No, prescription-only hormonal contraception is not extortion

by Russell Saunders on March 12, 2012

Post image for No, prescription-only hormonal contraception is not extortion

It is one of my signal frustrations to come across articles or statements attributing some standard aspect of patient care to self-interest on the part of doctors.  Perhaps I am overly generous with my peers, but I generally think most of us went into medicine for reasons other than money, and hearing money cited as the reason we do what we do sets my teeth on edge.

Thus, it was with rising indignation that I read Virginia Postrel’s column (via Andrew Sullivan) arguing in favor of over-the-counter access for hormonal contraception.  Not only do I think she’s wrong about it being a good idea for patients, I think she’s being incredibly unfair to medical providers in the way she describes the current prescription requirement.

Anyone — a local teenager, a traveling businessman, a married mother of four, an illegal immigrant, even a student at a Jesuit university — can walk into my neighborhood CVS any time, day or night, and, for less than $30, buy a 36-count “value pack” of Trojan condoms.

That’s enough to last most Americans at least three months, according to Kinsey Institute surveys. If you want more, you can buy out the store’s entire stock. There’s no limit, and you don’t need to see a doctor for permission and a prescription.

Contrary to widespread belief, there’s no good reason that oral contraceptives — a far more effective form of birth control — can’t be equally convenient.

True, making the pill available over the counter could reduce the amount of outrage and invective available for entertaining radio audiences, spurring political fundraising and otherwise amusing the American public. But the medical risks are quite low.

That last is not entirely true.  The medical risks for most women are quite low.  But for certain women, the risks are actually quite a bit higher.  Women who have a certain kind of migraine headache are at increased risk of stroke if they take most forms of oral contraceptive pill (OCP), particularly if they smoke.  The same applies to women with high blood pressure, which is almost always undetectable without a medical exam.  Certain kinds of clotting disorders can make OCPs very dangerous, and while taking a detailed family history may not detect everyone with these disorders, it’s a lot better than not asking at all.  The list of risk factors is not as short as Postrel implies.  Who will do that screening and counseling about this risk if OCPs are available without a prescription?

Requiring a prescription “acts more as a barrier to access rather than providing medically necessary supervision,” argues Daniel Grossman of Ibis Reproductive Health, a research and advocacy group based in Massachusetts, in an article published in September in Expert Review of Obstetrics & Gynecology.

And this is me arguing back.  (Unfortunately for all of us, Dr. [I assume] Grossman’s article cannot be accessed without a subscription, so I cannot speak to its quality.)  Yes, a prescription does create a barrier to access.  Sometimes barriers actually exist for a reason.  Requiring women to meet with their medical providers to have a thorough discussion of their risk factors actually does them a service.

Birth-control pills can have side effects, of course, but so can such over-the-counter drugs as antihistamines, ibuprofen or the Aleve that once turned me into a scary, hive-covered monster. That’s why even the most common over-the-counter drugs, including aspirin, carry warning labels. Most women aren’t at risk from oral contraceptives, however, just as most patients aren’t at risk from aspirin or Benadryl, and studies suggest that a patient checklist can catch most potential problems.

The difference between drugs like Benadryl or Aleve is that, at the dosages one is instructed to use on the packaging, the risk of life-threatening side effects is minimal.  With OCPs, taking the pills exactly right doesn’t lower their risk.  [Edited to add:  It occurs to me that yes, taking OCPs right does, in a sense, lower their risk.  If you take them wrong, the risk is higher.  But the increased risk of clotting comes with perfectly correct use, not overdosage.]

Postrel doesn’t link to any of those studies touting the efficacy of checklists at catching at-risk patients, so again we’ll have to take her word for it, I guess.  However, one assumes those checklists will be reviewed by pharmacists, who will be doing in a more cursory fashion (and, one also guesses, for free) what I do when I meet with patients to discuss starting OCPs.  I take half an hour to ask about their risk factors, check their blood pressure, review the correct use, and discuss warning signs of potentially life-threatening adverse effects.  A checklist will accomplish the same thing?  Or are we hoping that pharmacists will somehow function as quasi doctors, taking the same time and care but without expecting payment for the additional labor?

To further increase safety, over-the-counter sales could start with a progestin-only formulation, sometimes called the “minipill,” rather than the more-common combinations of progestin and estrogen. (Although we casually refer to “The Pill,” oral contraceptives actually come in about 100 formulations.)

Progestin-only pills, or POPs, have fewer contraindications. Unlike combination pills, they’re OK for women with hypertension, for instance, or smokers over the age of 35. The main dangers are fairly rare conditions such as breast cancer or current liver disease. “Not only are POP contraindications rare, but women appear to be able to accurately identify them using a simple checklist without the aid of a clinician,” declares an article forthcoming in the journal Contraception.

And here’s where I started a go a little nuts.  It is true that POPs are safer than OCPs containing estrogen, which is what increases the risk of clots.  However, pulling down my handy-dandy textbook, I can confirm that they are also less effective than combination OCPs, and are harder to use.  POPs must be taken at the same time every day, and patients cannot miss a pill and double up the next day like they can with combination pills.   They are a very fastidious medication, and for that reason I hardly ever prescribe them.  So, sure, it would probably be safe to make them available without a prescription, but with the notable downside that women may getting worse contraception than they think, particularly since nobody would be giving them detailed instructions.  (As an added downside, they cause menstrual irregularities in many or most women who take them.)

Aside from safety, the biggest argument for keeping birth- control pills prescription-only is, to put it bluntly, extortion. The current arrangement forces women to go to the doctor at least once a year, usually submitting to a pelvic exam, if they want this extremely reliable form of contraception. That demand may suit doctors’ paternalist instincts and financial interests, but it doesn’t serve patients’ needs. As the 1993 article’s authors noted, the exam requirement “assumes that it would be worse for a woman’s health to miss out on routine care than it would be to miss out on taking oral contraceptives.”

And here’s where I went completely nuts.  Extortion?  What a stupid, reprehensible overstatement.  I love that “aside from safety” bit  Aside from the cold, there’s no reason not to skinny sip in Juneau.  It is precisely for reasons of patient safety that OCPs are prescription-only.  Period.

Now, one might argue that patients who have taken OCPs safely for years should be able to get extended renewals without a follow-up exam.  I would counter that it is the standard of care for any long-term medication to require regular follow-ups, be it for antidepressants, acne medications, whatever.  We do them to make sure the medication is still working, to make sure patients aren’t having side effects they’re overlooking or tolerating that couldn’t be improved by changing medications, and so forth.  Doubtless this kind of oversight would full into the bucket that Postrel calls “paternalism,” but I prefer to think of as taking appropriate care of my fishing patients!  At the very least women should get annual blood pressure checks to make sure their risk factors for continuing to take OCPs haven’t changed.

I will also grant that pelvic exams should not be necessary for women to get OCPs.  As the reasons for doing them on adolescent girls are very limited, I perform them rarely and don’t require them for OCPs prescriptions.  However, as women get older they get more and more important as a screen for cervical cancer, and so annual pelvic exams are a good idea.  I can see an argument that pinning OCP renewal on having them is coercive, which speaks again to the notion of extended refills, but that’s not the same thing as extortion.

Postrel’s affection for a more laissez-faire approach to patient care really comes into full flower at the end:

Right now, the American women who have the most choice are those who live near the border with Mexico, where pharmacies sell oral contraceptives without a prescription, generally for about $5 for a one-month supply. A group of researchers including Grossman have conducted extensive interviews with more than 1,000 women who live in El Paso, Texas. Roughly half the women get birth-control pills from local clinics, often free, while the other half go across the border to pharmacies in Ciudad Juarez. The researchers find, not surprisingly, that those who cross the border have more ties to Mexico; 77 percent were born there, compared with 60 percent of clinic users. But there are also differences in priorities.

“Among pharmacy users, very large percentages noted both not having to go to a doctor to get a prescription and being able to send a friend or relative to pick up their pills as advantages of Mexican pharmacies,” the researchers write in a June 2010 article in the American Journal of Public Health. Clinic users, on the other hand, cite low cost and the availability of other health services.

Mexico!  Where you can get all kinds of wonderful medications without a prescription!  Why bother going to a doctor at all?  Just fire up WebMD and book a ticket to Tijuana.

This post has already gone on too long, so I need to wrap it up.  Let me conclude with this — as Postrel herself notes, there 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?  (Is there a similar push with other professions?  Are people out there touting pro se legal representation?)  Yes, it is inconvenient to take time out of one’s day and come see me.  But there is value in doing so!  Just because something is easy doesn’t mean that it’s good.

{ 51 comments }

1 Jaybird March 12, 2012 at 2:19 pm

Is Norplant and/or Depo still in use?

If they’re still around, did they require similar regular checkups?

2 Russell Saunders March 12, 2012 at 2:41 pm

Norplant isn’t used much with adolescents, as far as I’m aware, so I don’t have any real experience managing it.

I prescribe Depo all the time. However, since it requires an injection every three months, that gives a good opportunity to do a brief follow-up check. It also recommended that it be stopped after two years, because it alters bone mineral density.

3 Jaybird March 12, 2012 at 2:53 pm

Hrm… why isn’t Norplant used with adolescents? It seems like the absolute *PERFECT* window for it… I mean, if there’s a five year period where the person is most likely to need as-close-to-foolproof-as-we’ve-yet-gotten contraception, it’s between the ages of (adolescent window). Okay, maybe two treatments.

4 Russell Saunders March 12, 2012 at 3:07 pm

I should have just confirmed what I’d suspected before I replied to your first comment — Norplant is no longer available in the United States at all. There were legal issues surrounding side effects, difficult removal, etc., so nobody of any age can get it here any longer.

5 Jaybird March 12, 2012 at 3:19 pm

Ah, of course. When it first hit the scene, it was hailed as the next big thing. Five-year contraception! Finally!

I hadn’t heard anything about it in quite a long time… I suppose I should have jumped to the conclusion that that was because it didn’t live up to the hype rather than because it was just part of the background noise of daily living.

6 Will Truman March 12, 2012 at 5:12 pm

Up until I met my wife and became acquainted with all of the forms of birth control, the safety issues were actually all I knew about Norplant. I only vaguely knew it was a form of birth control. Then again, I come from a litigation-happy state, and I was probably informed of the safety issues by way of scary ads from lawyers wanting to sue the maker. Wyeth, Norplant’s maker, never actually lost a lawsuit, but ended up scotching it anyway due to the repetitiveness of the litigation.

I do think (without much basis) that the fear surrounding Norplant is one of the reasons that IUDs never took off. Up to ten years of birth control! Wait… they are putting what, where now? It isn’t the same as Norplant, but I mildly suspect surgical insertions got a taint by it.

7 Mary March 12, 2012 at 6:39 pm

“I do think (without much basis) that the fear surrounding Norplant is one of the reasons that IUDs never took off.”

I understand IUDs had issues in the 1970s (from what I read, I wasn’t alive at the time), but I feel like they are more widely used now. That could be because numerous women I know have them, including myself.

8 Mike Schilling March 13, 2012 at 2:10 am

One IUD in particular was associated with so many serious health problems that it pretty much killed the market for them: http://en.wikipedia.org/wiki/Dalkon_Shield .

(Many years ago, I was a juror in one of the liability suits filed against its manufactures,)

9 Mike Schilling March 12, 2012 at 2:28 pm

Certain kinds of clotting disorders can make OCPs very dangerous,

I first read this as “clothing disorders” and thought “Janet Jackson can’t take them.”

10 Rose Woodhouse March 12, 2012 at 3:35 pm

Aside from safety, the biggest argument for keeping birth- control pills prescription-only is, to put it bluntly, extortion.

Is it just me, or does saying “the biggest argument” sort of imply that it’s an argument people actually make? I mean, I’m not up to date on my subscription to Evil Cackling Tented-Fingered Moneygrubber Monthly, but are doctors going around actually saying “This is an excellent way to boost our bottom line!”? If not, couldn’t it be phrased as “I suspect” or “I worry” that doctors may be motivated by something other than patient health?

11 Russell Saunders March 12, 2012 at 3:38 pm

You never should have let your subscription to the New England Journal of Graft lapse.

12 DensityDuck March 12, 2012 at 5:33 pm

“Yes, it is inconvenient to take time out of one’s day and come see me. But there is value in doing so! Just because something is easy doesn’t mean that it’s good. ”

Great, I’ll negotiate with two different bosses to A: convince them that I need more than just condoms and B: that it really is okay for me to leave one job an hour early and get to the next an hour late, then go spend forty-five minutes in the waiting room of a doctor I’ve never seen but is the only one who had an appointment available in the next six months, talk to him for ten minutes, then pray that the traffic isn’t so bad that I’m later for the second job than I already am.

Because, y’know, it’s really important that I spend that ten minutes talking to some guy before I can get those pills. (Weekend? Evening? What, you expect a medical provider to be available?)

13 Russell Saunders March 12, 2012 at 5:40 pm

Life sucks and then you die, Duck. It is unfortunate that contemporary medicine has thus far failed to be totally convenient for everyone, and apparently that comprises the sum total of your argument for sidestepping it entirely. Me? I think we do some good, sufficient that it’s worth the inconvenience. Similarly, if my bathtub floods my kitchen, I have to make allowances in my day for the plumber to arrive. I’ve laid out why I think it’s important in the post, and you obviously disagree. Fine. You “win,” I guess.

14 DensityDuck March 12, 2012 at 6:23 pm

Wow, talk about privilege. I guess if you can’t afford to take an unspecified amount of time to the doctor so he can rubber-stamp a prescription then you just don’t deserve to have birth control.

15 Russell Saunders March 12, 2012 at 6:31 pm

Duck, ol’ buddy ol’ pal, please read the post I wrote above and pay attention to what it is I say I do. I don’t “rubber stamp” anything. To what degree that convinces you of anything, I could not possibly care less.

16 DensityDuck March 12, 2012 at 9:36 pm

I’m sure that you’re very careful and concerned about your patients, and take into account their medical history and other treatments.

You aren’t everyone. And, for that matter, not everyone has the time to visit the doctor every few months to establish a healthy baseline and let their provider work out what specific medications would work best (not “at all”, because we have already got things that work “at all”).

There are good arguments to be made that powerful body-altering medications (such as hormonal birth control) should include a medical provider’s supervision. Let’s not pretend like that doesn’t come with a cost. Let’s not act like that cost isn’t going to be too high for people, many of them the very people that these medications would help the most. And let’s not require prescriptions despite that cost and then stand around like butter wouldn’t melt in our mouths when we say that the high cost of birth control is more important than the free exercise of religion.

17 Jaybird March 12, 2012 at 7:02 pm

Duck, *I* get the meta-argument you’re making but it presents identically to you being jerky to our Dr. Saunders given that he wasn’t making the arguments that your arguments are facsimiles of.

Your shotgun blast isn’t hitting the folks you want to hit, and it’s instead hitting people you wouldn’t want to hit.

18 Lindsay Beyerstein March 12, 2012 at 7:05 pm

This has nothing to do with whether you deserve birth control. If you’re going to use birth control safely, you need some medical supervision.

Doctors are perfectly willing to write long-term refills for birth control. No matter how busy you are, you can find one day a year to get your prescription renewed. Imagine how much work you might miss from an unintended pregnancy, a blood clot, or the horrible periods that many women get from Virginia Postrel’s beloved mini-pill.

For some people, a doctor’s fee is prohibitively expensive and some areas are underserved by free clinics. In those cases, you might be able to make an argument that the benefits of increased access for women who would otherwise not be able to obtain birth control outweigh the risks of making birth control available OTC.

But after the Affordable Care Act takes full effect, the bc/OTC debate will hopefully become obsolete. If everyone is insured and birth control is covered with no co-pay, the barriers to access will be minimal. At that point, there won’t be any significant advantage to making the pill OTC.

19 DensityDuck March 12, 2012 at 9:24 pm

“For some people, a doctor’s fee is prohibitively expensive and some areas are underserved by free clinics.”

See, the thing is that the people who think birth control should be covered by insurance are already making this argument. If you think that access to doctors and contraceptives is simple and cheap and widely available, then the original argument–that the Catholic Church is oppressing women–is not valid. If that argument is valid, then it means that access is an issue. And there’s more than one barrier to access.

20 Russell Saunders March 12, 2012 at 9:50 pm

That is a perfectly good argument for increasing access to affordable healthcare in underserved areas. I’ll sing right along. However, that does not mean we should allow unfettered access to medications with side effects and contraindications that warrant prescription status.

21 Jeff March 12, 2012 at 8:47 pm

I don’t get the point. Some drugs have side-effects that you need to know about.

Do you feel that you’re entitled to your own personal physician who will drop everything just to see Mr DD?

Compared with the 4-hour chunk of time one has to allocate for the Cable Company (and they don’t always come in), this is a trivial complaint.

(If your doctor is only taking 10 minutes, you need to get a different MD.)

22 DensityDuck March 12, 2012 at 9:28 pm

“Do you feel that you’re entitled to your own personal physician who will drop everything just to see Mr DD? ”

Wait, wait, wait. So hormonal contraceptives–which are such a vital part of a woman’s life that it is, quite literally, oppression for her not to get them–are only dispensed by a doctor’s order, and suggesting that maybe the doctor ought to be responsive and flexible is acting entitled?

“Compared with the 4-hour chunk of time one has to allocate for the Cable Company (and they don’t always come in), this is a trivial complaint.”

Yeah, and that would be relevant if failure to provide me with cable constituted oppression.

23 Russell Saunders March 12, 2012 at 9:51 pm

Do show me where I have indicated that doctors ought to be unresponsive and inflexible. I seem to have missed it.

24 DensityDuck March 13, 2012 at 4:27 pm

Jeff says that expecting this is “feeling entitled”.

25 Russell Saunders March 13, 2012 at 5:05 pm

Then I will leave it to Jeff to reply to your comment.

26 Lindsay Beyerstein March 13, 2012 at 1:17 am

If you only have to go once a year, that’s pretty flexible.

There are all kinds of medical care that are vital parts of people’s lives that still require prescriptions. If the U.S. Council of Scientology Bishops bullied the government and insurance companies into no longer covering antidepressants, that would be a form of oppression. It would not be an adequate consolation prize that anyone who could afford to pay the full out-of-pocket price for whatever AD a pharmaceutical company saw fit to market, at whatever price they wanted to sell it for.

Birth control is part of health care, and if your insurance doesn’t cover birth control (or maternity care, or psychiatry, or any other basic part of medicine), you are not receiving adequate insurance. If your insurance is hobbled because a bunch of bishops lobbied the government, then yes, you’re being oppressed, regardless of what you can buy with your own money.

It’s oppressive for a doctor to deny a woman contraception or antidepressants because s/he seeks to impose religious beliefs on the patient. If a person’s religious beliefs conflict with standards of care, they should quit medicine, they’re not entitled practice substandard medicine to work around their religion.

However, it’s not oppressive for a doctor to refuse to prescribe contraception or antidepressants or any other drug if s/he feels it would be dangerous for the patient. That’s practicing good medicine.

27 DensityDuck March 13, 2012 at 4:30 pm

“If you only have to go once a year, that’s pretty flexible. ”

With most prescription fillers I’ve used it’s not “once a year”, it’s a twelve-month clock that starts when the prescription is written.

“Birth control is part of health care, and if your insurance doesn’t cover birth control (or maternity care, or psychiatry, or any other basic part of medicine), you are not receiving adequate insurance.”

A pack of condoms costs three dollars. Therefore an insurance plan could “cover birth control” by giving you three dollars every month to buy a pack of condoms. “But I wanna have sex more often than that!” Yeah, and quadraplegics wanna walk.

28 Daniel Grossman March 12, 2012 at 5:45 pm

Dear Dr. Saunders,
Regarding your frustration about not being able to access my articles, I would like to introduce you and your readers to PubMed, an open-access database of published medical literature hosted by the US National Library of Medicine and the National Institutes of Health (http://www.ncbi.nlm.nih.gov/pubmed/). You can access the abstracts of most of my published papers there, and for any study that was funded by NIH and is over one year old, you can link to the full-text article at PubMed Central. If there’s an article you would like that you cannot access on the site, you can always email the corresponding author, who will usually happily email you a copy (and the email is provided on PubMed).

Also, in response to the discussion about contraceptive implants above, Jaybird is correct that they can be a great option for adolescents–or anyone who wants long-term contraception. While Norplant is no longer available, Implanon and Nexplanon are both available in the US. They provide highly effective contraception for up to 3 years.

Thanks,
Daniel Grossman, MD
Senior Associate, Ibis Reproductive Health
Assistant Clinical Professor, Dept. of Ob/Gyn, University of California San Francisco

29 Russell Saunders March 12, 2012 at 5:53 pm

Thanks for taking the time to comment, Dr. Grossman. I am, of course, quite aware of Pubmed, and consider it a great resource. And I have access to almost all published literature through my own hospital staff access. However, usually when a link appears in a lay publication, I approach it the same way a lay reader would, since most readers don’t have access to the same databases I do. I also think it places an undue burden on readers when they are expected to access another site when the author’s links fail to provide sufficient access on their own. (I realize that this criticism is not appropriately directed at you, since Ms. Postrel is the author of the column in question, not you.)

And I agree that implanted contraceptives are, on the face of it, a great alternative for most women, including adolescents. With regard to the latter group, the problems come from confidentiality and cost. But as far as the modality itself goes, I think they have merit.

30 Kimmi March 12, 2012 at 6:23 pm

I would have a HELL of a lot more sympathy for folks if we were actually talking about something that Planned Parenthood won’t do for free.
$100 or so is a lot (plus the costs for “off work”). OTOH, that’s why we have clinics

31 Russell Saunders March 12, 2012 at 6:32 pm

I’m perfectly happy to have patients get their contraception for free at Planned Parenthood. All I care about is that it’s supervised by a medical provider.

32 Kimmi March 12, 2012 at 6:44 pm

Doctor,
What is your position on blackmarket birth control pills? In the event that it is hard/impossible to get a doctor to prescribe them, do you support using the blackmarket?
/not hypothetically speaking.

33 Russell Saunders March 12, 2012 at 6:48 pm

What kind of circumstances are you describing?

34 Kimmi March 12, 2012 at 7:17 pm

Social pressure, primarily, to the point where unmarried women are unlikely to be prescribed the pill.

35 Russell Saunders March 13, 2012 at 12:21 am

I think it would be awful for social pressures to exist that drive a woman to the black market.

36 Jaybird March 12, 2012 at 11:17 pm

Doc, one of the points made in the front page comments is that there are 100 different kinds of oral contraceptives.

How many do you tend to use in your practice? Is it a case where this particular one is good for half your patients (or these three are good for 90% of your patients)? If you have 50 patients (to pull a number out of my butt), do they have 50 different needs or is it more likely that 46 of them are likely to have the same need and the other 4 require serious calibration (for lack of a better vocabulary)?

37 Russell Saunders March 13, 2012 at 12:20 am

I tend to use two or three with regularity. I suspect most providers who prescribe contraception have a handful they prefer from the various categories — broadly speaking these are defined by how much throughout the cycle the dosages vary (monophasic, biphasic or triphasic), the dosages of the two hormones (an estrogen and a progestin), and the types of each hormone. Regarding your 50 hypothetical patients, most of them will all do fine using the same pill, with specialized needs for a few.

38 DensityDuck March 13, 2012 at 4:31 pm

What would happen to the patients with specialized needs who used the “standard” pill?

39 Russell Saunders March 13, 2012 at 5:07 pm

Their needs would, by definition, not be met.

40 BSK March 13, 2012 at 12:44 am

JB-
Thanks for asking this question. I assume you are referring to our earlier conversation. The good doctor’s answer is enlightening. I don’t know what this means for policy but, another piece of the puzzle is firmly in place.

Russ-
How different is the cost of these medicines, without insurance? More importantly, is there another family of drugs that shares such characteristics with contraceptives? How unique is the non-universality and wide range of formulas?

41 Russell Saunders March 13, 2012 at 2:08 pm

BSK, all of the OCPs I prescribe routinely are available as generics, as I think is probably the case for most providers. I don’t know for sure how much they cost, but from what I’ve seen recently it tends to be around $25 per pack.

If I understand the second part of your question correctly, you’re asking if there’s another category of medication where there are a number of similar but somewhat different medications, with providers tending to favor a few familiar medications from the larger list. The answer to this is yes. I can think of several off the top of my head, such as asthma medications, and topical and inhaled steroids.

42 Rogue March 13, 2012 at 1:16 pm

The problem is that almost ALL providers do require an exam to get the OCP. Even though pelvic exams are not medically necessary…they still require it. With the exception of the HOPE program offered by Planned Parenthood. So it most certainly IS paternalism. If the exam serves no purpose, then it is extortion. They cannot detect masses until they are quite large. Their clinical value is quite limited and they are not performed on asymptomatic women in other countries. It most certainly does serve as a barrier to use of the pill. Just because Dr. Saunders is more evolved in the care of his patients does not mean the rest of the medical community is cooperating.

43 Kimmi March 13, 2012 at 1:23 pm

20 year olds can have cysts. They’re better dealt with early.
not that I’m a doc, natch.

44 Russell Saunders March 13, 2012 at 2:18 pm

I think you are making some sound points, Rogue. I think there is a good argument to be made that requiring a pelvic exam is unnecessary, and demanding it as a condition of OCP renewal is coercive. I conceded as much in the main post. I would say that annual pelvic exams for cervical screening are of some value (though I know the data on when to start doing them have changed a lot in recent years), and the motivation to require them is based on patient care goals rather than financial gain on the part of the medical provider. However, I agree with you that many providers need to rethink their approach to renewing OCP prescriptions. I think the culture is shifting, and I wonder if younger providers will be less likely to make the same demands as those trained in an earlier era.

45 Rogue March 13, 2012 at 1:35 pm

I never mentioned patient age in my reply. What does a 20 year old have to do with anything?

46 Kimmi March 13, 2012 at 3:33 pm

Gomen. assumed you were responding to Russ, who had mentioned age in terms of not requiring pelvic exams.

47 Anis March 16, 2012 at 10:20 am

I really hope you under no circumstances end! This can be one of several top weblogs Ive ever go through. Youve got some mad ability below, male. I just hope that you just dont drop your fashion as youre undeniably one of the many coolest bloggers these days. Please maintain it up since the on-line requires someone like you spreading the word.

48 Elizabeth May 25, 2012 at 1:45 pm

I was 42 when a gyno prescribed a third generation COC for pelvic pain resolution. After 51 days I suffered from a pulmonary emoblus. Yes I have antiphospholipid antibody. No, I didn’t know this at the time. I had asked my doctor about the dangers, being over 35, having high blood pressure, being overweight and she said ‘the benfit outweighs the risk in this low dose’ Really?!
I believed her.
I find it pretty slack that it is not protocol for women to be tested for clotting issues especially as they get older as a pre-test to prescribing this type of drug that is KNOWN to cause clots.
With that I am all for the administration of drugs to be in the hands of the doctors to prescribe and monitor, but at the same time more thorough exams need to be done as part of the check-up leading to that little piece of paper being handed to the patients. As that piece of paper could just be their death warrant.

49 Ashley October 5, 2012 at 10:49 pm

This article answered a lot of my questions, but these various potential issues with OTC contraceptive pill sales all appear to be work-aroundable. There are many downsides to the barriers imposed by their prescription-only status, not least of which is that encountering difficulty booking an appointment to renew a prescription, which for many women means fighting for a spot at a downtown clinic, can be both disorienting to the menstrual cycle and downright painful. I found your article because I just made my third trip to my own clinic and was turned away again for lack of available staff. If most women can safely handle these hormones, this blockade I’m experiencing doesn’t need to exist. We can find effective solutions to keep women safe while allowing them OTC access to what may be an extremely important pill.

50 Vicki November 21, 2012 at 12:09 am

This is the craziest idea I’ve heard lately! No doubt has something to do with the politics of insurance. Can you imagine how many young and I do mean young ladies will go without yearly checks. I see cervical cancer souring, stds going untreated, strokes and so much more. I vote no to non-prescribed birth control pills!

51 zic November 21, 2012 at 1:08 am

Russell, I think Vicki has a point, one I wondered about, too. The annual exam is important for screening ongoing health, no? Catching STDs and other reproductive system disorders?

And as one of those women with Migraine, thank you.

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