Thursday, December 14, 2017
Opinion

The Pill belongs in drugstores

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. The medical risks are quite low.

Partly because birth-control pills are available only by prescription, people tend to think they're more dangerous and less well understood than they actually are. In fact, "more is known about the safety of oral contraceptives than has been known about any other drug in the history of medicine," declared an editorial in the American Journal of Public Health back in 1993. That editorial accompanied an article arguing for over-the-counter sales.

Unlike most medications, the article noted, birth-control pills require no medical diagnosis: "A woman herself determines her need for oral contraception; she assesses her own risk of pregnancy ... and the costs and benefits of both pregnancy and alternative contraceptions." Nearly two decades later, birth-control pills look even safer than they did then, and recent research indicates that women are both able and eager to manage their own purchase decisions.

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.

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.

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 okay for women with hypertension, for instance, or smokers over the age of 35. "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.

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.

Going to the doctor is costly in time, money and sometimes in dignity. Not surprisingly, the prescription requirement deters use of oral contraceptives. In a 2004 phone survey, 68 percent of American women said they would start the pill or another form of hormonal birth control, such as the patch, if they could buy it in a pharmacy with screening by a pharmacist instead of getting a doctor's prescription. Two-thirds of blacks and slightly more than half of whites and Latinas surveyed said they chose their current, less-effective method of birth control because it didn't require a prescription.

The real question now isn't whether allowing over-the-counter sales would benefit women and prevent unwanted pregnancies — the evidence is overwhelming that it would — but whether any pharmaceutical maker wants to change the status quo. Will some company take a chance on creating the Advil of oral contraceptives — making a prescription product a touchstone consumer brand? Are there public policy changes that could encourage the switch? If you're actually interested in preventing unwanted pregnancies rather than merely scoring political points, these are the questions you should be asking.

Virginia Postrel is the author of "The Future and Its Enemies" and "The Substance of Style" and is writing a book on glamor.

© 2012 Bloomberg

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