Should the contraceptive pill be available without prescription? No
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a3056 (Published 24 December 2008) Cite this as: BMJ 2008;337:a3056All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Hormonal contraceptives are too dangerous to be over the counter
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
Competing interests: No competing interests