Women using the contraceptive pill currently require a prescription from a doctor and to return once a year to renew it. But recent research suggests the relative safety of this oral contraceptive means we should consider making it more freely available.
For many women, the current model can involve a fair bit of effort – significant forward planning to get an appointment before the prescription runs out, an often lengthy wait to see the doctor and a hefty consultation fee – for a few minutes in the doctor's surgery to have a prescription renewed.
A recent research article has stimulated debate about the value of providing women with oral contraceptives, without having to go through all this.
While the position is supported by the American College of Obstetricians and Gynecologists, the Australian Medical Association has spoken out against the suggestion, even for experienced pill users.
But why shouldn't women be in charge of their own contraception if it's safe for them to do so? Let's consider some of the arguments for and against providing oral contraceptive pills over the counter.
Why it's a good idea – access
The requirement to keep returning to the doctor for repeat prescriptions can be expensive, and time consuming.
For young women, those who are socioeconomically disadvantaged, and others who find it difficult to access the health system, these barriers can be considerable. Both doctors and patients can be embarrassed about discussing sexual matters.
Without easy access to effective hormonal contraception women may not use any birth control at all, or they may rely on less effective methods (such as condoms or the withdrawal method).
And anyway, the emergency contraceptive pill is already available over the counter at pharmacies in Australia, so why not include other oral contraceptives as well?
In the United States, up to 30% of women who don't currently use contraception, or use a less effective method say they would probably start taking the pill if they could get it without a prescription.
For some women, the doctor's visit is a significant barrier to using hormonal contraception, so making it available in pharmacies will lead to more, and more effective, contraceptive use, and fewer unintended pregnancies.
Why it's a bad idea – health risks
Taking combined oral contraceptive pills has potentially serious health consequences.
The most dangerous of these is blood clots. Although rare, the sudden death of a healthy young woman because of a blood clot is shocking. Sadly this can happen even with the current requirement for a doctor's prescription.
Although many doctors thoroughly screen women and inform them about oral contraceptive use, the quality of consultations is variable. Reasons why a woman shouldn't take the pill can be missed, or simply be unknown, particularly for young women.
Thorough Medical Eligibility Criteria have been developed to minimise the risk of serious adverse events from using oral contraceptives. Women with hypertension, migraines with aura, a history of venous thromboembolism, or smokers at age 35 years or older, for instance, are at higher risk of adverse events and should not take the combined oral contraceptive pill.
Without proper screening by a doctor, there's a risk that factors that should stop women from taking the pill will be missed.
Why it's good – availability
Many women wish they could purchase their contraceptive pills over the counter.
In the United Kingdom, a pilot program evaluated the feasibility of community pharmacy providing combined oral contraceptives, progesterone-only ("mini") pills as well as information on and referral to long-acting reversible contraception.
Women participating in the study said they valued the convenience, anonymity, drop-in system, long opening hours and lack of waiting time.
Appropriately trained health-care professionals, including nurses and pharmacists, could effectively assist women with contraception. And they could do this using current eligibility criteria, just as doctors do.
Could concern about maintaining professional territories be denying women better access to contraception?
There's no reason why women couldn't get advice about their contraceptive options from pharmacies or other community settings. This advice could include referral to see a doctor or specialist as required
Why it's bad - sexual health screening
Doctors argue that having women visit them for a new pill prescription ensures they have a regular Pap test, breast examination and sexual health check.
While all these checks are undoubtedly important, there are many women who don't take the oral contraceptive pill, so the logic of this argument is not entirely satisfying. It's akin to the suggestion that condoms or aspirin should be provided by prescription so men visit a doctor for prostate examinations!
What's more, in Australia, women are advised to have a Pap test every two years and those guidelines are currently under review in light of the effectiveness of the HPV vaccination program on cervical abnormalities. And we have evidence that rates of sexual health screening remain high among women who get oral contraceptive pills over the counter.
It's also worth noting that the American College of Obstetricians and Gynecologists states screening for cervical cancer or sexually-transmitted infections is not medically required to provide hormonal contraception.
The uptake of the very effective long-acting reversible contraceptives (such as IUDs and implants) is low in Australia. Evidence from the CHOICE project indicates women choose long-acting methods when offered good information and cost-effective access.
The low uptake in Australia may be an indicator that doctors are not able to spend time with women discussing all the contraceptive options available.
We need to provide easy access to contraception and contraceptive information, while balancing the potential risk for side effects and adverse events.
Perhaps the way forward is to trial providing the progesterone only pill over the counter for a start because most women can take it with little risk.
What do you think?
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