Free the Pill! 

It's highly effective and "safer than aspirin." Selling it over the counter could prevent hundreds of thousands of abortions annually. So why on earth can't women get their birth control without a prescription?

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The legislature agreed, and in 2001 made California the second state, after Washington, in which emergency contraception is available direct from a pharmacist. Five other states -- Alaska, Hawaii, Maine, New Hampshire, and New Mexico -- have followed, and nine more have introduced similar legislation. (Washington enacted the policy with an administrative change, not a law.) On the federal level, however, the US Food and Drug Administration recently bogged down over whether emergency contraception should get over-the-counter status in every state, even though its advisory committees have already voted 23-to-4 in favor of deregulation. It is now considering a proposal that would make Plan B the first ever "dual-label" drug, which would be sold over-the-counter to one group (women sixteen and older), and by prescription to anyone else.

While Plan B is available through pharmacy-access programs in 49 of California's 58 counties, it isn't strictly "over-the-counter" -- you won't find it next to the Tylenol. The pharmacist must first give the woman a safety screening questionnaire and counseling -- she pays about $40 for everything. "I go over it with them; I warn them about the side effects," says Tertes of Farmacia Remedios. "If they're coming in frequently, I strongly recommend other types of birth control."

But that's about all he can do -- if a woman is interested in the Pill, he must refer her to a clinic such as Planned Parenthood. It's not just his Plan B clients who are interested, Tertes says. Almost daily he turns away women who walk up to his counter seeking birth-control pills -- which are available in Mexico and a handful of other countries without a prescription.

Tertes isn't the only frustrated pill-counter out there. Pharmacy Access Partnership recently completed another national survey showing that 85 percent of pharmacists are interested in providing prescription-free hormonal birth control. It's disconcerting, after all, to dole out Plan B packets to women who are clearly at risk for unintended pregnancy yet be unable to do more than point toward the condom aisle or give them a clinic's phone number.

Granted, there is a crucial difference between Plan B and the Pill. A woman may take Plan B once or twice in her lifetime, but might use daily contraceptives for months, years, even decades. They're not always one-size-fits-all drugs, and because women stay on them longer, there's a greater risk of long-term side effects. Is a health history questionnaire enough to safely dispense daily contraception? Don't you need a pelvic exam?

The surprising answer is no. True, in private doctors' offices, getting a prescription for the Pill has traditionally been coupled with an annual pelvic exam, breast exam, and Pap smear. These tests serve a valuable purpose in detecting infections and early signs of cancer. But in 2001 a San Francisco-led research team published an eye-opening reassessment in the Journal of the American Medical Association arguing that pelvic exams were not useful in detecting any conditions that would bar women from using hormonal birth control. The main risk factors with this category of drugs are decidedly nonpelvic conditions such as a history of blood-clotting problems, heart disease, stroke, hypertension, known breast malignancies, or being a smoker. These are the sorts of things more readily caught with a blood-pressure test and a thorough medical history. Mandating pelvic exams, the study concluded, "may reduce access to highly effective contraceptive methods, and may therefore increase women's overall health risks. These unnecessary requirements ... unwittingly reinforce the widely held but incorrect perception that hormonal contraception methods are dangerous."

The FDA, World Health Organization, and Planned Parenthood, among other public health agencies, no longer advocate a pelvic exam as a prerequisite, yet many private medical practices still use the promise of a new birth-control prescription as a hook to get women to take the exams. "Young women should be screened for sexually transmitted infections and should have a Pap smear," Darney says, "but holding their contraception hostage isn't the way to do it."

Nor is it necessary, if you extrapolate the results of last year's Pharmacy Access Partnership survey: 93 percent of the women using nonhormonal birth-control methods and 88 percent of those not using birth control reported that they'd voluntarily gone in for a Pap within the last 24 months. While the survey wasn't definitive, it strongly suggested that women already understand the benefits of the test.

With the Pap hurdle out of the way, at least in theory, Washington state launched a pilot program two years ago to gauge consumer response and see how pharmacists would handle the increased workload of assigning birth control. It operated much like California's emergency contraception program: Specially trained pharmacists took women's blood pressures and medical histories, and screened out those at risk. The women initially got three months' worth of pills, and had to return for a follow-up screening and blood-pressure check to get the rest of the year's supply. After paying $25 each for those two visits, the women got an unlimited number of free follow-ups; for the drugs, they could either pay out of pocket or bill their insurance companies.

Dr. Jaqueline Gardner, the University of Washington pharmacy professor who led the experiment, gives it a big thumbs-up, although the final results won't be published until later this year. The rate of adverse side effects mirrored what doctors see during ordinary clinical practice, and some of the drugstores said they'd be interested in offering similar services in the future. "The big research question at hand was: 'Could you put this into pharmacy practice and safely prescribe?' and we believe the answer is yes," Gardner says. "Our experience has been that every time pharmacists are brought into public health situations in which they could increase access to services that are not getting done ... they've shown themselves to be not only happy to do it, but people are very satisfied with what they provide."

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