Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Is pregnancy a young age a "lifestyle disease"?
- Sally R Greatrex (25 December 2008)
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Prescribing Oral Contraceptives - The Pharmacist's View
- Bob Dunkley (25 December 2008)
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Do long-acting progestogen only contraceptives cause more cancers?
- Ellen CG Grant (30 December 2008)
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The oral contraceptive pill should be available over the counter....but....
- Umo I Esen (31 December 2008)
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Re: Prescribing Oral Contraceptives - Another Pharmacist's View
- Sally Rafie (6 January 2009)
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Should oral contraceptives be available without prescription?
- Malcolm Potts (17 January 2009)
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Hormonal contraceptives are too dangerous to be over the counter
- Ellen C G Grant, Elizabeth H Price (26 January 2009)
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Sally R Greatrex, SpT Public Health Brimingham, B16 9PT
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Admittedly this is a very difficult question to answer. On the one hand there is evidence that uptake of oral contraception would be higher (and possibly more equitable) if it could be bought over the counter. On the other hand this would reduce the opportunities for women to be offered long-term reversible contraceptives. However to describe teenage pregnancy as a 'lifestyle disease' in order to defend the need for medical input is a step too far. Even though being a teenager increases specific risks in pregnancy, and even though there is some evidence that the children of young mums are at disadvantage compared to wealthier older mums, it is not and has never been a life style disease. Making oral contraceptives available over the counter may not be the best way to reduce teenage pregnancy rates. However labelling young mums as diseased will probably not encourage them to see their GP either. Competing interests: None |
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Bob Dunkley, Pharmacist Leeds LS15 8EP
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The articles published in the BMJ come from the point of view of health professionals, ie will pharmacists giving out the "pill" be harming or helping the recipient. To reduce unwanted pregnancies is undoubtedly a major aim in this scheme. But look at it from the point of view of a pharmacist on the high street. If we were allowed to "prescribe" the pill, then all and sundry women would flock to our pharmacies, seeking the pill, perhaps knowing that they would not get such a searching investigation as from their GP. Pharmacists do not have either the time, or the expertise to conduct a gynecological investigation, that is perhaps needed for a woman seeking the pill. We don't know that the patient's family might have familial blood disorders that preclude females in the family from having oral conctraceptives. Where the pill is concerned, hedonism is the driving force, and at the end of the day, as all GPs know - PATIENTS LIE to get what they want. Currently, when a patient comes through the door of a high street pharmacy, we know absolutely nothing about their medical history. OK we can see what medicines they have been prescribed and dispensed, FROM THIS PHARMACY: we cannot see what investigations they have had done, or what prescriptions they might have been issued with, and taken elsewhere. In other words - we are acting blind!! Oral contraceptives are powerfull medicines, that can have far reaching and sometimes fatal outcomes. Just because they are taken every day, and have no subjective effect on the patient,this does not lessen the danger - only in the mind of the recipient. If pharmacists are to "prescribe" the pill, then they should be provided with the full medical history of the patient in front of them - not something which I can see happening soon. Because if anything goes wrong with the patient,and they have an adverse effect then the onus is on the pharmacist, something that I think my colleagues have failed to grasp. Even if the initial supply is made by a GP, with full knowledge of the patient's history, and subsequent supplies made by a pharmacist, how does that pharmacist know that the patient's condition has not changed in the meantime? What I am saying here will be an anathema to my fellow pharmacists,as they want to start giving out the pill tomorrow, if not sooner, but we as a profession are ill-equipped to provide this undoubtedly valuable service. Until we get a sight of patient records, I will remain a staunch foe of the pharmacist prescribing of any medicine currently in the realm of the GP. Competing interests: None declared |
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Ellen CG Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, UK
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Dr Sarah Jarvis is advocating greater use of long-acting progestogens.1 This is potentially dangerous because the German Federal Institute for Drugs and Medical Devices has been receiving more reports of breast and other cancers with progestogen only contraceptives, including progestogen containing IUDs, than with more the more widely used progestin and oestrogen combinations.2 The International Agency for Cancer Research of the World Health Organization has already classified contraceptive and HRT combinations as Group 1 carcinogens.3 Progesterone-dominant contraceptives cause migraine headaches and depressive or irritable mood changes because monoamine-oxidase activity and angiogenesis increase for longer than in a normal premenstrual phase.4,5 Such effects can be continuous with progestogen-only use. The promotion of long-acting forms of progestogens whose carcinogenic and other effects cannot be stopped for several months or years seems irresponsible. Adverse effects from a few tablets are usually quickly reversible when discontinued. However I have no idea how to prevent women subjected to long-acting forms of progesterones from having migraines, sore breasts, weight gain, depression and irritability, irregular bleeding, immune system disorders like MS, ME or APS, and rapidly metastatic breast or other cancers or brain tumours. Perhaps Dr Jarvis can tell me? 1 Jarvis S. Should the contraceptive pill be available without prescription? No. BMJ 2008 ;337:a3056. 2 Giersig C. Progestin and breast cancer. The missing pieces of a puzzle. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2008;51:782-6. 3 IARC Monographs Vol. 91. Combined Estrogen-Progestogen Contraceptives and Combined Estrogen-Progestogen Menopausal Therapy.2007;528 pages. 4 Grant EC, Pryse-Davies J. Effect of oral contraceptives on depressive mood changes and on endometrial monoamine oxidase and phosphatases. BMJ 1968;3:777-80. 5 Grant ECG. Relation between headaches from oral contraceptives and development of endometrial arterioles. BMJ 1968;3:402-5. Competing interests: None declared |
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Umo I Esen, Consultant Obstetrician and Gynaecologist South Tyneside NHS Foundation Trust, Harton Lane, South Shields, Tyne and Wear NE34 OPL
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The oral contraceptive pill should be available over the counter as part of the overall strategy to prevent unplanned / unwanted pregnancies, but will need some sort of protocol or Patient Group Directives under which it is dispensed. This will plug a small loop hole which currently exists, where women who run out of the pill at weekends or extended holidays are unable to refill their prescriptions at their General Practitioners or Family Planning Clinics. Only a small number of unwanted pregnancies however result this way in the United Kingdom. Majority occur in women who are not using contraception at all, using condoms or taking the pill innappropriately(1),the core group requiring effective intervention. If the aim of over the counter availability of the pill is to topple the United Kingdom from its number one position in the European teenage pregnancy league, then it will achieve very little, as it fails to address the real issue . A two pronged strategy is needed to reduce teenage pregnancy rates. Firstly there should be compulsory and comprehensive sex education in schools, the content of which must be relevant and purposeful, rather than one which goes through the motions. Secondly the NICE guidelines recommending LARC as the contraceptives of choice need to be robustly implemented. General Practitioners have a crucial role to play, which at the moment, is largely unfulfilled as many surgeries do not offer or fit subdermal implants or intrauterine devices for contraception(2). Until General Practitioners take on this crucial aspect of health of their female patients not much is likely to be achieved. References 1. Esen U, Koram K, Doherty E, Orife S, Jones A. Termination of pregnancy in South Tyneside J Obstet Gynaecol. 2006 Nov;26(8):791-4. 2. Wellings K, Zhihong Z, Krentel A, Barrett G, Glasier A. Attitudes towards long-acting reversible methods of contraception in general practice in the UK Contraception. 2007 Sep;76(3):208-14. Competing interests: None declared |
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Sally Rafie, Pharmacist University of California, San Diego Medical Center (92103)
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I would like to offer a different pharmacist's perspective on this issue. As a pharmacist who is dedicated to caring for patients, I wholeheartedly support pharmacist participation in the provision of hormonal contraceptives. Pharmacists are well trained to provide patients with the pill, patch, ring and injectable forms of hormonal contraception. There is no argument that time is a limiting factor to provision of these services in the pharmacy, however this can be overcome if the pharmacy chooses to expand their services beyond dispensing. This barrier could be eliminated if the pharmacy was able to bill for the services, rather than just the product. This reimbursement issue needs to be explored by government and private payors. Pharmacists can effectively evaluate the patient's self-reported (as it always is) medical history and blood pressure to assess contraceptive options. It is well known that a physical exam is not necessary to determine a woman’s candidacy for hormonal contraception. Hormonal contraceptives are extremely safe and effective, but only when made available and taken. An unintended pregnancy can have far more grave consequences for a woman. I would welcome any flock of women seeking contraception. This is exactly what we should encourage, women empowered to seek health care and family planning services. Competing interests: None declared |
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Malcolm Potts, Bixby Professor of Population and Family Planning University of California, Berkeley, Berkeley, California 94720
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Sarah Jarvis argues that oral contraceptives should be limited to prescription unless there are compelling reasons to switch them to OTC availability. I suggest that the appropriate philosophy is to assume that any and all contraceptives should be available in the most straightforward way possible unless there is sound evidence they need to be on prescription. No one advocates placing condoms on prescription so users can “be offered a full range of contraceptives on every occasion”, even though some individuals might benefit from such advice. Evidence for removing oral contraceptives from prescription goes back over three decades. In 1973 the International Planned Parenthood Federation Medical Committee recommended non-prescription use commenting that OCs are “highly effective, relatively simple to use, and that the health benefits outweigh the risks in nearly all cases.” A year later the Medical Director of the UK FPA, together with a number of professors of obstetrics, including the late Sir Dougal Baird, suggested that it would be “a responsible and constructive step” to permit OC distribution by “state registered nurses, midwives and health visitors” without a medical prescription. In 1976 a Working Party of the Department of Health and Social Security officially endorsed this recommendation, but there was no follow through, possibly because at about the same time general practitioners were given an item of service payment for prescribing contraception. The scientific base for switching OCs to OTC status is sound. The problem is that contraception often raises many emotional issues and, for example, it took Japan 35 years to even register oestrogen/progesterone tablets as a contraceptive. It is to be hoped that the pilot distribution of OCs without prescription in parts of London will lead to offering women a choice that non-evidence based considerations have also delayed for 35 years. Malcolm Potts Bixby Center for Population, Health and Sustainability University of California, Berkeley Berkeley, California 1. Jarvis S. Should oral contraceptives be available without prescription? No. BMJ 2008;337:a3056 2. Kleinman RL. (Ed) Family Planning Handbook for Doctors. London: International Planned Parenthood Federation, 1974 3. Smith M, Backett EM, Baird D, et al. Distribution and supervision of oral contraceptives. BMJ 19 Oct, 1974: 161. 4. Report of the Joint Working Group on Oral Conrtacpetives. 1976. London: HMSO. 5. Samuels SE, Smith MD. The Pill: From Prescription to Over the Counter. Menlo Park, CA: A Publication of the Kaiser Forums. 1994. 6. Trussell J, Stewart F, Potts M, Guest F, Ellertson C. Should oral contraceptives be available without prescription? American Journal of Public Health. 1993; 83: 1094-1099. 7. Potts M. Why can’t a man be more like a woman? Sex, power and politics. Obstetrics and Gynecology 2005; 106:1065-1070. Competing interests: None declared |
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Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, Elizabeth H Price
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Malcolm Potts’ comparison of the risks of the pill with condoms is nonsensical. Unfortunately, genuine and valid concerns about “the menace of overpopulation” have led to continuous and emotional attempts to cover up the numerous health problems caused by exogenous progesterones in hormonal contraceptives, which alter the functions of thousands of genes and are amongst the most rapidly acting of all known carcinogens. It has been a case of shoot the messenger, as if hormonal contraception was the only option. Professor Sir Dugald Baird revealed in 1970 in his lecture, “The Obstetrician and Society” that the average family size had fallen despite the absence of help from the medical profession.1 By the 1930s, the net reproduction rate was less than 1; that is to say, there were more deaths than births and, therefore, a declining population. (It was training in the Dugald Baird school of Obstetrics and Gynaecolgy at Dundee in the 1950s which led me to a life time’s research into the effects of hormonal contraceptives.) Scientific truths should be liberating and empowering. In the 1930s few school girls were having sex. The “Pill culture” has extended the time women are at risk of pregnancy, sexual transmitted diseases and many progestogen-induced degenerative diseases. This is false emancipation. Big problems need the full light of scientific scrutiny and clear thinking. 1 Baird D. The obstetrician and society. Am J Public Health Nations Health. 1970;60:628–640. Competing interests: None declared |
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