Roundups Sexual Health

Sexual Health Roundup: Court Says Illinois Pharmacists Don’t Have to Distribute EC, Just as NYC Schools Stock Up on It

Martha Kempner

An appellate court this week ruled that Illinois cannot force pharmacies or pharmacists to sell EC. The New York City Department of Education, meanwhile, is offering it to students. And ACOG recommends IUDs and Implants for teens.

Pharmacists in Illinois Don’t Have to Distribute Emergency Contraception, but Students in New York City Can Get It in School

Emergency Contraception (EC), also known as the “morning after pill,” is a method of birth control that can be taken after unprotected sex. Women who had intercourse without birth control or experienced the failure of their regular method of birth control can take EC within five days in order to prevent pregnancy. Emergency contraception is a hormonal method that works, like the birth control pill, to prevent ovulation. EC does not end prevent a fertilzed egg from implanting in the uterus, nor can it end an existing pregnancy once implantation occurs. Despite this, many people continue to confuse EC with the “abortion pill” (which can end an existing pregnancy), and anti-abortion proponents continue to misrepresent it as an abortifacient. 

Illinois’ Health Care Right of Conscience Act says that health-care providers do not have to participate in any care that violates their consciences or religious beliefs. To ensure that this law did not prevent women from accessing EC, in 2005, former Gov. Rod Blagojevich mandated that all pharmacists and pharmacies sell the drug. In 2011, a judge in the state placed the law under an injunction, arguing that the law was not neutral because it was designed to target religious objectors. The judge noted that there was no evidence that EC had ever been denied on religious grounds. On Friday, an Illinois appellate court agreed and said that the Health Care Right of Conscience Act protects pharmacists who decide not to dispense EC due to their beliefs.

The ACLU of Illinois spoke out against the decision, saying:

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“We are dismayed that the court expressly refused to consider the interests of women who are seeking lawful prescription medication and essentially held that the religious practice of individuals trumps women’s health care.” 

If, indeed, it is true that pharmacists in the state have not been refusing EC on religious grounds, then this ruling should have little immediate impact. Unfortunately, it does set the stage for religious objections to all sorts of birth-control methods, such as, for example, the birth control pill and IUDs that have inaccurately been labeled abortifacients by anti-abortion proponents.

Despite the myths that remain around EC, the New York City Board of Education took the bold move this week of making this method available in the school nurse’s office. New York City schools already distribute condoms and are now adding EC as part of a city-wide program called “CATCH” (Connecting Adolescents To Comprehensive Health), which is aimed at stemming teen pregnancy. Thus far, the pills are available in 13 high schools. This is the first time that city schools have distributed hormonal contraception.

Parents have been notified of the CATCH program, and they’re able to “opt out” of it if they do not wish their children to have access to condoms or EC. Only about one-to-two percent of parents have chosen this option. Parents will not receive notice that their children have accessed EC. 

City Council Speaker Christine Quinn spoke highly of the program: “High school students are very sexually active and getting pregnant, so we don’t have that luxury to think that they are too young to be engaged in conversations about contraception and sexual education.” 

ACOG Report Tells Doctors to Recommend IUDs for Teens

Last week, the American College of Obstetrics and Gynecologists (ACOG) released a report suggesting that doctors discuss intrauterine devices (IUDs) and contraceptive implants with teens looking for long-term contraception. Termed Long-Acting Reversible Contraceptive (LARC) methods, these two options remove almost all possibility for user-error, making them more effective than other methods, such as condoms or the birth control pill. 

Because of its history, including the now-infamous Dalkon Shield—which caused infertility in many women in the 1970s—the IUD has a shaky reputation. For many years, it was recommended only for women who had already had children and did not desire more. In recent years, however, new brands have been introduced and have been proven to be safe and effective. 

In 2007, ACOG noted that these methods were safe for all women, including teenagers, but confusion still exists among women and health-care providers. ABC News, for example, reported that a physician told his teenage patient that she could use an IUD only if she was in a monogamous relationship. Since she was not, she had the device removed. She subsequently got pregnant and had an abortion.

With the new opinion, ACOG hopes to remove any confusion by using stronger language, stating that LARCs should be considered a “first line” birth control option for teenagers. The opinion also suggests that counseling on these options should be part of all health-care visits with sexually-active adolescents. The opinion concluded:

When choosing contraceptive methods, adolescents should be encouraged to consider LARC methods. Intrauterine devices and the contraceptive implant are the best reversible methods to prevent unintended pregnancy, rapid repeat pregnancy, and abortion in young women.

One remaining obstacle for teens, however, is the price of these methods. Though they  become very cost effective if they are used for their entire lifespan (three-to-ten years, depending on method), they do require a large up-front fee. Though many insurance providers cover this fee, teenagers on their parents’ health insurance policies may not want to use this payment option because of confidentiality issues. 

Roundups Sexual Health

The Nation’s Doctors Speak Up for Contraception Access

Martha Kempner

The nation's doctors are speaking up for expanded access to contraception. The American College of Obstetricians and Gynecologists endorsed making oral contraceptives available without a prescription and emergency contraception over-the-counter. The American Academy of Pediatrics suggested that pediatricians give young women prescriptions for Emergency Contraception before they need it. 

ACOG Suggests OTC Birth Control Pills

Last month, the American College of Obstetricians and Gynecologists (ACOG) suggested that oral contraceptive pills be made available over the counter. Though 30 countries make birth control pills available to women without a prescription, in this country they remain available only with a prescription from a health care provider. After looking at the most recent research and science, ACOG’s Committee on Gynecologic Practice concluded:

“Weighing the risks versus the benefits based on currently available data, OCs should be available over-the-counter.”

In its opinion, the committee declared that unintended pregnancy remains unacceptably high in this country and has not changed significantly in the last 20 years. It noted that access to and cost of contraception contribute to this public health crisis and pointed out that women who become pregnant unintentionally are more likely “…to smoke or drink alcohol during pregnancy, struggle with depression, experience domestic violence, and are less likely to obtain prenatal care or breast-feed.”

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The committee also took on the possible criticisms of making oral contraception available over the counter including concerns about the safety of the pill, contra-indications for some women, and continued adherence without a doctor.  

It noted that no medication—whether prescription or OTC—is completely safe and that the risks associated with the birth control pill may be smaller than those with some common drugs such as aspirin and acetaminophen. Moreover, while it is true that some women should not use the pill, studies have found that by using a simple checklist, women are able to figure out whether they are good candidates for this method without a physician. For example:  

“In one study that compared current family planning clients’ self-assessment of contraindications with clinical assessment, 392 of the 399 participant (females aged 15–45 years) and health care provider pairs obtained agreement on medical eligibility criteria.” 

Research also suggests that compliance may actually improve for women who are able to get their pills over the counter. In one study women in the United States were assigned to two groups—one group got their pills from a public clinic and the other got them from Mexican pharmacies. Though adherence rates were similar, the women who went to the pharmacies were slightly more likely to continue with their pills.   

Health care providers may also fear that women who get the pill the at the drug store will no longer come into the office for other preventive services and may forgo more effective methods that are only available by prescription such as IUDs and Implants. The committee dismissed this last concerned suggesting that:

“…efforts to improve use of long-acting methods of contraception should not preclude efforts to increase access to other methods.“

It went on to note:

“In one study, 68% of the women who might avail themselves to over-the-counter OCs reported not currently using any contraceptive method”

As for preventive services, the committee once again pointed to the research in which some women went to Mexican pharmacies and others to clinics and noted that the both groups received pap smears and STI screenings at similar rates (though those going to the clinic were slightly more likely to received other services). 

The final concern, however, is cost. As of August of this year, the Affordable Care Act required insurers to pay for contraception. Though there are still some questions, it is likely that OTC contraceptive methods such as condoms will not be covered. Tait Sye, a spokesperson for the Department of Health and Human Services, agreed that if the pill were sold without a prescription, it would not be covered under the provision which could ultimately make the pill more expensive.

Despite this important opinion by ACOG, it will likely be many years before we see birth control pills in the feminine hygiene aisle at the local Walgreens. The ultimate decision would have to be made by the Food and Drug Administration (FDA) which did say it would be willing to sit down with any company that was interested in making the pill available without a prescription to discuss what additional studies might be needed. That said, it’s unclear if any manufacturer would want to take this one on especially after watching the application process for making Emergency Contraception available over the counter which became highly political—spanning two administrations—and is, in fact, still going on. 

AAP Urges Providers to Give Teens EC Scripts Ahead of Time

With this latest decision ACOG launched what may be the first strike in the debate about  making birth control pills available over the counter but last month its members also weighed in on the ongoing controversy over doing the same thing for Emergency Contraception (EC). The Committee on Health Care for Underserved Women released an opinion recommending steps to improve access to EC including removing age restrictions on its OTC availability, encouraging insurers to cover the method whether obtained by prescription or OTC, and launching media campaigns to increase knowledge of this important pregnancy prevention method. 

This week their colleagues at the American Academy of Pediatrics (AAP) also took on access to EC when they suggested that health care providers give young women prescriptions for the drug even before they need it.

Emergency Contraception is a high dose of hormones that can prevent pregnancy (by preventing ovulation) if taken within three to five days of unprotected intercourse. The sooner it is taken, however, the better it works. This is why health care providers have sought to make EC as accessible as possible and continue to argue that over-the-counter access is important. The efforts to do so have taken the better part of a decade.

The makers of Plan B first requested OTC status from the FDA in 2003. That same year an FDA advisory panel voted 23-4 in favor of the application but in a very delayed decision, the FDA rejected the request citing a lack of information on EC use in those under 16. A report to Congress found this to be a “highly unusual” decision.

In 2005, the company that made Plan B submitted a new application that asked for OTC access only for those over 16. The FDA delayed the decision on this amended application for quite some time and then asked the company to submit a third application this time making EC available OTC to consumers 18 and over and by prescription for those 17 and under.  In the summer of 2006, the FDA agreed to this and OTC sales began at the end of that year. 

The debate did not end there, however, a federal judge ruled in March 2009 that the FDA had to make EC available to consumers 17 and older within 30 days and urged the agency to remove all age restrictions. That change took place in August of 2009 and the FDA began to consider evidence about removing the age restriction. The FDA was set to remove the age restriction in 2011 when, in a completely unprecedented move, Secretary of Health and Human Services stepped in and overruled its decision.

This brings us to today; Plan B is available behind the counter without a prescription for women 17 and older and by prescription only for anyone younger than that. As Kirsten Moore explains in her article this had caused a lot of confusion over the years with doctors and teens being given misinformation about the age restrictions and men being told by pharmacists that they can’t buy the drug at all. The end result is delays in access for many women and complete lack of access for others. Moore began a petition asking for this rule to be overturned once and for all. 

In the meantime, however, the AAP is now urging providers to routinely hand out prescriptions to those under 17 so that they can have immediate access when needed. The decision, written by the AAP’s Committee on Adolescents will be published in the Journal of Pediatrics in December. According to the committee the goal of the decision is:

“…to (1) educate pediatricians and other physicians on available emergency contraceptive methods; (2) provide current data on safety, efficacy, and use of emergency contraception in teenagers; and (3) encourage routine counseling and advance emergency-contraception prescription as 1 part of a public health strategy to reduce teen pregnancy.”

In writing the decision, the committee pointed to research that suggests that young people are more likely to use EC when it is prescribed in advance. It also noted the important role that pediatricians can play in preventing unintended pregnancy among young women. 

Both of these new opinions are very encouraging as physicians are coming forward to help increase access to contraception even if it means they will see their patient’s a little less. 

Analysis Sexual Health

Annual Visits to the Gynecologists Have Just Become More Affordable For Many. But Are They Still Necessary?

Martha Kempner

The ACA now requires most insurers to cover annual gynecological checkups for women without a co-pay. But is an annual checkup still necessary?

When I was a peer sexuality education at the UMASS-Amherst, one of my tasks was to conduct the mandatory pre-appointment workshops that students needed before seeing a gynecologist or nurse practitioner for prescription birth control. The idea behind the workshops was to make sure all young women arrived at their appointments having already learned about their contraceptive options so that they had a good idea of what might work for them, thus shortening their meeting with the health care provider (we only had a handful at the health center). One of the other things we did was walk them through a standard gynecological exam since many of them had never had one and some got understandably nervous at the thought of the stirrups and the speculum. My favorite part was always the movie—shown on a reel-to-reel projector mind you—that we liked to call Marcia Brady Gets a Pelvic. Even though it was the early nineties, the movie, which starred a young woman with long straight blond hair (parted neatly in the middle) and bell-bottoms, was clearly made in the seventies. We watched and giggled a little as “Marcia” met with her gynecologist and received a standard annual exam complete with an examination of her external genitals, an internal exam with speculum, a pap smear, and a breast exam.    

Last week, preventive care coverage for women under the Affordable Care Act kicked in requiring most insurers to fully cover annual checkups for women, including yearly visits with a gynecologist like the one “Marcia” had. Obviously, this is great news, but it comes just months after the American College of Obstetricians and Gynecologists (ACOG) teamed with the American Cancer Association and the U.S. Preventive Services Task Force to issue new guidelines which pushed back the age at which young women should begin to have internal pelvic exams and suggested that most women only need pap smears once every three years. Given these guidelines, some health care professionals and women are questioning whether an annual visit to the gynecologist is still necessary. 

ACOG says yes. Its Committee on Gynecological Practice released an opinion this month underscoring the College’s support for the well-woman’s visit: 

“The annual health assessment (“annual examination”) is a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems, and establishing the clinician–patient relationship.”

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Currently, the College recommends that young women see a gynecologist beginning between ages 13 and 15. The main focus of this visit should be on patient education and the visit does not usually include an internal pelvic exam though it should include an external examination of the patient’s genitals. I was pleased to see that ACOGs suggests the visit should also include “age-appropriate discussion of anatomical development, body image, self-confidence, weight management, immunizations (including the human papillomavirus vaccine), contraception, and prevention of STIs.”  These are the kinds of conversations that too many young women (women of all ages actually) are not having with their health care provider or anyone else for that matter. Moreover, these conversations can certainly help establish a relationship with a provider that with luck can last over many years. 

After that first visit, the committee continues to recommend annual appointments to assess a patient’s general health as well as her sexual and reproductive health. The components of the annual visit, however, change depending on a woman’s age, prior health, and risk of STIs.  Here’s a summary of what ACOG and other groups recommend.

Pelvic Exam

Though a standard pelvic exam actually has three parts (an external examination of the genitals, a speculum exam of the cervix and vagina, and a manual internal examination of the uterus), the phrase tends to conjure up those images of the stirrups and the speculum and is often used to denote just the internal exam. Currently, ACOG does not recommend internal pelvic exams for women younger than 21 regardless of whether they are sexually active and suggests that women can received prescriptions for hormonal contraception without an internal exam.

ACOG continues to recommend that women over 21 get a pelvic exam every year though the committee did acknowledge that this guideline is based on logic and not evidence as there is “no data to support a specific time frame or frequency of such examinations.” In fact, the committee says that the decision on whether to do the internal exam is one that should be left to the patient and her provider. 

It points out, however, that a pelvic exam is always appropriate regardless of a woman’s age if she is reporting menstrual disorders, vaginal discharge, infertility, vaginal discomfort, pelvic pain, abnormal uterine bleeding, or changes in bowel or bladder function.

Pap Smears

Pap smears screen for cervical cancer. Health care providers typically perform this test during the speculum part of the pelvic exam by scraping some cells off the surface of the cervix (using something that looks like an extra-large mascara brush to me). Pap smears can not only detect cervical cancer, they can pick up pre-cancerous changes to the cervix which can then be treated to prevent cancer from ever developing. Pap smears were introduced in the forties and this routine screening has reduced the rates of cervical cancer in this country by an impressive 75 percent. 

While it was once recommended that women start getting these tests as soon as they became sexually active and then get one every year after that, recent guidelines suggest that especially when paired with tests for HPV (which is the cause of most cases of cervical cancer) they can be effective even when given much less frequently. 

ACOG now suggests that women under 21 do not need pap smears but this test should be given when a woman turns 21 regardless of whether she is sexually active. From 20 to 29, women should be tested every three years. Women between 30 and 65 have a choice of getting a pap smear every three years or combining a pap smear with an HPV test and getting both tests every five years. Women who are over 65 or have had a hysterectomy in which the cervix was removed do not need pap tests unless they have a history of pre-cancerous lesions or are otherwise at high risk. 

It is important to note, that the HPV vaccine does not affect these recommendations.  Women who have been vaccinated should follow the same pap-smear schedule.  

STI Screenings

One of the points we used to stress after we would watch “Marcia’s” pelvic exam is that STI testing is not a standard part of the annual gynecological exam meaning that women who had had an exam should not assume they’d been tested and women who wanted to be tested needed to ask for it. This holds true today and there are some guidelines on who should requests such tests. 

Obviously, anyone who is sexually active and has symptoms such as discharge, itching, or burning should be screened for possible STI infections but since STIs are so often asymptomatic women who feel fine should consider screening as well.  The Centers for Disease Control and Prevention (CDC) specifically recommends that all sexually-active women under 25 be tested for Chlamydia each year. ACOG’s new committee opinion agrees and points out that an internal pelvic exam is not necessary as providers can screen for both Chlamydia and gonorrhea using urine tests. As for older women, the CDC recommends screening those at increased risk which include women who have multiple sex partners, who do not use condoms consistently, who are having sex under the influence of alcohol or drugs, or those who are having sex in exchange for money or drugs.

Breast Exams

During a breast exam a heath care provider gently palpates a patient’s breasts to feel for lumps that could be tumors (though it is comforting to know that most—8 out of 10—lumps found are not actually cancerous). According to ACOG there is no data on the ideal age to start clinical breast exams in low-risk patients but based on current information and expert opinion, the College (along with the American Cancer Association and the National Comprehensive Cancer Care Network) recommend that women ages 20 to 39 receive a breast examination every one to three years and that women 40 and over receive one annually.

ACOG also points out that the annual well-woman exam is a good place for women to learn about the importance of breast self-awareness and self-exams. Women who know what their own breasts feel like are in a better position to recognize changes and should immediately report such changes to her health care provider.  (Click here for a step-by-step guide to doing a self-breast exam.)

In the past the annual trip to the gynecologist was pretty much synonymous with a pelvic or a pap smear. In fact, that’s why you made the appointment—to get your pelvic, your pap, and possibly your prescription for birth control. Now, just as these annual appointments are likely to be covered by your insurer, public health experts have decided that most of us don’t need a pap or even a pelvic every year and, in fact, that we can get the coveted pill prescription without having either of these tests. So it’s understandable to wonder whether it’s still worth taking the time out of our busy schedules to see our gynecologist each and every year (I don’t know about yours, but mine always keeps me waiting forever). 

In the end, experts say it’s up to us but they seem to agree that it is a good tradition to keep in order to check our overall health and help maintain an ongoing relationship with our health care providers. 

My appointment is on September 26th, and yours?