The hormonal formulation we call the pill is much more than a contraceptive. (Los Angeles Times )
Presidents, politicians and physicians are fighting over who should pay for contraception, and women are getting hurt in the process.
Roman Catholic bishops reject even President Obama's recent compromise not requiring religiously affiliated hospitals and universities to pay for contraception, saying it does not meet their standard of "religious liberty and moral convictions." Planned Parenthood President Cecile Richards calls the row over insurance payments part of "a misleading and outrageous assault onwomen's health."
But before the acrimony grows any greater, let's pause for a moment and consider one of the medical advances at the heart of this controversy — and how it might yet be a game-changer.
The hormonal formulation we call the pill is much more than a contraceptive. Our ancient ancestors didn't ovulate as many times over their lifetimes as today's women. They had later puberty, and once they started having children, they breast-fedwithout ovulating for long intervals. Evidence suggests they had as few as 30 menstrual cycles in a lifetime, compared with 300 or more today. This is significant because studies show that the greater the number of menstrual cycles a woman has, the greater the risk of uterine and ovarian cancer.
Women taking birth control pills are in a different situation. Because the pill mimics the hormone profile of pregnant and lactating women, those who take oral contraceptives tend to be hormonally more like their forebears, even though they tend to reach puberty earlier, have fewer pregnancies and lactate less often and for shorter periods.
Several years ago, British medical scientists published a 39-year follow-up of 23,000 women who started using the pill in the 1960s and 23,000 who did not. Among pill users, they found a significant reduction in ovarian, uterine and bowel cancers, and even melanomas. Another study of 17,000 women found that use of the pill was associated with a small but measurable increase in life expectancy.
Last December, at the Pontifical University of the Holy Cross in Vatican City, two Australian scientists, Kara Britt and Roger Short, gave a keynote address titled "The Plight of Nuns." They recommended that nuns should take the pill for a couple of years during their lifetimes to reduce the increased risk of cancer associated with not having children. It was not a tongue-in-cheek criticism of the Vatican but good medical advice based on impeccable statistics and sound biological insights. It was also theologically sound.
The pill was first marketed in the 1950s not as a contraceptive but to regularize menstruation, and Pope Pius XII approved this use of the drug. More recently, Pope Benedict XVI endorsed the non-contraceptive benefits of condoms in some circumstances to prevent HIV infection among gay men.
The non-contraceptive benefits of using the pill are so powerful that the church should consider lifting restrictions on doctors in Catholic institutions and allow them to prescribe low-dose estrogen and progesterone tablets forwomen's healthbenefits. Michael Galligan-Stierle, president of the Assn. of Catholic Colleges and Universities, maintains that Catholic institutions can prescribe drugs only for preventing disease. But the pill falls squarely into that category. In fact, more than 1 million women already take the pill for non-contraceptive purposes.
If the church is still queasy, here's another idea. One simple solution to today's birth control battles would be to sell the pill over the counter. The epidemiological data on pill safety are now so compelling that it seems likely the Food and Drug Administration would go along with such a proposal. The dose does not have to be adjusted to fit the user, and no one — not even a toddler who found her mom's pills — has ever died from an overdose. An over-the-counter pill packet would need to carry some clear warnings: Women over the age of 35 who smoke should not use the pill, and those who are hypertensive or diabetic should seek the advice of a health professional. But many nonprescription drugs carry similar warnings.
Selling birth control pills over the counter would reassure millions of women who don't take them because of misinformation about risks and side effects. The category of nonsteroidal anti-inflammatory drugs, to which aspirin and ibuprofen belong, is associated with 16,000 deaths a year, while the pill actually causes users to live slightly longer than average. The wider availability of the pill would help those who lack insurance or can't afford to go to a doctor. Today, poor women have three times as many unintended pregnancies as wealthier women.
So why isn't the pill sold next to aspirin in every pharmacy or gas station? Commercial greed and a strong patriarchal streak in American politics.
Prescription medicines bring higher profits thanover-the-counter drugs. As a doctor, I would recommend my loved ones use a low-dose generic pill whose safety has been well documented over a generation of use. A good generic manufacturer can make a packet of pills for under 20 cents, and they could be sold for $8 a month or less and still make a profit.
Sooner or later, one generic manufacturer will break ranks and ask the FDA to let the pill be sold without a prescription. Let's hope it's sooner.
Malcolm Potts is an obstetrician and reproductive scientist and a professor at UC Berkeley. He has studied oral contraceptives since the 1960s.