Leave pill prescribing to GPs, not pharmacists, for the sake of women's health

Buying the contraceptive pill from the pharmacy without a prescription, as is being considered by Australia’s drug regulator, might be convenient for women or even save the health system money. But it risks women’s health for a number of reasons.

After determining the most appropriate form of contraception with each woman, it’s important for a doctor to monitor potential side effects. In bypassing their GPs to get the pill directly from the pharmacy, women could lose out on reproductive health care and preventive health care more broadly.

Read more: How to choose the right contraceptive pill for you

The Therapeutic Goods Administration (TGA) classifies medicines into schedules that determine whether they’re available “over the counter”, or can only be dispensed with a prescription. Currently, the contraceptive pill is Schedule 4. Women need a new prescription for the pill each year.

The TGA recently held consultations about whether the contraceptive pill, among other medicines, should be made available over the counter (Schedule 3).

Pharmacists have suggested reclassifying the contraceptive pill to Schedule 3 would reduce the need for trips to the doctor, saving time and lowering costs.

But to continue to provide a high standard of reproductive health care, Australian doctors should still be required to prescribe the pill.

Contraceptive choice

There are many different contraceptive pills, with varying dosage of synthetic hormones. These hormones “switch off” ovulation, preventing pregnancy (although not 100% of the time).

A GP consultation to discuss the pill requires considerable time taking the patient’s history, measuring her blood pressure and weight, and discussing contraceptive options.

There may be a number of reasons a particular woman should not take the pill. A doctor will work with the patient to determine the choice of contraception that’s going to best meet her needs. The pill is only one of many modern contraceptive options.

If a woman chooses the pill, regular monitoring by her GP is important.

While the pill is usually well tolerated and safe, common side effects can include bloating, fluid retention, breast tenderness and nausea. Serious complications from the pill are rare, but can include blood clots or, more rarely, heart attack and stroke.

Although the risk of heart attack or stroke is small, it is heightened when the pill is prescribed without regular blood pressure monitoring.

One review of the results of 24 studies found the risk of high blood pressure increased by 13% for every five years a woman was on the pill.

An annual GP consultation offers an opportunity to discuss and monitor any pill side effects, as well as each woman’s individual contraceptive needs.

Continuity of care

When women visit the doctor to get a new prescription, it also offers an important opportunity to discuss reproductive health and general well-being.

The Royal Australian College of General Practitioners suggests a number of preventive activities should be provided for women of reproductive age, including blood pressure checks and discussions about weight and physical activity.

Read more: Making more drugs available 'over the counter' would be a win for the public and the health care system

GPs have also often developed a trusted therapeutic relationship with their patients over several years. This means they are well positioned to manage sensitive and interrelated issues, including relationships, mental health, sexual health, contraception, smoking, alcohol and drug use.

Annual consultations also offer an opportunity to provide education around women’s health issues such as cervical and breast cancer screening.

Health benefit versus risks in rescheduling the pill

The authors of a study published last month hypothesised that reclassifying the contraceptive pill from Schedule 4 to Schedule 3 might save the health system A$96 million a year and perhaps 22 lives over 35 years.

But they also acknowledged possible adverse health impacts from rescheduling the pill. These include 122 more cases of sexually transmitted infection, 97 more cases of depression, five more strokes and four more heart attacks each year.

Preventive health advice from the GP can have significant individual health benefits in the long term, which can also save the health system money.

For example, roughly 67% of Australians aged 18 and over are overweight or obese, including many women who take the pill.

Cost-effectiveness research on obesity has found interventions aimed at tackling obesity by improving diet and increasing physical activity through health education and counselling in primary care (that is, GP visits) are effective in improving health and longevity, and are more cost-effective than treating chronic diseases once they emerge.

Read more: Over-the-counter contraceptive pill could save the health system $96 million a year

Investment in women’s health has practical benefits across a range of areas, including nutrition, management of communicable and noncommunicable diseases, screening and management of cervical and breast cancer, gender-based violence prevention and response, and pre-pregnancy risk detection and management.

It is naive and potentially dangerous to attempt to separate the potential health and cost benefits derived from pharmacy access to the contraceptive pill from the health and cost benefit of comprehensive reproductive and broader health care provided for women in the primary care setting.

Doctors and pharmacists have a role

Australian pharmacists are not trained to conduct consultations regarding contraceptive options and reproductive health. These are more appropriately conducted in mainstream general practice, or in specialised women’s health clinics.

But pharmacists do know a great deal about the range of contraceptive medications that are prescribed by doctors, and have an important role in educating women about correct medication use and potential side effects.

Education by both GPs and pharmacists is vital for Australian women to understand the diverse range of contraceptive options available to them, and how their informed choice of contraceptive method can best fit into a healthy lifestyle during their reproductive years.

Read more: Freer sex and family planning: a short history of the contraceptive pill