Self-serve birth control? The future of OTC contraceptives
November 22, 2022
How women access contraception has been a topic of debate in recent years, particularly whether to make more forms of birth control available over the counter. That could soon become reality as the Food and Drug Administration (FDA) is reviewing data and the application for what would be the first birth control pill available without a prescription in the U.S.
About half of pregnancies in the U.S. are not planned, and non-use or inconsistent use of birth control is a leading cause. Both issues can be tied, in part, to a lack of accessibility.
Nearly a third of women report encountering problems getting a birth control prescription or refill. The number jumps significantly in young people, according to the 2022 Oral Contraceptives Access Survey. Barriers range from financial to cultural factors.
The American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) support over-the-counter access to oral contraceptives. If approved, OTC birth control could limit or eliminate in-person visits to a doctor’s office to renew the prescription, but there are still many benefits to annual in-person exams. Women can talk with an expert about whether a short- or long-term birth control option is best for them.
Match your goals to your birth control choice
When a woman expresses interest in a contraceptive method, one of the first questions I ask is, “What are your goals for wanting to be on birth control?” Preventing pregnancy isn’t always the main reason. A woman may want to regulate her periods – or avoid them altogether – help manage pain due to menstruation or endometriosis or prevent a sexually transmitted infection.
Not every birth control method can do all of these things, so we want to make sure we are choosing the best option to meet your goals. Each comes with potential side effects. This is why we ask about your medical history so we can determine if you have any conditions that would increase the risk of complications.
Only after your goals have been determined, your medical history has been considered, and the risks and benefits of each option have been weighed, can we come to an informed decision on the best contraceptive method for you.
There are many types to choose from:
- Barrier methods: Condoms, diaphragms, and contraceptive sponges are single use and prevent sperm from reaching the uterus. Barrier methods can help prevent the spread of sexually transmitted infections. However, their failure rate is about 18%, meaning 18 of every 100 women using this method will get pregnant. Often, this is due to improper use.
- Hormonal methods: Birth control pills, the vaginal ring, the patch, and contraceptive implants or shots use hormones to reduce the risk of pregnancy. Their failure rate is 6% to 12%, often due to missing a dose, improper use, or interactions from other medications. However, these methods can cause hormone-related side effects such as low mood, blood pressure changes, and weight gain.
- Intrauterine devices (IUDs): Inserted in the uterus, IUDs are the most effective long-acting reversible contraception (LARC) method. The failure rate is less than 0.2%, meaning less than 1 per 100 women will get pregnant when using an IUD.
- Sterilization: Getting your tubes tied (tubal ligation) is also highly effective, with a failure rate of less than 0.2%. It is considered an irreversible form of birth control. A woman should not choose this option thinking they may reverse it in the future.
- Natural family planning: This method relies on estimating ovulation dates and avoiding sperm-to-uterus contact during fertile days. The failure rate is 2-23%.
- Withdrawal method: This method relies on the male partner "pulling out" before ejaculation. However, sperm can be released prior to ejaculation, and the failure rate for this method is 22%.
Related reading: Nearing the end of pregnancy? Time to talk birth control
Your annual exam should be about more than birth control
A physical exam is not always necessary to get a prescription for birth control. But that shouldn’t be the only reason to visit your doctor every year.
Annual well-woman exams are an opportunity to talk about ongoing health concerns and focus on disease prevention. We'll discuss routine measurements such as height, weight, and blood pressure; perform a pelvic exam, breast exam, and a Pap test if you're due; determine whether you’re due for any vaccinations; and discuss concerns about tobacco and alcohol, intimate partner violence, and depression.
Discussing birth control will be related to these conversations. For example, while the risk of hormonal birth control causing a blood clot or stroke is low, it increases with risk factors such as smoking and high blood pressure. If you begin smoking or develop high blood pressure after being prescribed a birth control, we want to know so we can talk about quitting smoking, controlling the condition, or changing to a new contraceptive method that may be safer.
Another advantage to these visits is that your provider can alert you to new forms of contraceptives, such as Phexxi, a contraceptive gel approved by the FDA in August 2022 that can replace traditional spermicides.
Related reading: Personalizing birth control to minimize health risks
Concerns about over-the-counter birth control
A September 2019 research letter published in the New England Journal of Medicine outlined the results of a small study that examined the safety and efficiency of telecontraception, the practice of receiving a prescription for contraception through a website or smartphone app. Patients completed an online questionnaire – and in some cases participated in a follow-up phone call – about their health and, if approved, received a prescription at a local pharmacy or through the mail.
The researchers found that while such services improve access to contraception, there are some concerns regarding potential gaps in the process of determining a patient's best options based on her health needs and goals.
As with telecontraception, while over-the-counter medications may be safe for most patients, two main concerns remain potential side effects and accessibility to all types of birth control.
1. Potential side effects
The recent study found a high rate of adherence to the recommended use of birth control in patients who used telecontraception services. However, there were a few gaps in the information requested in telecontraception online questionnaires and follow-up calls. For example, few organizations asked whether the patient could take a pill daily or whether they have other health issues that might cause unexpected side effects.
2. Accessibility
Barrier methods such as condoms already are available over the counter. Today, telecontraceptive services apply only to a few hormonal forms of birth control such as the pill, patch, and ring. An over-the-counter option wouldn’t be possible for methods like an IUD, arm implant, or birth control shot, which must be placed by a medical professional.
Related reading: Would an IUD or birth control implant work for me?
Increasing access to birth control
So, how can we increase access while ensuring safe and effective contraceptive use? One way is to avoid making women visit a clinic or doctor’s office multiple times a year to renew a prescription. The more often a woman has to make a trip to a doctor, the more likely she is to discontinue use or to use it sporadically.
There are next to no reasons I can think of why a woman couldn’t receive a yearlong prescription. We could review the effectiveness of the method during her annual exam, and she'd be good to go for another year. Annual visits are less time consuming and financially burdensome than having to stop in multiple times, particularly for underserved populations, those who live far away from their provider's office, and those with limited transportation options.
If questions arise throughout the year, our providers are just a phone call or telehealth visit away.
Getting better access to birth control empowers women to take control of their bodies and their health. By simplifying the process, we can help more patients stay on the contraceptive they choose, even when life gets busy between appointments.
