Birth Control Sans Doctor

This week Oregon followed California's lead and made headlines as legislators passed a series of bills giving pharmacists the ability to give out birth control to women over 18 without a former prescription, or under 18 with a former prescription. (Article found here)

Firstly, I am all for birth control choices for women who are making informed decisions about their future. I also recognize that having easier access and not having to wait for a physician to write a prescription may lead to some great benefits in terms of lower rates of unintended pregnancies. However, I have a few major reservations.

The main issue I have is that birth control is not harmless. A meta-analysis performed by Cochrane (pretty much the top research review group) showed that across the board, oral birth control pills increased risk of developing blood clots, or "deep vein thrombosis" as it is termed medically. This risk increased as the dose of hormones in the pill rose.

For those not in the know, a deep vein thrombosis (DVT) forms when the blood is too thick/sticky, when there is injury to the blood vessel, or when there is turbulence/stasis. This fabulous little triad is known as Virchow's triad and is familiar to every first year medical student. Well, the hormones in birth control make the blood more sticky and thus more apt to forming clots. These often form in lower extremities when there is also stasis, such as long airline flights. As long as the clot stays put in the the leg it's not a life threatening emergency, although it can be mighty uncomfortable. Where the real trouble comes in is when the clot breaks away and travels to somewhere like... the lungs (called a pulmonary embolism) or the brain (called a stroke).

There have been a few media stories lately about young women who developed blood clots that threatened their life after starting oral birth control pills. These are tragic and scary stories that make you think twice about popping that little pill every morning and there is good reason to pause and think.

Thankfully, in the hands of good and diligent physicians, the risk of developing a DVT from birth control can be minimized. Every woman who is considering oral birth control pills who comes through the naturopathic clinic system where I was trained was screened very carefully for anything additional in her health history that might increase her clotting risk. Things like age (over 35), smoking history, history of prior blood clots, NSAID use, family history of clotting disorders, early heart disease, diet, cholesterol, liver disease, blood pressure, etc. These are all little drops in the bucket that if combined with oral birth control can lead to greatly increased risk of DVT. If a woman has no additional risks, most birth control are considered oaky options. However, if a woman has multiple risk factors, careful consideration is given before a prescription is written. Often we would counsel her on her other options for birth control such as an IUD, or discuss using the lower dose oral birth control options. All in all, this can be a lengthy conversation that can sometimes take weeks (if there are labs involved) before a final decision is made.

I understand that to the rest of the medical world, this often seems like overkill, but in Naturopathic medicine we take our first tenet very seriously "first do no harm" and we would like to avoid any of our patients having a serious health consequence that could have been avoided through due diligence. I have counseled some older women to switch to a different pill or use a different method when they have been prescribed (sometimes very high) birth control pills by a different physician. One woman was over 40, had smoked for 20+ years, and had a history of hepatitis C which can alter blood coagulability. She was on one of the highest doses available! How could I let her walk out of the office without practicing yet another tenet of naturopathic medicine "doctor as teacher" and informing her of the risks she was unknowingly taking with her health. She was so grateful she called me a week later to thank me after having a conversation about the situation with her other doc. Maybe I saved a life?

My hesitation with whole heartedly endorsing this new ruling in Oregon has to do with everything I mentioned above. Is a pharmacist trained and qualified to fully evaluate all of these aspects of a woman's health? I plan to ask my local pharmacist the next time I am in what training they have around this issue, but I fear it may be less than my ideal of holistic health. I absolutely hope that we do not see a significant rise in DVTs due to improper use of birth control, but I definitely think this needs to be part of the conversation moving forward.