I am on the record as opposing over-the counter access to oral contraceptive pills.
It seems that stance now puts me at odds with the American College of Obstetricians and Gynecologists.
From the ACOG committee that drafted their recent recommendations:
In the interest of increasing access to contraception, and based on the available data, the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice makes the following conclusions and recommendations:
- Weighing the risks versus the benefits based on currently available data, OCs should be available over-the-counter.
- Women should self-screen for most contraindications to OCs using checklists.
- There are concerns about payment for pharmacist services, payment for over-the-counter OCs by insurers, and the possibility of pharmacists inappropriately refusing to provide OCs.
- Screening for cervical cancer or STIs is not medically required to provide hormonal contraception.
- Continuation rates of OCs are higher in women who are provided with multiple pill packs at one time.
My concerns about non-prescription status for OCs are several. The first is that even proper use of these medications puts a small but significant number of women (eg. those with a predisposition for blood clots, those with a specific kind of migraine headache, etc.) at increased risk of certain very serious, potentially devastating health problems (eg. stroke, blood clots in the lungs or legs).
Is a medical visit to screen for risk factors necessary? ACOG says no, and clearly believes a checklist is sufficient. Further, they note:
However, it is important to understand that the rate of venous thromboembolism for OC users is extremely low (3–10.22/10,000 women-years) … and to put this risk in context by recognizing the much greater risk of venous thromboembolism during pregnancy (5–20/10,000 women-years) or in the postpartum period (40–65/10,000 women-years) …
It’s very hard to counter that argument. Given that I prescribe OCs far less frequently than (presumably) the members of the ACOG Committee on Gynecological Practice, I am inclined to defer to their recommendations. Sort of.
I can understand and accept the reasoning that women should be trusted to do their own screening for certain high-risk conditions. And I obviously don’t dispute the science vis-à-vis the relative risk of OCs vs pregnancy. But it’s not merely to mitigate the risk of the former that I think medical visits for prescriptions are of value.
As I said in my earlier post on the subject:
[T]here are about 100 different formulations of OCP available. They vary in the type of hormones used, and the dosages throughout the cycle. Different hormones have different benefits and different side effects. Ortho-Cept is not the same as Ortho-Cyclen is not the same as Ovral. Why is it paternalistic for me to maintain that, after having gone through medical school, residency and a fellowship specifically tailored to this kind of medicine, I have expertise that might help women get the best care?
I suppose one could argue that patients already have to navigate a dizzying number of OTC medications, from treatments for allergies to acid reducers to analgesics. All of these different medications and formulations have different side effects and benefits, yet we trust consumers to wade through and pick their own choice. Why not with OCs? And I can accept that point of view. Perhaps women shouldn’t be required to get my advice about which formulation would be best for them. But given that some are better for women who have heavy, painful periods while others are better for women who also want help with acne and so on, it seems to me that a benefit is lost when OCs are obtained without a medical evaluation.
Finally, when I prescribe OCs, not only do I do a thorough risk evaluation and try to tailor the prescription to the patient’s needs as comprehensively as possible, I also review the proper way to take them, and what side effects they can expect. Admittedly, people do without this kind of advice when they take other OTC medications. But the stakes are different when the medications are for allergies or acid reflux than when they’re for contraception. An unintended pregnancy is a much bigger deal than persistent nasal congestion. When I start my patients on OCs, I discuss what to do if they miss a pill, which can vary a bit from one formulation to another, and what medications may interact and lower their effectiveness.
Do I delude myself that these instructions lead to perfect OC use? No. I would have to be a nincompoop to believe that, and my own experience from follow-up appointments with my patients belies that conclusion. Perhaps a set of written instructions will serve just as well. But I must admit I’m skeptical, and wonder if some of the benefits of non-prescription OC status would be alloyed with an increase in incorrect use and unintended pregnancy.
As I have also already stated, I certainly agree that using the prescription-only status of OCs to corral patients into one’s office for unrelated gynecologic care is bad medicine. It is paternalistic and coercive to do so, and of course I agree with ACOG’s penultimate bullet point above. While I also think there’s some value in doing at least one or two follow-up visits to make sure patients are tolerating the medication and using it correctly (as well as to do a blood pressure check), there is likely little need for such visits for patients who have been on OCs safely for years, and there is certainly no basis to demand they get a pelvic exam, even if doing so would be a good idea for unrelated reasons. Physicians who hold OC prescriptions hostage to such exams should be admonished to stop.
All of this is to say that I’ve softened by earlier position, and wouldn’t actively oppose making OCs available without a prescription. It seems relatively convincing that the benefits of doing so outweigh the costs. But I definitely think there would be a cost in doing so. I worry that checklists may be inadequate to prevent some high-risk women from starting OCs and suffering adverse effects. I worry that, absent counseling about warning signs of such things as blood clots in the leg, some women may not realize they are related to their medication and might not give them proper heed, delaying medical intervention when time may be of the essence. And I worry that other undesirable outcomes, while less dire, may still come to pass, even if it’s as simple as taking one pill when another will work better.
Do I think women must see a medical provider before they have access to OCs? I guess not as much as I used to. But I still think it’s a good idea to see one anyway.