accessing birth control and gave it legitimacy at the same time so it was no longer taboo but seen as something essential to women’s health,” says Barot, explaining some of the historical reasons behind restricted access to the pill.

    However, old reproductive health standards are being altered left and right these days. Between the legalization of over-the-counter Plan B and President Obama’s reversal of the abortion gag rule, it seems as though many of the contraceptive norms of past generations are rapidly changing.

    Breaking down the barriers
    Aside from the age-old taboo against contraceptives, it seems that there must be some medical reason behind restricted access to oral contraceptives. But many doctors argue that this is not the case.

    “You can start most women on a low-dose pill and the vast majority will do very well on it,” says Dr. Cassing Hammond, director of the Section and Fellowship in Family Planning and Contraception at Northwestern’s Feinberg School of Medicine. “The biggest risk is not the Pill, it’s an unplanned pregnancy,” he adds.

    The Pill contains a combination of estrogen and progestin, both of which naturally occur in the body, that prevent women from releasing an egg each month, making the chances of conception very slim. Because the levels of estrogen present in the Pill today are very low, there are very few negative side effects associated with taking oral contraceptives. There is no aspect of the Pill that necessitates a vaginal exam before prescription, according to experts.

    “Contraception became intertwined with other women’s health services. For example there were things like Pap smears and pelvic exams or screening for [sexually transmitted infections] that became part of a package of things included in these visits,” Barot said.

    It’s important to screen women for a history of heavy smoking and high blood pressure, both of which may make women more likely to form blood clots, a very rare side-effect of the pill, according to Hammond. But while Pap smears and screening for STIs are crucial aspects of gynecological health, they aren’t necessary for a doctor to give a prescription for the Pill.

    “We need to inform women about the importance of pap screening but not hold their contraception hostage,” Grossman said.

    The final barrier: a doctor’s prescription
    Recent studies show that women may be able to accurately screen themselves without a doctor’s help for conditions that would make taking oral contraceptives dangerous.

    Women can accurately assess themselves for contraindications to taking birth control pills by following a simple checklist, according to a study published in Obstetrics and Gynecology in 2008. When given a checklist of medical conditions that make taking the Pill risky, only 6.6 percent of women mistakenly thought they were safe to use the Pill.

    Evaluations and prescriptions were actually put in the hands of the pharmacists in a study done by researchers at the University of Washington in 2008. Women filled out a checklist and were evaluated by a pharmacist to determine if they were good candidates for the Pill and several other contraceptive methods. If approved, they could obtain a prescription directly from the pharmacist, instead of a doctor.

    However, some say that this method would just replace one barrier with a new one. Pharmacists still have the right to refuse prescriptions for some medications, like birth control pills, in certain areas of the country.

    “I think that could be really harsh for people, just feeling the discomfort and the reality that there are some people who are going to judge the fact that you’re on birth control. People don’t hide their emotions really well and they can make it really uncomfortable to buy something that you’re getting for your health and safety,” said Kreutzer, who believes that giving pharmacists control over Pill prescriptions could make the situation even more difficult.

    Despite the positive findings of these studies, over-the-counter access to the Pill is a long way off and mountains of bureaucratic red tape stand in the way. A drug company first needs to file an application with the FDA. The company would need to prove the safety of over-the-counter use as well as develop an appropriate over-the-counter label that would allow women to safely screen themselves. After that, a panel of experts would need to review all of the evidence and vote on the issue before a high-ranking member of the FDA could give final approval.

    Furthermore, any movement to offer the Pill over the counter will face significant opposition. Some doctors fear that allowing women to obtain the Pill without visiting the doctor will mean that some women will skip visits to the gynecologist entirely. This could lead to a decrease in Pap smears and STI screening tests. Others worry about the cost of birth control increasing beyond affordable levels without the cost break provided by insurance coverage.

    Despite her desire for easier access to the Pill, Kreutzer also sees risks associated with such a move.

    “I do worry that it would be used without caution and thought by a lot of girls,” she says.

    Paving the Way
    In the meantime, doctors and health clinics are making efforts to increase accessibility to the Pill. Northwestern Health Services does not require a pelvic exam for a birth control prescription, according to Kathleen Parker, RN, unless one is deemed necessary for other medical reasons. Women are required to fill out a women’s health history form and then undergo a blood pressure test.

    The system used at Northwestern Health Services is very common. Planned Parenthood clinics offer similar access to the Pill. The nearest clinic can be located on Planned Parenthood’s Web site.

    While it is easy to obtain access to the Pill, there are still factors that may prevent women from consistent contraceptive practice. While some doctors will refill a prescription without an in-person visit, especially to those who have been on the Pill for a long time, others will not. At Northwestern Health Services, a woman is required to make an appointment once a prescription runs out.

    Receiving more pill packs is associated with a longer duration of usage, according to a study published in Obstetrics and Gynecology in 2006.

    “Women talk about the difficulties of getting in for an appointment: the long wait, the doctor’s hours are inconvenient, it’s hard to get off work or school,” said Grossman, of his experience in his own practice.

    To avoid constantly finding yourself with an expired prescription, ask your doctor for a year-long prescription, advised Grossman. Then, when you head to the drug store to pick up the pills, make sure you ask the pharmacist to give you the maximum number of packs dispensable at one time.

    Receiving more pill packs is associated with a longer duration of usage, according to a study published in Obstetrics and Gynecology in 2006. Women who took home 13 cycles of pills at once were 28 percent more likely to be protected 15 months later than women who received only three cycles of pills.

    Whether you forgot to take your Pill or ran out of your prescription, know that Plan B, a form of birth control that helps prevent pregnancy after you’ve already had unprotected sex, is available over-the-counter to anyone over age 18. Plan B reduces chances of pregnancy by 89 percent when taken up to three days after unprotected sex, according to Planned Parenthood. There are no serious complications associated with taking Plan B, and you can take it as often as you like, although your chances of becoming pregnant are even smaller if you use regular contraceptives like condoms or the Pill.

    Someday access to the Pill may be as easy as access to condoms or Tylenol. Until then, taking preventative measures and knowing your options may prevent that moment of panic the next time you open your desk drawer to realize your birth control pack is empty.

    Updated 10:46 p.m: The original version of this article referenced “sexually transmitted illnesses.” A more appropriate term is “sexually transmitted infections.” Thanks to commenter Olivia for pointing this out.


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