Should birth control pills be available without a prescription?

The New York Times wonders. The American College of Obstetricians and Gynecologists thinks they should be over the counter. The Catholic Medical Association and the American Association of Pro-Life Obstetricians and Gynecologists disagree, of course, because their religious beliefs should obviously dictate the kind of health care that the rest of us are able to access.

After all, oral contraceptives have been available in the United States for more than half a century, and few medicines have been so thoroughly vetted. Despite some catchy new brand names, the pills I took 25 years ago are essentially the same as those my daughter takes today. If anything, pills have become safer because they contain lower doses of estrogen.

While oral contraceptives bring with them some tiny risks, especially if used improperly, they arguably pose fewer dangers than many other medicines bought freely at the pharmacy, experts say, including nonsteroidal pain pills like Motrin (which can cause stomach bleeding) and decongestants like Sudafed (which may raise blood pressure). With a simple packaging insert about proper use and precautions, women would be fully capable of using them safely, the gynecologists’ group maintained.

“Nonsteroidal medicines kill far more people than birth-control pills,” said Dr. Eve Espey, a professor of obstetrics and gynecology at the University of New Mexico, who was involved in writing the position paper. “For most women, the absolute risk of taking the pill is far less than the risks incurred in pregnancy.”

There are actually some good reasons to require a prescription for birth control pills. It does require women to go to the gynecologist, which usually means a Pap smear, STI screening and a chance to talk to your doctor about your health. For lots of women, the gynecologist is the only doctor we regularly see. Making birth control over the counter would almost surely decrease regular gynecological appointments, potentially to the detriment of women’s health.

But I’m not sure that’s more important than making birth control accessible. Requiring a doctor’s appointment means that women without health insurance or who are under-insured aren’t easily able to get the birth control they need, leading to higher rates of unintended pregnancy.

The Times article also highlights the fact that while birth control is incredibly safe, like any medication it poses risks, especially for certain patients — women who smoke, for example. But there’s a pretty simple fix for that:

As for safety, the most common birth-control pill — which combines progestin with a low dose of estrogen — poses a very slightly elevated risk of blood clots and a few other conditions. But that is mostly for certain groups of women, including those with high blood pressure or those who are over 35 and smoke, for example (these women are advised not use them). But warnings could be conveyed in package labeling, just as patients with a history of ulcers are advised not to take certain pain medications. And a few alternative birth-control pills that contain only progestin are generally safe for all.

So far the debate has been argued in black and white. But there is, in fact, a middle ground: many countries that allow pharmacies to sell birth-control pills require that a pharmacist screen women for contraindications with a few simple questions.

My daughter spends hundreds of dollars a year for a gynecologist’s visit to obtain a prescription for the same pill I got a quarter-century earlier. She goes through elaborate machinations to get them if she runs out while away on a summer job. The Affordable Care Act of 2010 seeks to improve access to the pills by eventually eliminating patient copays when prescriptions are filled. But many doctors think it would be even smarter to just eliminate the prescription.

105 comments for “Should birth control pills be available without a prescription?

  1. bleh
    April 22, 2013 at 12:14 pm

    There is an assumption here that seeing a doctor is an inherent good. Many studies suggest that seeing a doctor increases your chances of negative health outcomes. See Overdiagnosed etc. Women attend doctor visits at much higher rates than men do – often because they must go to get OC. Fewer doctor visits could free up time and money to do really healthy things like plan meals, work out, meditate, garden. Win win!

    • Lu
      April 22, 2013 at 1:43 pm


      Also, you do not need a yearly pap (unless you have had previous abnormal ones) but most doctors will push for one and refuse hormonal birth control prescriptions otherwise.

      • sabrina
        April 22, 2013 at 4:20 pm

        not to mention the fact that not all uterus having people who are on the pill are actually at risk for HPV. If this is actually a concern and keeping cervix havers from being able to access the medications that they need why can’t we just advocate for HPV testing (this is different from an actual pap smear. All a pap smear actually checks for is abnormal cells in the cervix, not HPV) to be covered by insurance? Then a cervix having person would only need to have one done when zie has a new partner instead of every year which is more economical and they can do a pap smear if zie has other risk factors for cervical cancer (such as family history) as often as their doctor recommends.

      • EG
        April 22, 2013 at 4:34 pm

        Is there an HPV test? My understanding–based on a friend’s experiences a year or too ago–is that there is not, there is only the Pap, which is why cis men cannot get tested for HPV.

      • sabrina
        April 22, 2013 at 5:07 pm

        eg, yes there IS an HPV test for those with cervixes. Doctors can order for both when they run a normal pap smear, but most insurance companies will not pay for it unless a pap smear comes back abnormal and even then some insurance companies still won’t pay for it.

      • April 23, 2013 at 4:58 am

        You can’t have an HPV test without going through the same physical examination that is required for a Pap test. Simultaneous Pap testing and HPV DNA testing gives the most accurate result.

      • April 23, 2013 at 5:14 am

        You can find more information on the HPV test here. Since it involves the same physical exam as a Pap test, and since Pap/HPV DNA co-testing are so much more accurate, it doesn’t make too much sense just to do an HPV test without a Pap test. The physical experience is the same for the patient; the only difference is that two tests are performed in the lab instead of just one.

    • bleh
      April 22, 2013 at 4:55 pm

      Cis men CAN get tested for HPV. This lie must die. It’s just that they don’t like what the test entails (a little sandpaper to their bits) and the medical industry does not ask men to endure the types of tests that they ask women to endure.

      • EG
        April 22, 2013 at 5:03 pm

        Really? When my friend asked for one, he was told that there was no test. Nice.

      • bleh
        April 23, 2013 at 9:06 am

        I am in the US and this information comes from one of the people who administered the clinical trials (phone interview) for Gardasil. She told me it could be done, but it may be true that the FDA has not approved it. (for the same reasons that we do not require difficult tests of men, especially younger men)

      • EG
        April 23, 2013 at 9:51 am

        So even when younger men ask for this test, they’re told it’s not possible. Great. Way to discourage those who want to be responsible, to themselves and/or their partners.

      • Pseudonym
        April 23, 2013 at 12:35 am

        Prostate exams?

      • TomSims
        April 23, 2013 at 2:35 am

        The test for men is known as the Prostate-Specific Antigen (PSA) Test. I’ve been getting one for the past 16 years. But there are many false positives, making the test unreliable. It’s a simple blood test.

      • bleh
        April 23, 2013 at 2:19 pm

        There are two tests – PSA, which is a blood test, and DRE – digital rectal exam. Neither is required to get any other kinds of health care, and MDs have pushed back the age at which men are encouraged to have them (not 16-21 like first pap, but more like 50 or later). Also PSA was created by researchers because men pushed back about DRE. There is research toward cervical cancer blood tests but no Gyno in the world would push the FDA in direction of losing their major source of income.

      • April 23, 2013 at 5:01 am

        There is no FDA-approved HPV test for cis-men. Tests involving an emory board to the genital region are used for research purposes, but are not very accurate and currently not approved for general use.

      • April 23, 2013 at 5:17 am

        This article (scroll to the bottom and read the second-to-last paragraph) gives some information about testing for HPV in males. I would love to see these kinds of HPV tests improved and approved by the FDA, so more people can know their HPV status.

  2. April 22, 2013 at 12:18 pm

    I am swiftly running out of middle finger raising ability for these evil little shitweasels.

    Thank you for covering this, Jill. You’ve really been hitting it out of the park lately.

    • April 22, 2013 at 12:38 pm

      Thanks Mac. Very much appreciate the positive feedback.

  3. Quicksilver
    April 22, 2013 at 12:30 pm

    The main issue I see with moving BC to over-the-counter is that health insurance will no longer necessarily cover it, and then we go back to female-bodied people having to pay out-of-pocket for BC. Which puts up different barriers to access. (When Claritin became OTC, my friend’s health insurance stopped covering the cost, and she was no longer able to afford it.)

    The Catholic church should _support_ BC going over-the-counter, since it means Good Moral Catholic Employers will no longer be Forced To Compromise Their Values by providing health insurance that actually provides essential health care to people with uteruses. This _solves_ the problem they had with the ACA’s contraception-coverage mandate. That they oppose it is just further evidence that the Catholic church’s opposition to BC coverage has nothing to do with religious freedom and everything to do with wanting to control women.

    • Anon21
      April 22, 2013 at 1:02 pm

      The main issue I see with moving BC to over-the-counter is that health insurance will no longer necessarily cover it, and then we go back to female-bodied people having to pay out-of-pocket for BC.

      I don’t see any reason why that should be the case. The contraceptive mandate from the ACA requires all employers (except churches/similarly religious organizations) to offer insurance policies that cover contraception with no copay. I don’t see any reason that that regulation has to be tied to prescription status; after all, it’s HHS writing the rules, so they needn’t focus on irrelevant distinctions if they don’t want to.

      • April 22, 2013 at 1:36 pm

        You don’t see any reason why it shouldn’t does not = my insurance company won’t see any reason why they should pay for it.

        Anything that’s not a prescription, my current health plan does not pay for. That includes meds that used to be prescription-only. Why would this be different?

      • Anon21
        April 22, 2013 at 2:53 pm

        Anything that’s not a prescription, my current health plan does not pay for. That includes meds that used to be prescription-only. Why would this be different?

        I’m far from an expert, so I don’t know how the contraceptive mandate applies outside the context of employer-provided plans. But when it goes into effect (which it hasn’t yet), it at least defines the minimum acceptable standards for employer-provided plans, and it may define the minimum acceptable standards for all insurance plans. If so, then your insurer could no more charge you a copay for oral contraception than it could refuse to take you on as a customer because you have a pre-existing medical condition (once that regulation goes into effect).

      • Kierra
        April 22, 2013 at 4:50 pm

        Anon21, by all accounts, the mandate doesn’t cover OTC contraception like Plan B, condoms, spermicide, or sponges. So if oral contraception is moved OTC, it would follow that it would no longer be covered by the mandate. Also, the mandate has already gone into effect.

      • Anon21
        April 22, 2013 at 5:42 pm

        So if oral contraception is moved OTC, it would follow that it would no longer be covered by the mandate.

        I think that only follows if you assume HHS would ignore the change. The mandate would become much less meaningful if it stopped covering oral contraception because the FDA approved it for OTC distribution. The Obama HHS wants it to be meaningful. Thus, if oral contraception goes OTC, I would expect there to be a serious effort to change the regulation to reflect that changed reality.

        You’re correct that it’s already gone into effect. I think I was thinking of some deadline for employers to start doing something related to it, which was relevant to one of the “religious freedom” cases challenging it that I was reading about.

      • Kierra
        April 22, 2013 at 7:27 pm

        I think the mandate would still be meaningful. It would encourage women to switch to more effective and goof-proof methods like the ring, shots, or IUDs that don’t require remembering pills everyday.

      • Anon21
        April 22, 2013 at 8:59 pm

        I think the mandate would still be meaningful. It would encourage women to switch to more effective and goof-proof methods like the ring, shots, or IUDs that don’t require remembering pills everyday.

        I doubt that’s the administration’s policy goal in creating the contraception mandate in the first place. And regardless of the merits of the other methods you mention, many women have only used/are only familiar with oral contraception, meaning that if they can’t get it paid for by insurance they’ll probably either go with less-effective but cheaper methods of contraception or will shoulder the costs of oral contraception themselves. I think that’s a scenario worth avoiding, so I hope and expect that if the FDA were to make oral contraception available over the counter, HHS would rewrite the regs to keep it financially available for women who want to use it.

  4. a lawyer
    April 22, 2013 at 12:40 pm

    In my state you literally cannot buy Sudafed without showing a driver’s license. It doesn’t seem hard to suggest that those same folks can manage to ask if you’re a smoker. If need be they can simply make it so you actually need to talk to a pharmacist. Even if that costs an extra $5 (only once, the first time you go to that store) it would still be VASTLY more accessible than via prescription.

    Moreover, to the best of my knowledge, Plan B is less safe (relatively speaking) than the pill, and that should also available OTC when the courts get through with it. Unlike comparisons to aspirin, this one makes even more sense, since it is blindingly obvious that less access to the pill > more use of plan B.

    Ans if even THAT can’t work, then perhaps it’s time to implement alternative paths for “low impact” meds. IOW, medications which are possibly a bit problematic to leave OTC (I don’t think package inserts do a damn thing to protect users; they’re mostly about liability) but for which there’s no particular reason to involve an MD.

    • offfwhite
      April 22, 2013 at 2:05 pm

      Moreover, to the best of my knowledge, Plan B is less safe (relatively speaking) than the pill

      EC is progestin-only, and threfore safer than estrogen-containing pills. The risk of blood clots comes from the estrogen part of the pills.

    • a lawyer
      April 22, 2013 at 2:14 pm

      Are you sure? I thought that there was an additional ancillary risk to the higher doses in plan b, or maybe it was from the physical effects of taking the higher doses…? I may well be wrong, of course; I haven’t read up on it in a while. But that said, we seem to agree and I don’t want to derail with a medical discussion,

      • offfwhite
        April 22, 2013 at 2:23 pm

        Yes, I’m sure.

        In addition, frequent use of emergency contraception can result in side-effects such as menstrual irregularities, although their repeated use poses no known health risks.

        There are no medical contraindications to the use of levonorgestrel emergency contraception pills.

      • offfwhite
        April 22, 2013 at 2:32 pm

        Oops! Hit “post” instead of “preview.”

        I also apologize if this is derailing, but I think, as advocates, we need to be as informed as possible.

      • a lawyer
        April 22, 2013 at 3:08 pm

        I stand corrected ;) thanks

  5. TomSims
    April 22, 2013 at 1:59 pm

    Great post Jill. You are 100% spot on.

  6. Altarego
    April 22, 2013 at 2:24 pm

    I really agree that easy, affordable access to a doctor is crucial, but I take serious issue with requiring it before one can obtain birth control. I feel like that is just another way to remove an element of control from the patient.

    I also have a lot of medical anxiety, so for a while now, I’ve chosen to not use birth control partly because doctors hold it hostage unless I have a Pap test. Again, I’m not saying that the pap is unimportant or that my scenario applies to that many people, but it is a huge issue to me.

  7. nonskanse
    April 22, 2013 at 4:05 pm

    “It does require women to go to the gynecologist”…

    rephrase to:
    ‘It does require women to let somebody stick foreign objects inside their vaginas’

    To get a fucking prescription. I have an IUD now and I’m going treasure every minute of the 5 year freedom. I might go anyway… but I might not.

    Thanks for 5 years medical-rape free, IUD!

    • sabrina
      April 22, 2013 at 4:31 pm

      I take issue with you calling medically necessary tests rape. Both as a rape survivor and the daughter of a cervical cancer survivor.
      Yes pap smears are invasive medical procedures. Yes some doctors won’t prescribe birth control without a pap smear. This is fucked up. That doesn’t mean that all doctors require a pap smear to provide you with bc. Pap smear=/= rape.

      Seriously we need a giraffe here.

      [Moderator note: Thank you for sending a giraffe alert.]

      • April 22, 2013 at 4:39 pm

        Agreed, and seconding the call for a giraffe.

      • bleh
        April 22, 2013 at 4:57 pm

        I’m not sure her experience of medical forced testing requires a giraffe. Check yourself for a moment. Maybe the language was strong, but forcing a woman to endure something inside their vagina is forcing a woman to endure something inside their vagina. Just because it happens in a doctors office, doesn’t make it ok.

      • sabrina
        April 22, 2013 at 5:18 pm

        this a reply to bleh. She did not say that she feels like she was raped while having a pap smear. She said pap smear=rape without any qualifications whatsoever
        That is extremely insulting to rape survivors and to doctors who do not rape their patients while performing medically necessary tests.

      • nonskanse
        April 22, 2013 at 5:33 pm

        A voluntary pap smear is not rape.
        Someone sticking their fingers and medical gear inside of you when you don’t want it – what else do you call it?

        It’s always terrible for me. I’ve 5 years of freedom, bought with only a slightly worse experience (IUD).

      • April 22, 2013 at 5:48 pm

        I’m not sure her experience of medical forced testing requires a giraffe.

        I wouldn’t have reacted to it that way if she hadn’t phrased it to imply that all pap smears are rape. Certainly any pap smear could be rape, if the person hasn’t freely consented.

      • April 22, 2013 at 6:17 pm

        Someone sticking their fingers and medical gear inside of you when you don’t want it – what else do you call it?

        I guess I’ve been being orally raped by my dentists for decades then. I mean, it’s not like they had to do any of that stuff (that I went there and asked them to do) by touching me. I’m sure they could have made my cavities go away by doing a nice arati and putting a pottu on my forehead, or used their super special Druidic powers to extract my milk teeth that refused to fall.

        As others have said, there’s a vast difference between “ugh, annoying, uncomfortable, invasive medical procedure” and rape. If the patient said “hey, no, I don’t want you to touch me” and the doctor did it anyway, that’s medical rape. If the patient was consenting throughout the procedure, even if it was uncomfortable, it’s not. That said, non-necessary medical procedures (like those “mandatory” unnecessary transvaginal ultrasounds for women who want abortions) definitely fall under rape.

        That said, I’m horrified at doctors who won’t prescribe BC without a pap smear. WTF?

      • EG
        April 22, 2013 at 7:07 pm

        extract my milk teeth that refused to fall.

        You too! Teeth twins!

      • Shadow
        April 22, 2013 at 10:39 pm

        I’m sure they could have made my cavities go away by doing a nice arati and putting a pottu on my forehead

        All my laughs are yours

      • April 22, 2013 at 10:41 pm

        Teeth twins!

        So much teeth twins! -_- I had a shoddy-ass dentist for some of them, too; finally quit going to him when he decided to anaesthetise the wrong tooth…good times.

      • Anon
        April 23, 2013 at 12:33 am

        Hmm, I guess I’ve been anally raped multiple times by my GI doctors with rectal exams and colonoscopies to diagnose and monitor my colitis. I definitely did not want fingers and cameras up my butt, it was definitely not pleasant, and I definitely felt sullied afterward.

      • LemonDemon
        April 22, 2013 at 5:52 pm

        There are other birth control options besides oral bc. You can always refuse to get a pap smear. You can’t refuse rape.

        So yes, I’m thirding for a giraffe. Particularly when rape as a word gets bandied about when it shouldn’t be. Dunno about everyone elses’ generation, but mine seems to love using rape as a comparison-word for ‘things they really fucking dislike’.

        That isn’t to say that a pap smear should be required for a bc scrip.

        I’m also not getting into when your rights are waved, which sometimes happens when being committed re; mental illness, et cetera. We’re not even going there, since that isn’t the topic.

      • LemonDemon
        April 22, 2013 at 6:00 pm


        “A voluntary pap smear is not rape.
        Someone sticking their fingers and medical gear inside of you when you don’t want it – what else do you call it?”

        I’d call that rape. There’s a difference between ‘experience I don’t want but need to get anyway so I made an appointment and sat through it” and “rape”. There’s this idea in western society that anything someone doesn’t want is rape. It’s erroneous and actively harmful.

      • LemonDemon
        April 22, 2013 at 6:01 pm

        My bad- I’d call that rape if the patient changed their mind and said no, and the doc went through with it anyway.

      • Bonn
        April 23, 2013 at 4:34 am

        I don’t know if I would call it “rape,” but it is rape-y, for sure.

        I have been on hormonal bc for ten years for health problems. I have also had sex exactly 0 times. For me, getting the pap test is just a humiliating and expensive hoop that I have to jump through in order to get my pills. It’s not like being raped, but it IS like letting your husband f*** you even though you don’t want to, because he said that if you don’t he won’t give you the car keys. And then you won’t get to work.

        (My pain during periods–even pill periods–is so bad that I would miss work every month without my pills.)

      • wembley
        April 26, 2013 at 9:05 am

        It’s not like being raped, but it IS like letting your husband f*** you even though you don’t want to, because he said that if you don’t he won’t give you the car keys. And then you won’t get to work.

        But… that… is… rape. Am I missing something here?

    • anon1221
      April 22, 2013 at 4:52 pm

      I agree that medically necessary tests are not rape when the patient gives consent. Of course. I’ve had a pap test many times and zero of those times were rape (for me). But I think there is some truth to the fact that when birth control is tied up with pap tests, some people may be coerced into getting the test and coerced into being penetrated. I personally find pap tests fairly stressful. I don’t find them triggering, but I imagine some people could. Or experience them as rape. Regardless, taking about one person’s experience of not completely voluntary penetration doesn’t have to detract from or minimize another person’s experience. We contain multitudes and such. If someone felt that unwanted contact was rape, then it’s not for us to say otherwise, in my opinion.

      “That doesn’t mean that all doctors require a pap smear to provide you with bc.” Very true but not everyone is able to shop around for doctors, realistically. I’ve been required to have a pap before getting birth control several times. I was fine with it, but that’s just me.

      I don’t meet at all to discourage pap tests either with this comment. Just trying to be fair to our diverse experiences.

      • Shai
        April 24, 2013 at 5:05 pm

        I think this discussion involves the issues of coerced compliance (which involves tacit consent but not actual consent), and the conditions by which medicines are withheld to leverage consent. I have PCOS…regulated by BC meds for years, which led to diabetes…regulated by oral meds for years. In the two decades of these conditions, I have always had the threat of medical witholding leveraged against my medical appointments. I have had to decide between groceries, gas and paying for doctors’ appointments. Even with insurance and incredibly benevolent doctors.
        So yes. Coerced compliance with invasive body procedures is doubly invasive, triggering, anxiety ridden. It can feel like rape to some people. If we haven’t felt like that ourselves…I’d call that an expression of privilege. I think the assumption that non-consensual body invasion or rape being always accompanied by violence is damagingly inaccurate. It can be coerced, it can be quiet, and it can be institutionalized.

    • April 22, 2013 at 7:20 pm

      Rather than the need of a giraffe could we just close the subject of medical testing based rape and move back on to the subject birth control pills and whether or not they should be available with a prescription?

      • Synna
        April 23, 2013 at 6:29 am

        But Steve, I think this is important. People with uterii are saying they feel coerced to consent to a pap test in order for their gyn to prescribe bc pills. That’s a huge affront to agency and respect for patients imho. And for sure, it may feel like rape for some persons with uterii. Coercion does not equal consent, nor does it allow consent to be given in an informed and free manner. This situation may be limiting some people from obtaining proper medical care.

        This I think, lends weight to the argument of bc pills being available without prescription.

        My only caution is that some pills are ineffective or not as effective for fat people, as the dosage may not be enough (if I’m remembering correctly things I read ages ago). This would need to be taken care of by pharmacists if bc was OTC.

  8. Schmorgluck
    April 22, 2013 at 4:09 pm

    I don’t know if it’s the case in the US, but in France gynecologists have a tendancy to focus on oral contraception to the exclusion of every alternative. They even recently have been caught overprescribing fourth generation pills, with all the issues it involves. I’ve had a few female friends who believed IUD and hormonal implants can’t be prescribed to women who haven’t already given birth (which is totally false) because their gyn told them so.

    Is this kind of misinformation as common in the US as it is in France?

    • EG
      April 22, 2013 at 4:18 pm

      I don’t know about misinformation, but I have had at least one GYN who was obsessed with getting me on hormonal birth control. Even though every visit I would explain patiently and in detail my reasons for not wanting to, even if the previous visit during which I had done so had been only two weeks previous, she would try to convince me to go on hormonal BC. But that was only one, and I have not had similar problems since her.

    • Angie unduplicated
      April 23, 2013 at 10:00 am

      Yes. I had the Dalkon Shield when I was young, and was told that it was the only IUD which could be used by a woman who has never been pregnant. I could not use the pill because of constant morning sickness and was told each time I was fitted for a new diaphragm, after Shield complications, that I could not use an IUD because of pregnancy status.
      I’ve noticed that cigarettes, which have no conceivable medical use, which create disease, which often are fatal, are sold without a prescription to both women and men, and originally were sold only to men. Not selling a therapeutic drug OTC which specifically is designed for uterus owners, strikes me as serious bigotry. Indeed, the primary health risk for OTC contraceptives is using them with cigarettes, which drastically increases the risk of blood clots. If it’s legal for religious bigots to refuse sale, it should be equally legal to refuse to sell OCs to smokers, or cigarettes to OC users.
      Many, many women locally have no health insurance because of unemployment, employers who don’t offer insurance, or because minimum wage currently disqualifies one from Medicaid. OTC pills would be a blessing to women who can’t afford OB/GYN visits. Requiring doctors’ visits is just more bourgeois privilege, IMO.

  9. Theaz
    April 22, 2013 at 4:58 pm

    I haaaaate the pap/BC annual doctor visit connection, mostly as a result of truly terrible experiences through numerous campus health providers who will not make BC available without a pap. It’s the straight up policy at my University, and it was at the University I was at before this as well. They have been insulting, degrading, shaming and at times physical about getting the pap to get the rx, and most GPs won’t take on a patient identified as a student who thus has access to a campus health GP. I have no idea why they are so adamant that these paps take place, I’ve heard explanations that it’s tied to billing and had experiences that fell low and high on the sexualized-creepiness-vibe scale. But one of the biggest benefits, as far as I’m concerned, of making BC available OTC would be taking the power out of the hands of physicians to withhold prescriptions if the patient hasn’t had a pap.

    • faultystar
      April 22, 2013 at 8:29 pm

      It’s a risk assessment decision written into a checklist so that it’s out of the NP’s and PAs hands. The checklist is based on clinical practice guidelines/good medical practice standards/etc. developed by the AMA and supplemented by other speciality organizations. (I think. It’s been a while since I really had to know this stuff.)

      This is because NPs and PAs now have the right in an increasing number of states to write prescriptions and see patients, but they still can’t be sued for malpractice. However, there aren’t enough DOs and MDs to watch them closely enough to make sure they don’t screw up. Consequently, administrators think the only reasonable course of action is to force them to practice “cookbook” or “checklist” medicine.

      So administrators — who usually have business or legal backgrounds, not medical ones — look at anything that has a risk 2-3 times higher than the baseline and prohibit the NPs and PAs from prescribing it. Unfortunately, they don’t really understand the difference between relative and absolute risk: i.e., that two times an incredibly small number is still an incredibly small number. This is why most Planned Parenthoods, college campus medical offices, etc. flat out refuse to prescribe hormonal BC to women with migraines/smokers/women over 35/etc. They don’t want you to be one of the 25 in 100,000 who gets a MI/stroke/whatever, dies, survives has a religious conversion experience, and sues them for med mal.

      If you want someone to treat you as you and “step outside the rules” and skip the traumatizing pap, you 1) see a MD, DO, or (2) skip primary care/ OB/GYN altogether and go straight to a specialist (i.e. endocrinologist or, occasionally, immunologist). IME, they’re more likely to discriminate against you for being fat/Latina/foreign/etc. than NPs and PAs are, but at least they’re given more freedom in what they’re allowed to do. So it’s helpful if you have (1) a misdiagnosed condition, (2) a normal condition that’s not responding well to conventional treatment, or (3) an incredibly rare condition that NP/PAs just don’t have the training to spot.

      • Theaz
        April 22, 2013 at 10:34 pm

        Interesting, but I’m Canadian and so the decision making context is much different. I don’t think that’s the explanation here. But it’s disturbing that it’s standard practice in multiple jurisdictions in both countries (I’ve experienced it in 3 provinces).

      • faultystar
        April 23, 2013 at 8:32 pm

        My apologies: I saw the word “billing,” played the numbers, and assumed you were also American. I have no idea what the reasoning is in Canada. Probably something rational?

      • faultystar
        April 23, 2013 at 8:37 pm

        Gargh, hit return too soon.

        I mean rational in terms of your single-payer system. I can’t imagine that you’re just following America’s convoluted lead or outdated research for no reason.

      • April 23, 2013 at 8:39 pm

        Hmm. I’m American, and I see a nurse-midwife for my BCP/yearly exam. I also can’t tolerate penetration, and thus find pelvic exams massively traumatic and painful.

        The people I see recognize this, and they don’t make me have a yearly Pap or pelvic. They did one when I went in for the first time, and then they’ve been doing one every three years after that.

        I go to a women’s clinic, not a GP or college campus-based office, but every time I’ve been there the person I’ve seen was a nurse-midwife, not an MD. So apparently you don’t *have* to be an MD to exercise discretion in this matter?

        Maybe it varies by what kind of medical facility you’re going to, and what kind of liability policies they have?

      • faultystar
        April 23, 2013 at 11:24 pm

        IME, it’s usually based on how much the administrators trust the NPs/PAs. The more that administrators trust the NPs/PAs, the more discretion they have. As I understand it, that trust is based on insurance policies and/or state law. In my state, MDs/DOs are required to supervise NPs/PAs, but I don’t know if that’s true in every state.

        For example, the hospital where I’m doing my residency doesn’t trust the NPs/PAs because we’re sued every 2.5 nanoseconds in a state the NPs/PAs cannot be sued for malpractice. So my employer’s insurers requires us to be extremely defensive about monitoring them.

        This part I’ve only heard about second-hand and I don’t really understand. They’re trying to make a physician responsible for insurance reasons. Under normal circumstances, multiple physician and hospital insurance companies get together and split the difference if they lose a med mal case. If only a hospital insurer’s on the line, they’re going to be extra paranoid about limiting liability. Conversely, if a physician isn’t there full-time but fully liable, they’re also going to be extra paranoid about limiting liability by implementing strict systems of control. I know I would be if my livelihood were on the line. Eitherway, it’s a really constricting for PAs/NPs and their patients.

        Also, I suspect that this may change as the ACA kicks in and payments are tied to patient satisfaction. I’m not 100% sure, though.

      • faultystar
        April 23, 2013 at 11:28 pm

        Also, PP in my state is really awful about this and made me get a pap, even though I got one last year. They told me it’s for the same reason my hospital is really bad: they’re sued and/or audited every 5 minutes, their insurers couldn’t take the risk, etc.

      • Kerandria
        April 25, 2013 at 5:01 am

        If you want someone to treat you as you and “step outside the rules” and skip the traumatizing pap, you 1) see a MD, DO, or (2) skip primary care/ OB/GYN altogether and go straight to a specialist (i.e. endocrinologist or, occasionally, immunologist).

        Um.. what? So you’re saying that the only providers that can ‘treat you as you’ are MDs/DOs that don’t specialise in women’s health? While we’re on the fantasy specialist train, let’s imagine for one second how likely it is that a patient is going to be able to get in to see an endo/immuno doc for a fucking BC rx without the patient having other medical issues that would warrant a referral to a specialist. Generally speaking, in the US (not sure where you’re doing your residency), you need a referral from your GP to see a specialist – many insurance companies won’t cover specialist visits made without a referral, and increasingly more specialist offices won’t accept patients coming in WITHOUT a referral.

        We ought to be encouraging our patients to be stewards of their own healthcare by helping them make good, evidence-based choices in line with their own personal beliefs and not simultaneously encouraging the culture of referrals while deriding the ability levels of NPs and PAs.

        IME, they’re more likely to discriminate against you for being fat/Latina/foreign/etc. than NPs and PAs are,

        Are.. are you seriously shitting me here? So you, one person (a resident to boot), are going to speak for a huge swath of highly trained professionals by painting them to be sexist/racist/misogynistic?

        an incredibly rare condition that NP/PAs just don’t have the training to spot.

        That they won’t likely ever have to see because with the exception of a few things like women’s health, MDs and DOs are specialists. Why should anyone expect a provider not trained in a specialty to be able to discover/diagnose ‘an incredibly rare condition’?

        The ‘us vs them’ attitude supported and perpetuated by the MD/DO establishment toward providers like PAs and NPs is toxic and doesn’t serve to promote best standards of care for our patients.

  10. Sarah
    April 22, 2013 at 6:56 pm

    Actually, OTC contraception is covered by the ACA already, so no worries on that one. The HRSA requirement says, “All Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.” A FAQ put out by HHS and the Dept. of Labor clarifies, “Contraceptive methods that are generally available OTC are only included if the method is both FDA-approved and prescribed for a woman by her health care provider.” (

    Although that site says male condoms aren’t covered, some health insurance companies do seem to be covering them for free now as well for women with a prescription. Of course, this means that if you want it to be free, you won’t be able to skip the doctor’s visit.

    -your friendly neighborhood med student

    • Pseudonym
      April 23, 2013 at 12:50 am

      Some health insurance companies are covering the cost of male condoms… for women? I guess it’s the woman who’s at risk for pregnancy, but on the other hand I doubt the insurer would cover vasectomies for a woman’s one-night stands.

  11. theLaplaceDemon
    April 22, 2013 at 7:06 pm

    I am somewhat sympathetic to the seeing-a-gynecologist angle, but…

    You can still get birth control without getting an OB/GYN exam. Not all doctors require them, a lot will take a “just not today please” excuse, a lot of the time doctors will refill a prescription without seeing you in person if you ran out and need more.

    And since hormonal birth control is not itself causally associated with any gynecological issues, forcing the two together feels *really* coercive. Like, it’s one thing if you’re talking a drug that puts you at risk for anemia, and your doctor wants to do regularly blood tests if they prescribe you the drug. That makes sense. But hormonal birth control doesn’t cause cervical cancer, so why should you need a pap smear to get it?

  12. miga
    April 22, 2013 at 7:08 pm

    I think that for most people the availability of OTC birth control is a good idea, but my personal experience speaks otherwise.

    I was originally prescribed oral BC for PMDD- my mood swings were and are incredibly severe around my period. Allowing something that alters ones mood so drastically to be sold OTC makes me worried. For the first couple of months when I was on the pill it was awful- I was moody all the time, sweaty, nauseous, and I wanted to eat everything in sight. When I came off it was the same. One of my close friends had similar issues x10, but hers was because she is so small the standard dosage of oral BC is too much for her.

    That’s my only objection- if it can be dealt with I have no problem with it being OTC.

    • kb
      April 22, 2013 at 7:21 pm

      except that by this argument, caffeine, alcohol, many antihistamines, and cough medicine shouldn’t be OTC. yes, some people have mood effects from hormonal bc. Many don’t. Some people have mood effects from all the things I mentioned. many don’t. and I don’t think it’s denying your experience to say, allowing OTC sale isn’t the same as forcing you to buy it. You are allowed to not buy anything that has a bad mood reaction for you. You are not allowed to use that as a reason to prevent me from buying it.

      • miga
        April 23, 2013 at 3:35 am

        Oh no, I don’t think it should be outlawed at all. I’m just worried about mood-related side effects. My oral BC was prescribed because I became suicidal once per month, and it’s not uncommon for doctors to prescribe BC for period-related mood swings.

        Maybe my description of the side-effects of taking it were tangential, but as a person who is on mood stabilizing medication I’m just very leery of people going on and off without medical supervision. Especially when you add in that many people don’t know their mood has changed until it’s either a) pointed out to them by someone else or b) something drastic happens

    • minuteye
      April 22, 2013 at 7:34 pm

      A lot of medications sold OTC have some rare, and potentially very scary side effects. I understand your concern, but there is a precedent for having “___ is NOT NORMAL. If you experience ___ SEE A DOCTOR IMMEDIATELY” on the side of the bottle.

      • miga
        April 23, 2013 at 3:53 am

        That’s a fair point. Perhaps my experience with MI is making me overly anxious on this.

        I’m also not saying that I don’t think it should remain illegal to provide it OTC- I think it would do a world of good for many people…I just think it would do so much bad for quite a few others, and those others might not realize it until something irreversibly bad happens. It doesn’t sit well with me, but maybe having a big fat warning in bold would help.

    • theLaplaceDemon
      April 22, 2013 at 7:53 pm

      I’m not sure how requiring people see a doctor will help with that? The doctor had no way of knowing you would have those side effects before prescribing it, so whether it’s OTC or prescription there is still going to be a trial and error aspect to birth control, as there is for every other drug on the market.

      As for your friend who was too small, that could be fixed with a chart or note on the bottle about “people under X weight may want to consult a doctor about getting a different dosage” or something.

      • miga
        April 23, 2013 at 3:37 am

        My description of my symptoms going on and off were probably tangential, I apologize. My point is that significantly mood-altering medication being sold OTC makes me nervous, and my BC was prescribed for the severe and dangerous mood swings I went on around my period.

      • theLaplaceDemon
        April 23, 2013 at 5:08 pm

        Well, I suppose the answer would be to weigh the frequency of severe mood alterations (particularly ones that don’t go away once you stop taking it) against other OTC medications. My guess (though I don’t know for certain) would be that epidemiological data has shown that a small enough percentage of women using hormonal BC experience your symptoms that the benefits of having it OTC outweigh the risks.

        But still, even then – what greater level of control/protection does it offer to have it prescribed? If there isn’t a test the doctor can do to predict how you will react to it*, it’s still trial and error. Your doctor gives you the BC, you have a bad experience, you either stop taking it or go back to the doctor, vs. you get it OTC, you have a bad experience, you either stop taking it or you call your doctor.

        *it is totally possible, if it’s genetically correlated at all, as many drug reactions are, that there will be a test for this in the near future

      • April 23, 2013 at 8:31 pm

        … “people under X weight may want to consult a doctor about getting a different dosage.”

        Or over Y weight, too!

        I was already going to have to have a combination pill for other reasons, but even without those I am big enough that a progestin-only-pill might be less effective in me.

        It has always struck me as weird that there isn’t a range of dosages of BCP, since people with ovaries/uteri come in all sizes.

    • Alara Rogers
      April 22, 2013 at 11:45 pm

      I was prescribed a BC pill that drove me insane. Literally. I became clinically depressed, a condition that I now recognize I have a predisposition to but at the time I hadn’t suffered from in 10 years and hadn’t recognized it the first time it happened, and I wanted to kill myself. I used to hide from the telephone because the ringing sent me into panic attacks, and fantasize about driving my car into a concrete pylon.

      I went to a psychiatrist who prescribed me Prozac. She did not counsel me to think about the connection between my BC pills and my mood change. In fact I don’t think she mentioned my BC pills at all. My gynecologist hadn’t mentioned the issue either. *I* figured it out, because I have a BA in psychobiology and the day I tried to kill myself because my boyfriend yelled at me for buying the wrong tomatoes, I realized, if the stress in my life has normalized and I’m getting enough sleep and I have a job and everything is ok now, and yet this still happens to me on my period, maybe it’s hormonal… so could it be my BC pill? The answer was yes.

      So while I do fully understand your concern… the fact is that right now, gynecologists and psychiatrists aren’t considering the mood effects of BC consistently in practice, so would it actually be any different if women could get the pills OTC? I’d have been better off with a bottle that had clearly labeled drug warnings on it than I was with two doctors and prescription pills that came with a leaflet in eyestrain-o-vision type.

      In fact, if a doctor prescribes you something and doesn’t tell you about X effect, you assume X effect isn’t related to your pills because wouldn’t your doctor have said? If the med is OTC, you might be a lot faster to pick up on the fact that it’s causing X effect because no one you trusted to advise you left the information out; you *know* you don’t know everything about what it might do, if you bought it for yourself OTC.

      • whistlewren
        April 23, 2013 at 3:29 am

        This happened to me too. Very soon after going on BC pills I was depressed bordering on suicidal and stuck in a loop of intense, unending panic attacks. I would barely drag myself through each day til I could get home and curl into a ball. It is only because it was reminiscent of the initial adjustment for my SSRIs, and of PMT, that I made the connection, as my GP had never mentioned it as a possible side effect.

      • miga
        April 23, 2013 at 3:44 am

        That’s strange- my doctor (a pediatrician) prescribed BC specifically *for* my period-related mood swings, and I’d heard that it wasn’t an uncommon occurrence.

        It’s also my experience that many people don’t know their mood has altered until it’s specifically pointed out to them by a friend or by a drastic incident that forces them to realize it. Kind of like when you grow and you don’t notice until someone says something about it or you go to put on your pants and realize they’re too small. And that scares me- what if that moment comes only after significant damage has occurred?

      • April 23, 2013 at 8:26 pm

        [M]y doctor … prescribed BC specifically *for* my period-related mood swings

        Same for me — well, almost. I’d already been treated for depression, and I feared that messing with my hormone levels might make it worse, so I mentioned this to the nurse-midwife I saw for my BC. She gave me a combination pill specifically to protect my mood.

        So I would definitely have needed to see someone to pick a pill that would NOT have driven me crazier than I already was.

        I’m glad they’re making it OTC, I just hope there are warning labels for people with mood disorders, too, along with everything else that might contraindicate hormonal BC.

      • Mr Rabbit
        April 23, 2013 at 5:58 am

        My chronic depression descended into a new level of hell on birth control pills. I was suicidal and unlike my pre contraceptive pill suicidal ideation I could not promise I wouldn’t go through with it. I lost so much and am still trying to repair my life.

        I found GPs, gynos, psychologists and psychiatrists quite dismissive of the effects of progestin / estrogen on my depression.

        Furthermore, I am allergic to all progestins. They give me urticaria, facial swelling and breathing difficulties. I’ve had doctors demand I take progestin after progestin to prove I’m telling the truth. (I needed to take progestin to delay endometrial cancer; I ended up having a hysterectomy instead… after a long battle with doctors because of my age and not having had children. Trying to convince various gynos that the mirena coil would probably kill me via suicide or anaphylaxis was not easy. “Just try it and see.”) A lot of GPs don’t believe progestin allergy is possible. Even some immunologists aren’t aware of the issue. (My relief at an immunologist who understood and confirmed my allergy.)

        I don’t see birth control pills as relatively harmless. Some people can take them without a problem. Some people have side effects they can live with. And some people find them life threatening.

        If they were no longer offered by prescription, more information would be needed to be given to people taking them. People would need to know the risks. And that over the counter does not mean you can be blase about what you’re taking. (We tend to trust that over the counter means safe.)

        In Australia low income people can get a lot of prescription medications for $5.80 so making them nonprescription might make birth control pills unaffordable for low income people. I can’t comment on the price issue from a US perspective.

        I’m leaning on the side of having contraceptive pills continue as prescription (at least in Australia) though I am sympathetic to the arguments about body autonomy. It would be great to hear other people’s points of view, especially if you need or want to take these medications. What are the advantages and disadvantages for you?

      • Lu
        April 23, 2013 at 10:46 am

        The requirement to get a prescription in Australia isn’t as onerous because the doctors visit is free if the doctor bulk bills. Also, the prescriptions are usually obtained from a GP rather than a gynecologist.

        As I understand it, part of the problem in America is that many people don’t have access to free doctors visits, so requiring a prescription can exclude those people from access.

      • Mr Rabbit
        April 23, 2013 at 11:38 am

        I agree Lu, the situation is different in the US and your post perfectly highlights that. Also, the contraceptive pill is often prescribed by a GP without having a pap smear, so hopefully no one has to undergo an examination they do not want to have in order to get these pills or devices in Australia (though I’m sure it unfortunately and unacceptably happens on occasion). The other important difference is that Australia does have a vocal and influential conservative Christian movement but it is no where near as powerful as that of the US. This makes the case for over the counter stronger in the US than in Australia. I’ve been thinking about these differences since my original comment.

      • theLaplaceDemon
        April 23, 2013 at 5:21 pm

        Two things –
        If you were the one picking up the progestin pills off the shelf, rather than your doctor writing you a prescription or trying to force another delivery method on you, wouldn’t that give you more control over dosage, rather than having to fight with dangerously ill-informed and generally disrespectful doctors so much?

        “And that over the counter does not mean you can be blase about what you’re taking. (We tend to trust that over the counter means safe.)”

        True, but that is the case for many OTCs. I know someone who was an alcoholic and died from what would have been for most people a normal dose of Tylenol.

  13. LemonDemon
    April 22, 2013 at 7:18 pm

    “That’s my only objection- if it can be dealt with I have no problem with it being OTC.”

    That’s what those pamphlets they give you with meds are for, m’pretty sure. Not that they’re particularly accessible, god knows I can’t read them.

    • theLaplaceDemon
      April 22, 2013 at 7:57 pm

      Srsly. Can we please have a Legible Medical Pamphlet movement, or something? Minimum size 11 font and bold headings, please.

      • LemonDemon
        April 22, 2013 at 8:22 pm

        I’d rather have it in braille.

      • theLaplaceDemon
        April 22, 2013 at 11:45 pm

        Fair enough. My initial plan was clearly flawed.

      • miga
        April 23, 2013 at 3:47 am

        Do they provide medicinal information in braille? Or aurally? I’m a bit embarrassed to say I’ve never thought of it.

      • LemonDemon
        April 23, 2013 at 1:41 pm

        To the best of my knowledge nobody does braille for anything. If I want information aurally I have to ask specific questions.

      • Angie unduplicated
        April 23, 2013 at 10:24 am

        Several websites, including manufacturers’ websites and NIH, have the sheets in decently sized fonts/typefaces.
        If a medication has side effects that aren’t on the sheet, users often self-report online. It’s often possible to find side effects by researching by chemical or chemical constituent name.

    • Pseudonym
      April 23, 2013 at 12:47 am

      Those little pamphlets are included more for liability reasons than for actually informing the patient, hence why they’re so little.

      • Kerandria
        April 25, 2013 at 5:20 am

        I really wish that guidelines for comprehensive, easy-to-read rx package inserts had been a part of the ACA.

  14. Hnought
    April 23, 2013 at 12:43 am

    In regards to ob/gyn exams – I live in OR and I went to see a NP to get an IUD put in and she told me they’re following the newer every two years recommendation now. Maybe it was just where I went to get my IUD, but I wasn’t required to get a pap smear or anything to get it, it just took a little longer then getting a prescription for the pill or NuvaRing would have. I went in for a consultation one day where she explained my bc options and anything I wanted to know (and more) about an IUD and then I had to come back to get it put it. (I was totally fine with having to make two appointments – an IUD is kinda an invasive procedure)

  15. April 23, 2013 at 5:22 am

    A lot of people here seem angry that so many doctors (at least here in the United States) hold hormonal birth control hostage unless their patients submit to Pap testing. That makes me angry, too, as it reduces access to important medication. While I recognize the incredible importance of Pap testing from a public-health perspective, I think it’s unethical to withhold medication like birth control (also incredibly important from a public-health perspective!) from people who don’t wish to undergo an invasive and possibly upsetting or traumatizing physical exam.

    I would encourage you to look into Planned Parenthood’s HOPE program, which offers hormonal contraception without a Pap test. They will take your blood pressure and ask you some questions, and while they’ll strongly encourage Pap testing, it is not a requirement for a prescription.

    Also, FYI, the guidelines changed last year, and Pap testing is generally only recommended once every three years, not annually!

    • Angie unduplicated
      April 23, 2013 at 10:27 am

      Damned preachers have run PP out of numerous Southern cities. Now a PP appointment entails a trip to Atlanta on expensive gas or bus tickets, and long wait times for an appointment.

    • Kerandria
      April 25, 2013 at 5:18 am

      Angie – you’re absolutely right, and it puts a knot in my stomach every time I suggest PP to a patient only to be told that their rural location precludes their ability to get to a city clinic.

      The desperate need for meaningful, practical community health centers across the US cannot be stated enough. The need comes with so, so much bitterness for every person that uses their religion/wallet to curb the ability of people to have access to the healthcare they need.

      This sort of shit sets my fucking heart on fire.

  16. Ursula L
    April 28, 2013 at 10:39 am

    How would OTC birth control pills work with the Obamacare provision requiring coverage of birth control?

    Every insurance plan I’ve had would cover prescription medications, but didn’t cover over-the-counter medications.

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