Birth Control Without a Prescription

An unusual Republican proposal makes medical sense, kind of.

Let it never be said that Republicans are fighting a Forever War on contraception. In several states, Republican candidates are calling for more birth control—on demand and sold right next to the Tylenol.

"The pill ought to be available over the counter, round the clock, without a prescription,” says Colorado’s Cory Gardner in a new campaign ad.

For the GOP candidates supporting this measure, it’s a way to woo women voters while sidestepping Obamacare’s mandate that companies cover birth control on their health-insurance plans—and that health plans offer the pills without a co-pay. One way to please both women and conservative-leaning corporations is to simply make Ortho Tri-Cyclen more like Claritin: You want it, you go to Walgreens and get it.

At first this sounded, to me, like the worst idea ever. Almost every woman I know who’s on the pill has experienced side effects so severe they almost make baby-free sex not seem worth the hassle. Though all so-called “combination” pills contain both a synthetic estrogen and a synthetic progesterone, the ratio and type of each hormone vary among the different pill brands. Women’s health sites beckon women to “find the right one for you.”

But the quest for the “right” pill can sometimes turn into choose-your-own adventure novel where the only possible denouements are things like “inexplicable crying in meetings” or “cramps that feel like fiery mount Orodruin has relocated to your uterus.” Yaz might help with PMS, for example, but in some women it actually makes it worse. Lybrel makes it so you only have your period once a year, but it makes the uterine lining so thin that it “can become unstable and shed at random.” Surprise!

Navigating all of these pitfalls seems difficult enough with a gynecologist’s help, I thought. Why would you want to go it alone? It seemed even weirder that the initiative is being supported by the American College of Obstetricians and Gynecologists, a.k.a. the people who profit from your birth-control-consultation copays. So I called Daniel Grossman, vice chair of ACOG's Committee on Gynecologic Practice Bulletins, to find out why the doctors’ group is in favor of the over-the-counter push.

First, Grossman thinks that women can profile themselves for the major contraindications against using oral contraceptives, like smoking, without the help of a doctor. “That part is pretty straightforward,” he assures me. Women would still need to get their blood pressure checked, but they could do so at a drug-store kiosk.

What about the part where you try a pill, it makes you crazy or teary or bloaty, and then you drag your puffy self back to the OB-GYN to figure out a better one? Grossman thinks, essentially, that laywomen won’t be any worse at this trial-and-error process than doctors are.

Where Can I Buy the Pill Without a Prescription?
K. Grindlay et al. Contraception 88 (2013)

“The reality is that there isn't a lot of good scientific evidence about that in the first place,” he said. “If the woman doesn't have any medical conditions or contraindications, we might have a favorite low-dose pill for her to start on. We'll see how she does. If she has side effects that might be related to the kind of progestin, we might change it. It's a little bit more of an art than science.”

And if the pill were available without a prescription, women could still see a doctor for advice on which pill to choose. Grossman thinks it’s actually the mini-pill, which contains only progestin, that would likely be approved for over-the-counter use first, since it has the fewest contraindications and potential side effects.

Much of the developing world already offers the pill prescription-free, presumably because the health risks of pregnancy are much worse that the health risks of a poorly-chosen pill.

One other big issue is that, unlike with prescription pills, most insurance companies would not cover over-the-counter birth control. The over-the-counter pill, some Democrats say, could run women $600 a year or more, compared to the current rate of $0 under Obamacare.

Grossman said one solution would be for insured women to get a prescription anyway, even though they would no longer need one. Which would, of course, defeat the purpose. Still, the over-the-counter version would be an option for women who are undocumented, who fall in the Medicaid gap, or who are otherwise unable to get to the doctor to get their prescriptions renewed.

In other words, interesting thought, Republicans. Now you just need to get a handle on your ladyparts-oriented word choice, as evidenced by this recent GOP pollster's interview with NPR:

"What's happened with the over-the-counter birth control issue is that the Democrats didn't see it coming," Kellyanne Conway said. "They think that they've got a monopoly on talking to women from the waist down.”