Oregon Gets it Right! The Case for Over the Counter Birth Control Pills

by Lauren Sreicher, MD

 

Mexico is known for beautiful beaches, great guacamole and, as any woman who’s forgotten to bring along that all-important pack of pills knows, over-the-counter hormonal contraception. That’s right. You can wander into any pharmacy in Mexico and pick up a pack of birth control pills without a prescription – a convenience that until now, with Oregon's new law, has not existed in the US.

 

A lot of people, including most gynecologists, agree with the  change. Even  the American College of Obstetricians and Gynecologists (ACOG)  released a position statement in 2012 recommending that oral contraceptive pills be sold over-the-counter.

The reasons for that endorsement are clear. According to the Guttmacher Institute, 50% of the pregnancies that occur in the United States each year are unplanned. By age 45, half of all American women will experience an unintended pregnancy. Every year, failed contraception, or no contraception, contributes to 3.2 million unintended pregnancies.

Barriers to obtaining contraception, such as the prescription requirement, contribute to our nation’s sky-high unintentional pregnancy rate. It is irrefutable that increasing  availability of pills will improve usage of contraception. Other studies have consistently proven that when barriers such as cost and access are eliminated, unplanned pregnancy rates plummet.

Getting a prescription is a huge burden to many women who have no regular physician, no insurance, and a job that doesn’t allow the luxury of taking an afternoon off to go to see a doctor. The college student without a gynecologist (and without a car) doesn’t have it any easier. Not to mention, many insurance companies only release one month of pills at a time. It’s understandable how a prescription can lapse.

Opponents to the OTC initiative say it is too dangerous. They express concern that high-risk women are likely to take birth control pills which will lead to in an increase in serious side effects such as blood clots and heart attacks. Please! Women deserve a little more credit. The average woman is more than capable of self-screening and determining if taking pills would be dangerous or inappropriate. No woman wants to have a stroke. If someone is 40, overweight, and a smoker, she is going to be informed that she is not a candidate for hormonal contraception just as a man with kidney failure is informed that over-the-counter painkillers are not safe. ACOG, known to be a medically conservative organization, strongly states that the benefits far outweigh the risks.

Truth be told, the same people that say pills shouldn’t be sold over-the-counter are often the same people that think insurance shouldn’t cover contraception in the first place. And that abstinence education actually works. Or that easy access to contraception will increase teenage sexual activity. In other words, their political agenda, not women’s health, is their priority.

Mexican women are more likely to stay on their pills and have no higher rates of complications than American women! In addition, evidence shows that even if the pill is available without a prescription, women will continue to show up for their annual checkups, Pap tests and STD screens.

Most women spend the majority of their reproductive years trying to avoid becoming pregnant. The solution to lowering the country’s high unintended pregnancy rate is not going to be completely solved by increasing access to contraception, but it’s a really good start and I’m all for it.

 

When Taking the Pill Takes Away Your Sex Life

By Lauren Streicher, MD

10/6/2014 doctoroz.com

For the last 50 years, birth control pills have given women the power to determine when they get pregnant. But for some women, the very pill that allows this freedom can impact libido and vaginal lubrication such that many lose the desire to have sex in the first place.

If you take birth control pills and can’t figure out why your vagina is like the Sahara Desert in spite of being 25 years old and totally in lust with your partner, you are not imagining it. It’s real and it’s likely that your birth control pill may be the problem.

For Most Women, the Pill Is a Good Thing
For the lucky majority of women, hormonal contraception enhances sexual health, and most pill users have more frequent sexual thoughts and fantasies, better orgasms and more interest in having sex. Removing fear of pregnancy, cramps, PMS and heavy bleeding also goes a long way to a better sex life.

For Some Women, the Pill Is a Problem
Thanks to the groundbreaking work of Dr. Andrew Goldstein, who sees hundreds of women a year at his Center for Vulvo-Vaginal Disorders, it is now appreciated that a small but significant percentage of women on hormonal contraception not only have reduced libido but also experience painful intercourse. Dr. Goldstein observed that many young women taking low-dose birth control pills experienced symptoms normally seen only in menopausal women with low levels of estrogen, the hormone that increases sex drive and contributes to normal vaginal lubrication. Given that birth control pills contain estrogen, one would think that the pill would be a major sexual booster, but Dr. Goldstein discovered that the explanation was in the other part of the hormone cocktail that’s responsible for sexual health: testosterone.

Less Testosterone, Less Libido
Birth control pills lower the amount of testosterone produced by the ovaries and increase a protein secreted by the liver known as sex-hormone-binding globulin (SHBG). SHBG binds to testosterone and makes the molecule inactive. The higher the SHBG level, the lower the functional testosterone level. Lastly, the synthetic progesterone component in some birth control pills actually poisons the testosterone receptor if given in high doses. Since both estrogen and testosterone receptors in the vagina contribute to lubrication, it is understandable that low testosterone not only makes things drier, but also more painful, a condition known as hormonally mediated vestibulodynia. (The vestibule is the area at the opening of the vagina, anddynia is the Latin root for pain).

If that wasn’t bad enough, low testosterone can also lead to fatigue, lethargy and moodiness, all symptoms that make you more likely to want to take a nap than make love.

Anatomical Changes
If you needed any more convincing that the changes that occur on the pill are not just “in your head,” a study that was published in the Journal of Sexual Medicine in 2012 measured the thickness of the labia minora, the size of the clitoris and the size of the entrance of the vagina in women on the pill. It found that after only three months of use, pill users had thinner labia, smaller clitorises and a decreased entrance of the vagina that correlated with increased pain during intercourse. In addition, these same researchers showed decreased orgasm in the women on the pill.

The Terrible Testosterone Trifecta
While most women do not have this problem, Dr. Goldstein discovered that about 5% of women have a genetic variant that results in a defective or inefficient testosterone receptor. These women require much more testosterone to keep the vulvar and vaginal tissue healthy and for their glands to function normally. The effects are not obvious until testosterone levels become lower than normal, but that happens to every woman who takes the pill.

So, in women with this genetic variant, the problem is threefold:

1. The pill causes the ovaries to produce less total testosterone and less is in a usable form.

2. The synthetic progesterone found in newer birth control pills poisons the testosterone receptor at high doses.

3. The testosterone receptor doesn’t work well, making it extra dependent on high amounts of testosterone being present.

The Solution
So, if you are on the pill and find you would rather play Sudoku than play with your partner, what options do you have? Ideally, women who have this condition should not take the pill and instead use an alternative method of contraception, such as an IUD. A local vaginal estrogen and testosterone cream (by prescription from a compounding pharmacy) can also facilitate healing. Be patient, it usually takes months.

If another method of contraception is not an option, know that some pills may be better than others. Very-low-estrogen pills that contain drospirenone, desogestrol or norgestimate seem to have the greatest negative impact on libido and vaginal dryness, so if you’re taking one of these, talk to your doctor about whether it’s contributing to any symptoms you might have. Use a silicone lubricant, and ask your doctor for a prescription for hormonal creams to apply to the opening of the vagina. And know that you are not crazy.

Glaucoma and Birth Control Pills: Seeing the Big Picture

By Lauren Streicher, MD

Published Nov 19, 2013 EveryDay Health

Hormonal contraception is the most common prescription medication used by healthy young women so it’s always disconcerting to hear that there may be a serious health consequence as a result. This week, researchers reported that women who take oral contraceptives for three years or more are more than twice as likely to develop glaucoma, which can cause blindness if untreated. Before you flush your pills down the toilet, you need to know that the risk of getting glaucoma in the United States is less than 1% in individuals under the age of 55. More important, association is not the same as cause and effect. In other words, while women in the study who took birth control pills were twice as likely to have glaucoma, the researchers acknowledge that the pills didn’t necessarily cause glaucoma. It’s an interesting observation and is not the first time that estrogen levels have been associated with glaucoma risk. In fact, it has been known for some time that numbers of affected women increase immediately after menopause, when estrogen levels take a dive. But, everyone agrees that more research is needed to determine how and whom an alteration in estrogen levels impacts the most.

To further keep things in perspective, keep in mind the pill not only provides excellent contraception, but reduces or eliminates health problems that are far more common than glaucoma including heavy menstrual bleeding, anemia, painful menses, issues from endometriosis, and cancer. That’s right; women that take the pill have a significant reduction in ovarian, colon and uterine cancer, the most common gynecologic cancer. The up to 50% reduction in uterine cancer rates with one year of pill use alone goes under the heading of “the greater good”

So while the observation that birth control pills in women may increase the risk of glaucoma, keep the big picture in mind. This is not to minimize the impact of glaucoma, which is the second leading cause of blindness in the United States after cataracts. Get screened for glaucoma if you are over 40, earlier if you are African American , are diabetic, or have a family history of glaucoma. It’s not a reason to stop taking your pill.