Should the contraceptive pill be available without prescription? YesBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a3044 (Published 24 December 2008) Cite this as: BMJ 2008;337:a3044
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The points cited by Drs Grossman and Sarah for and against the
availability of contraceptives over the counter are not over a common
issue of reasoning. While Dr. Grossman supports the policy of
availability of OCT pills over the counter on the ground that there is no
value addition if OCT pills are prescribed by a physician, Dr. Sarah has
not touched on the clinical Propriety. On the contrary she based her
argument on other issues. The discussion would have been interesting had
it it been on common ground than on two divergent issues.
One needs to
consider the available peer reviewed literature in deciding the safety of
OCT without a clinical workup and assessment. The examples quoted by Dr
Grossman are limited to one country at a particular time. Decisions based
scant evidence to support one's view ignoring the accumulated wisdom would
be at one's own peril. The fact that in many countries the OCT is
available without prescription does not preclude the necessity of
Competing interests: No competing interests
My perspective as an American- allow hormonal contraception available
without a prescription. American women already have one of the highest of
rates of unintended pregnancy and teen pregnancy among developed nations,
and the recent Health and Human Services (HHS) “conscience” regulation,
which I hope will eventually be overturned, allows healthcare providers
increased opportunities to refuse to provide contraceptives and accurate
health information to women (so much for the importance of the patient-
Hormonal contraception meets the Food & Drug Administration (FDA)
standards for non-prescription status: clinicians are unnecessary,
potential for misappropriate use is low, consumers can easily identify
indications and assess contraindications, directions for use are
uncomplicated, and the benefits outweighs the risks. Yet not only is
hormonal contraception still not available without a prescription, many
clinicians force unnecessary medical examinations before allowing women
access, and now have the right to outright withhold prescriptions and even
give patients inaccurate medical information, if they so choose.
Hormonal contraception has been proven to be safe (the health risks
of pregnancy are far greater than the risks of using contraception).
Pills can bring about a stroke or heart attack, as can other
nonprescription drugs, but this is extremely rare. Acetaminophen,
available without a prescription, is much more likely to cause liver
damage than pills are likely to cause stroke or heart attack. Requiring a
trip to the doctor's office for access to contraception creates an
unnecessary obstacle for women, thus reduces contraception access, puts
women at risk, and perpetuates the idea that either 1.birth control is
dangerous or 2.women aren’t competent enough to assess their needs and
make informed choices.
Not only is hormonal contraception being denied to women without
prescriptions, women are often forced to have unnecessary physical
examinations and tests in order to receive their prescriptions. The World
Health Organization’s medical eligibility criteria for hormonal
contraception doesn’t require breast and pelvic examinations, yet many
clinicians in the United States require these exams before allowing
patients their prescriptions. Regular physicals, including breast exams,
pelvic exams, and pap smears, are recommended in order to maintain good
health, but they do not provide medical information regarding hormonal
One concern is that women will stop going for annual exams and pap
tests if health centers do not have a policy of withholding contraception.
According to that logic, no one should be allowed any medications unless
they have all recommended physical exams. Over 50 and haven’t had a
colonoscopy? Sorry, no flu shot for you. Since pelvic exams and a pap
smears are medically unnecessary in order to prescribe birth control, a
better standard of care would be for health care providers to recommend
that their patients have physicals, but ultimately respect their patients’
There are, of course, women who want to have the examinations and
give their consent voluntarily, but telling women that examinations and
pap tests are mandatory to receive birth control is a form of coercion,
not informed consent. Informed and voluntary decision making is
instrumental to patients’ rights. Don’t patients, including women of child
-bearing age, have the right to autonomy and bodily integrity? Withholding
contraception from a woman if she does not wish to submit to unnecessary
physical exams and tests is nothing short of provider bias and
paternalism. This is medically unethical.
Another concern is that women might not understand how to take their
contraception or they might choose the wrong kind if they don’t first
consult with a physician. Medical information is readily accessible these
days and women are capable of making sophisticated choices about their
health. According to research conducted by Family Health International and
published in the journal Studies in Family Planning, “over-the-counter
provision of oral contraceptives by pharmacists is a safe, effective, and
practical way to distribute this popular contraceptive method in Jamaica.”
Are American (or British) women any less capable of making informed
decisions about their health than Jamaican women? Let’s let women decide
what contraception they need, especially since we can’t feel confident
that we are getting accurate information from our health care providers
Lift the prescription status of hormonal contraception, allow women
easier access to contraception, and the right to decide for themselves if
they wish to have medical examinations. Not doing so is unethical,
violating to women, and counterproductive.
Competing interests: No competing interests
Dr Grossman is so keen that oral contraceptives should be available
over the counter that he minimises the numerous serious health risks
caused by taking the pill.1 These include a range of cancers, vascular
diseases, mental illnesses, metabolic and immune disorders and increased
mortality which have been reported in a series of papers from the Royal
College of General Practitioners Oral Contraception study.
Cancer is the commonest cause of death in hormone takers and breast
cancer is the commonest fatal cancer which decreases in incidence when
hormone use declines.2,3 Carcinogenesis does not depend on reasons for
use. Progestogen and oestrogen combinations, whether given for
contraception or as HRT, are classified as Group 1 carcinogens by the
International Agency for Cancer Research of the World Health
Current and longer use of progestogens and oestrogens increases the
risk of ovarian cancer when given as HRT.5,6 The 45 ovarian cancer and
oral contraceptive studies reanalyzed by a Collaborative Group involved
women with an average age of 54, presumably because ovarian cancer is rare
in young women under age 35. Among these mostly older women use had been
on average 18.6 years previously and less than 5% were currently taking
the pill.7 In contrast, many older women develop ovarian cancer while
currently taking HRT. Unfortunately, all 45 studies made the mistake of
including women who had never taken the pill as never user controls, even
if they were currently taking HRT. This inevitably and erroneously reduced
the risk estimates to the point where benefit was claimed.8 Oral
contraceptive ovarian cancer studies therefore fail to prove that taking
hormones can protect a woman from ovarian cancer, which is a long-held but
We do not agree that there is any justification for over the counter
availability of the contraceptive pill in view of the very serious risks
to the health of young women.
1 Grossman D. Should the contraceptive pill be available without
2 Grant ECG. Reduction in mortality from breast cancer: fall in use
of hormones could have reduced breast cancer mortality. BMJ 2005; 330:
3 Colditz GA. Decline in breast cancer incidence due to removal of
promoter: combination estrogen plus progestin. Breast Cancer Res 2007; 9:
4 IARC Monographs Vol. 91. Combined Estrogen-Progestogen
and Combined Estrogen-Progestogen Menopausal Therapy.
528 pages; ISBN 978 92 832 1291 1
5 Beral V, Bull D, Green J, Reeves G for the Million Women Study
Collaborators. Ovarian cancer and hormone replacement therapy in the
Million Women Study. Lancet 2007; 369: 1703-1710.
6 Greiser CM, Greiser EM, Dören M. Menopausal hormone therapy and
risk of ovarian cancer: systematic review and meta-analysis. Hum Reprod
Update 2007; 13: 453-463.
7 Collaborative Group on Epidemiological Studies of Ovarian Cancer.
Ovarian cancer and oral contraceptives: collaborative reanalysis of data
from 45 epidemiological studies including 23 257 women with ovarian cancer
and 87 303 controls. Lancet 2008; 371: 303-314.
8 Grant ECG. Ovarian cancer and oral contraceptives. Lancet
Competing interests: No competing interests