Attitudes of female college students toward over-the-counter availability of oral contraceptives

Should oral contraceptive pills be available without a prescription? A systematic review of over-the-counter and pharmacy access availability

Introduction

Making oral contraceptives (OC) available over the counter (OTC) could reduce barriers to use. To inform WHO guidelines on self-care interventions, we conducted a systematic review of OTC availability of OCs.

Methods

We reviewed data on both effectiveness and values and preferences surrounding OTC availability of OCs. For the effectiveness review, peer-reviewed articles were included if they compared either full OTC availability or pharmacist-prescribing (behind-the-counter availability) to prescription-only availability of OCs and measured an outcome of interest. For the values and preferences review, we included peer-reviewed articles that presented primary data (qualitative or quantitative) examining people's preferences regarding OTC access to OCs. We searched PubMed, CINAHL, LILACS and EMBASE through November 2018 and extracted data in duplicate.

Results

The effectiveness review included four studies with 5197 total participants. Two studies from the 2000s compared women who obtained OCs OTC in Mexico to women who obtained OCs from providers in either Mexico or the USA. OTC users had higher OC continuation rates over 9 months of follow-up (adjusted HR: 1.58, 95 % CI 1.11 to 2.26). One study found OTC users were more likely to report at least one WHO category 3 contraindication (13.4% vs 8.6%, p=0.006), but not category 4 contraindications; the other study found no differences in contraindicated use. One study found lower side effects among OTC users and high patient satisfaction with both OTC and prescription access. Two cross-sectional studies from the 1970s in Colombia and Mexico found no major differences in OC continuation, but some indication of slightly higher side effects with OTC access. In 23 values and preference studies, women generally favoured OTC availability. Providers showed more modest support, with pharmacists expressing greater support than physicians. Support was generally higher for progestogen-only pills compared with combination OCs.

Conclusion

A small evidence base suggests women who obtain OCs OTC may have higher continuation rates and limited contraindicated use. Patients and providers generally support OTC availability. OTC availability may increase access to this effective contraceptive option and reduce unintended pregnancies.

Systematic review PROSPERO registration number

CRD42019119406.

Over-the-Counter Access to Oral Contraceptives

Making oral contraceptives (OCs) available over the counter (OTC) could help to reduce the high rate of unintended pregnancy in the United States. Surveys show widespread support for OTC access to OCs among US women. Studies indicate that women can accurately use checklists to identify contraindications to OCs. Continuation is as good or better among OTC users compared with women using OCs obtained by prescription. Women and clinicians have expressed concerns related to making OCs available OTC. These concerns can be addressed by existing data or through research required by the Food and Drug Administration as part of the application to make OCs available OTC.

A Survey of Teenagers' Attitudes Toward Moving Oral Contraceptives Over the Counter

CONTEXT

Evidence suggests that over-the-counter access to oral contraceptives may help expand use among adult women. Teenagers may particularly benefit from this approach, as they experience disproportionately high rates of unintended pregnancy and face unique challenges accessing contraceptives. However, limited research has explored teenagers' attitudes toward over-the-counter access.

METHODS

In 2014, a sample of 348 females aged 14-17, recruited via Facebook advertisements, participated in an online survey assessing teenagers' attitudes toward over-the-counter access and their understanding of how to use oral contraceptives after reading a prototype over-the-counter product label. Differences by participants' characteristics were assessed in bivariate analyses (Pearson chi-square and Fisher's exact tests for categorical measures, and independent t tests and one-way analyses of variance for continuous measures).

RESULTS

Seventy-three percent of participants supported over-the-counter access, and 61% reported that they would likely use oral contraceptives available through this approach. Few subgroup differences were found. Notably, sexually experienced participants were significantly more likely than others both to support this approach (85% vs. 63%) and to be interested in obtaining oral contraceptives this way (77% vs. 48%). Participants understood an average of 7.1 of eight key concepts that the prototype product label was intended to convey; no significant differences were found among subgroups.

CONCLUSIONS

Over-the-counter access may be a promising approach for providing oral contraceptives to teenagers. Additional research is needed to evaluate whether teenagers can screen themselves for contraindications to oral contraceptive use and correctly use oral contraceptives obtained over the counter.

Barriers to contraception and interest in over-the-counter access among low-income women: a qualitative study

CONTEXT

Barriers to contraceptive access encourage nonuse and gaps in use, which contribute to the high prevalence of unintended pregnancy in the United States. One strategy to improve access to oral contraceptives is to make them available without a prescription.

METHODS

From March 2007 to January 2009, focus group discussions and in-depth interviews were conducted with 45 low-income women in the Boston area to explore how they obtain contraceptives and their opinions about making oral contraceptives available over the counter. Transcripts of the discussions and interviews were deductively and inductively coded. Data were analyzed thematically, and illustrative quotes were extracted.

RESULTS

Overall, participants reported ease in obtaining contraceptives, which were available at multiple accessible locations throughout Boston. However, various barriers-unaffordable copays and clinic visits, the time required for clinic visits, restrictions on the number of packs of prescription contraceptives (e.g., the ring, the pill) purchased monthly and the limited time frame in which to purchase them-deterred consistent use of preferred methods. Most participants supported over-the-counter access to oral contraceptives; however, they raised concerns about cost, as well as the safety of such access for minors, first-time users and women with medical conditions.

CONCLUSION

Women's concerns about over-the-counter access to contraceptives must be addressed if this approach is to improve use and potentially help reduce the unintended pregnancy rate.

Medication usage among young adult women: a comparison between Sweden, the USA, and Greece

This study evaluated whether or not medication usage among young adult women differed across three countries. An additional aim was to evaluate the association between medication use and sociodemographic factors and exercise habits. A sample of 1098 young adult women were selected in Sweden, the USA, and Greece. Consistent medication usage by young adult women in the three countries related to oral contraceptives and vitamins; nevertheless, there were differences. The main differences were found in the use of laxatives, iron supplements, analgesics, antidepressants, and antacid medication. The most outstanding differences were the frequent use of laxatives in Sweden and vitamins in the USA. Different association patterns were found between medication use and culture, sociodemographic factors, and exercise. The assessment of medication use among young adult women can be performed very easily and provides an immediate indication of their well-being and needs for preventative care.

Attitudes toward oral contraceptive use among women of reproductive age: a systematic review

Despite the effectiveness of oral contraceptives (OCs), their popularity differs across populations. Attitudes are a significant factor that influences OC use. This report systematically reviews 28 studies on attitudes toward OC use among women. The Matrix Method was used to review the literature. Affective, cognitive, and behavioral components of attitudes were analyzed, including satisfaction, safety, fear/anxiety, and inconvenience. In general, negative attitudes still prevail across countries. Positive attitudes are more prevalent in Europe. Effective counseling and education are needed for those negatively disposed toward OC use. For favorable users, compliance strategies for longer continuation with OC regimen must be provided.

Short-term oral contraceptive use and the risk of epithelial ovarian cancer

Oral contraceptive (OC) use has been consistently linked to a reduction in ovarian cancer in a dose-dependent fashion. Whether short-term OC use is protective remains controversial. In 1994-1998 in the Delaware Valley of Pennsylvania, the authors examined the association between short-term OC use and ovarian cancer in a population-based case-control study comparing 608 incident epithelial ovarian cancer cases with 926 community controls. Using unconditional logistic regression and adjusting for known confounders, they found a significant reduction in ovarian cancer risk for women who had used OCs for < or =6 months (odds ratio = 0.73, 95% confidence interval: 0.54, 0.99). This protective effect was observed in only that group who had used OCs for < or =6 months and stopped because of side effects (odds ratio = 0.59, 95% confidence interval: 0.40, 0.87 for side effects and odds ratio = 0.91, 95% confidence interval: 0.60, 1.37 for non-side-effects). Women who used OCs for >6 months were at a reduced risk independent of their reason for stopping. Results were similar when stratifying by parity and hormone therapy use. Thus, OC use for as little as 6 months provides significant protection against ovarian cancer risk, protection that appears limited to those women who stop using OCs because of side effects. Mediating factors may reflect endogenous hormone levels, OC metabolism, or OC bioactivity.

Preliminary comparison of papanicolaou smear and speculoscopy for assessing cervical cancer precursor lesions in pregnant adolescents

BACKGROUND

The objective of this study was to assess the efficacy of speculoscopy in screening pregnant adolescents for abnormal cervical pathology.

METHODS

This was a prospective comparative study of the Papanicolaou smear and speculoscopy in pregnant adolescents (< 17 years of age at the time of examination) presenting for their initial obstetric visits. This study was conducted at private offices of a general obstetrics and gynecology academic practice. Interventions included Papanicolaou smears and speculoscopic examinations; patients with a positive result for either intervention were offered colposcopy. Main outcome measures were Papanicolaou smear and speculoscopy outcomes and results of colposcopy and cervical biopsies.

RESULTS

Thirty consecutive pregnant adolescents were included in the study. Papanicolaou smears and speculoscopic examinations were well tolerated by all adolescents. Twenty-one adolescents had negative Papanicolaou smears and speculoscopic examinations, and one woman had a positive Papanicolaou smear and a negative speculoscopic examination. Four adolescents had positive speculoscopic examinations and negative Papanicolaou smears; of these cases, significant pathology was found in one case. Four adolescents had positive Papanicolaou smears and speculoscopic examinations, with significant pathology in two of these adolescents.

CONCLUSION

This preliminary study shows speculoscopy to be well tolerated, not causing cervical trauma, and as effective as the Papanicolaou smear for detecting cervical pathology in pregnant adolescents.