“The technology exists”

I interviewed a physician this weekend to get another perspective on my project research. This doctor is a surgeon with a foundation in family practice. To protect privacy I will not reveal his name, but wanted to make a note of his insights to help strengthen my own understanding of women’s health.

Common complaints

According to the doctor, some common reasons women come into the doctors office are to seek contraception, get treated for sexually transmitted infections (STIs). Younger women have a range of issues around menstrual periods, such as cramping and heavy periods. More mature women seek care for issues related to their children’s health and breastfeeding. Blood pressure is also a concern. Women who are planning a pregnancy also need guidance, such as recommendations against drinking.

The doctor said that studies have shown that pregnant student struggle with grades, and that universities are “not giving women a fair go” by meeting their needs as mothers. One university, Duke, has childcare and a support system for graduate students with kids. He opines that other universities should be embarrased by comparison and should increase their facilities and resources for child family care.

Preventable problems

Access to contraception is a real problem in preventing unwanted pregnancy, according to the doctor. “We have the highest teen pregnancy rates in the developed world. Other countries have worked out that you can make it available and kids will use it,” he said. It’s “crazy” and a “catastrophe” that contraception is not more widely available.

He referenced a study done by “Wash U” where IUDs were offered, along with a range of other options, for free, to 10,000 women and let them choose. They gave them information on each method, and 50% chose the IUD, which has a lower rate of pregnancy than other common methods, like pills and condoms. IUDs last for 5 years, he said, you don’t have to remember to take it every day. “Our system is not educating women about their choices.”

Unintended pregnancy has a high social impact for women, he said. “Pregnancy leads to challenges.” High school and high school grads who get pregnant have a change in their social trajectory, which impacts the next generation as well.

Barriers to birth control include social opinions against public health and women’s rights. Consequences to society are the institutionalization of poverty and a lack of mobility in society resulting from making contraception difficult to get.

On college campuses, smoking cessation and weight gain are also concerns for women. Women aged 20-35 who smoke or gain a lot of weight are at risk for developing diabetes.The tobacco industry is experimenting with promoting smoking on college campuses, he said. “The industry was chased out of marketing to 5-15 year olds, so they changed their focus to 18 and up.”

Student health should “flood the campus with strategies” to help student deal with reproductive issues, smoking cessation, and weight management. Focus on these issues is being neglected, he said.

Self-treated health issues

The doctor mentioned he’d ever heard of “take your own pap smear” tests, which could be useful in parts of world with fewer resources. He said that a self-Pap kit might be “a way to get preventive service to women.” Some STI issues may be moving towards more self-treatment,” he said. Not needing to go through a provider for health care is becoming more common, with treatments for yeast infections and the trends in women opting for home birth. In Mexico and other countries, birth control pills are over the counter.

The doctor said he doesn’t know about any STI equivalent of dipstick test for self-diagnosis you can buy. “The technology is there to be able to do it, but it’s just not in the market,” he said. “You can’t do HIV/AIDS test here but technology is there,” to do the test yourself, he said.

How much instruction does it take for a patient to self-treat a medical problem?

When women go to the doctor for a diagnosis, they usually end up administering the medication themselves, be it a birth control pill, an antibiotic, or a cream. What level of instruction does it take to get the patient to self treat? I asked the doctor.

“We give too much information and not clear enough set of instructions,” he said. “Adherence to medication and treatment strategies is not great. The providers giving instructions are often giving complicated messages when the bottom line is two tablets a day. Don’t go into all the other stuff.”

When instructions look complicated, they’re probably not being followed. The strategy needs to be to “get it down to self-diagnosis and self management. Get more appropriate use of treatments,” he said. For example, with blood pressure, one of the challenges of treating is people not taking their medication. It’s “a lot of work to look at ways to simplify” the instructions. But with the right skills, you could be pushing providers to bring messages down to a simpler level. “These are the three things you have to do.” In the worst cases, like diabetes, instructions can be so difficult to follow, “people give up and don’t do anything.”

Women taking birth control pills

Challenges for women taking birth control pills include forgetfulness and cost, the doctor said. “They know it, they just forget.”

Besides this, problems related to birth control have more to do with timing, which isn’t really related to requiring the pill to be available by prescription. “You don’t need to see a gynecologist to learn how to take a pill every day. The real challenge is can you afford to renew the prescription?”

The costs associated with staying on the pill long term, including health insurance and exams can get in the way of actually continuing month to month. “We’ve made it hard for women, particularly in lower income settings, or those with less insurance” to stay on the pill, he said.

To this effect, I wonder, why can’t women get a lifetime prescription for birth control? Or a 20 year prescription? Why are prescriptions written for 12 months (or less)? Many women stay on their method of birth control for years at a time, even decades. Why insist on regular visits just to continue the method they are using?

Dangers of misuse?

Are there dangers of misuse associated with taking the pill? I ask this because of the way the pill seems to be so tightly controlled. One can usually only get a 30 day supply from the pharmacist. 90 days max. Why is it treated like a controlled substance?

The doctor explains that birth control pill can have risks for certain women, like those who smoke and are over 35 years old. But it doesn’t seem to explain why birth control pills are only available by prescription, since warning labels could be clear on the packaging if it were over the counter.

“If you’re between 35-45, the risk of breast cancer goes up, in part because of age, but the risk is low at 25, no one worries about it,” he said. “I don’t think providers really question birth control use after the age of 35,” so the restrictions are “not meeting a need.”

Why is the pill only available by prescription?

My biggest issue with hormonal birth control methods are that they are only available by prescription, which makes them harder to get and harder to stay on. After all, unlike implants, IUDs and sterilization, hormonal methods are self-administered: take a pill, put on a patch, or insert a ring. The doctor’s answer surprised me.

“It’s a paternalistic, medical view that the provider knows best and can mysteriously be on the lookout for complications, when I don’t think they are.” “It’s part of keeping an income stream going,” he said. Women must see them, call them, and get a Rx. There’s a “Toll along the way for each trip.”

What about pharmaceutical companies? Wouldn’t they be motivated by profit to put birth control pills on the shelves of pharmacies and grocery stores where women can buy as much as they want?

“If birth control was available over-the-counter,” he said, “drug companies wouldn’t be making as much money. So, it’s not in their interest” to push for making available OTC. Once a drug is “over the counter, the price goes down,” he said. Like popular antacid medications that went down in price once they transition from being prescription to OTC, “contraceptions would be in the same boat.”

In his opinion, at the “political level, lobbyists from pharmaceutical companies work opposing over-the-counter availability, since they make more money having a prescription.”

“Compare this to other countries, where you can have contraception over the counter,” he said.

When should a woman come into the doctor and not 

Since my thesis focuses on self-care, I wanted to make sure that I understood the limits of when a woman should be able to handle things herself and when she should really go to the doctor. I asked the doctor when should a woman go for a consultation?

“Pregnancy,” he said. Also in cases where a patient is bleeding, it’s best to see the doctor.

In general, if a woman tries to self-treat a condition and doesn’t see improvement in 3-5 days, then you go see a provider. In younger age group, you’re more likely to be safe going the self-treat route.”

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