The Shameful Reason Young Women Are Being Forced To Pay For The Pill

Photographed by Ashley Armitage.
NHS contraception waiting times are driving women to buy oral hormonal contraception privately when they could be accessing it for free via the NHS where there are no prescription charges, Refinery29 has learned. 
Dozens of women have told us that they have chosen to buy their combined hormonal contraceptive pill online or over the counter in a pharmacy for as much as £50 because the wait for a GP or sexual health clinic appointment (where they could get it for free) was too long. 
According to the latest research, NHS sexual health waiting times have been rising. This is due to a combination of two things: cuts to funding over the last decade and the coronavirus crisis, which has put pressure on GPs. 
According to a 2020 inquiry carried out by members of parliament who sit on the All Party Parliamentary Group on Sexual and Reproductive Health (APPG SRH), "women in England are facing difficulty in accessing contraception, with many being bounced from service to service."
The APPG SRH cited 13% cuts to the contraceptive budget between 2015 and 2018 as a likely reason for "obstructed and reduced access to services", resulting in long waiting times for women. 
"It mostly comes down to the convenience," said 29-year-old Emily from London, who paid £19.99 to buy three months' worth of her combined oral contraceptive pill, Levest, from Superdrug’s online pharmacy. "I love the NHS but getting a same-day appointment is impossible when it comes to women’s health whereas I could pick up my prescription the same day at Superdrug."
She added that this service has been particularly helpful when she has forgotten her pill while away or "needed a six-month course which doctors are always reluctant to prescribe".
Similarly, 23-year-old Caitlin from Oxfordshire cited long waiting times and dissatisfaction with her GP as reasons for purchasing her combined oral contraceptive pill, Gedarel, online from Superdrug. "NHS doctors appointments take too long to organise," she explained. "It’s really annoying if you have a busy life."
"I have also found that GPs seem to have archaic views about women’s bodies and I know which pill works for me now so I don’t want to be told to take something that doesn’t work for my body, which always seems to happen at the GP," she added. 
On paper, the ability to purchase contraception with ease online or in a physical pharmacy might seem like progress. However, experts warn that there is a key difference between being able to purchase the progesterone-only pill (which is broadly side effect-free) and the combined pill (which poses a low but serious increased health risk with conditions such as cardiovascular disease and stroke, venous thromboembolism (blood clots), breast cancer, cervical cancer and changes to mental health including anxiety and depression).
Earlier this year the progesterone-only pill became available over the counter for the first time without a prescription. This is something that experts such as the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Pregnancy Advisory Service (BPAS) had long been calling for. 
This change was described as "momentous" by Professor Anna Glasier, an obstetrics and gynaecology expert, in the British Medical Journal. "Some 27 years ago, in 1993, The Lancet published an editorial arguing the case for oral contraceptives over the counter (OTC)," she wrote. "It opened by saying that the oral contraceptive pill (OCP) had helped women ‘escape from the confines of their own reproductive system’ but that ‘these ex-prisoners remain on probation’ because they still needed to see a doctor regularly for a repeat prescription. This month, almost 60 years after approval in the UK, at last an oral contraceptive has been approved here for initiation and use without a doctor’s prescription."
It took a long time for this to happen. The pill is arguably one of the most widely used drugs in the world so it made sense to make its safest form – the progesterone-only contraceptive pill – more accessible.
Dr Edward Morris, president of the RCOG, explained: "The RCOG campaigned for progesterone-only contraceptive pills to be made available from pharmacies without prescription for several years and we are delighted this has been introduced. It’s a way of improving access to contraception and removing barriers for women who want quick and convenient access to contraception, which has been increasingly difficult during the pandemic as people struggle to get appointments with their doctors."
He added: "We do recognise that the additional cost of the pill from the pharmacy can still act as a barrier and we would be keen to see this product made freely available in pharmacies in future."
Similarly Katherine O’Brien, associate director at BPAS, said: "We supported the reclassification of the progestogen-only pill so that it can now be sold directly to women without a prescription. This gives women another option to access this method of contraception if they cannot access their GP or prefer the ease of ordering online. However, enabling women to purchase contraception does not negate the importance of NHS-funded family planning. There have been huge cuts to funding for sexual health services, forcing some clinics to close or restrict access to only certain groups of individuals, such as those under 25. Contraception is essential healthcare, and it should be accessible to all."
Crucially, this shift was only meant to apply to the progesterone-only pill, the version of oral contraception that has far fewer side effects. Despite this, pharmacies and private companies are now selling both the combined and progesterone-only pill online. Unlike the progesterone-only pill which has been approved for sale without a prescription, the combined pill is sold with a prescription. Nonetheless, you can buy it online without reference to your GP’s medical records or in-person assessment by medical professionals.
This raises two key issues: first, the cost of contraception when it ought to be free and, second, whether women and people with wombs who opt to buy the combined pill because they can't get to a GP or sexual health clinic are being given the level of care they need.
Thirty-five-year-old Leah from London told Refinery29 that she paid £50 for her combined pill, Yasmin, via Superdrug online. "It’s annoying to have to pay for it and it’s not cheap but I see it as paying for convenience because it’s such a nightmare to get an NHS appointment," she said. "I’m lucky to be able to afford it and I can just take my own blood pressure."

It's annoying to have to pay for it and it's not cheap but I see it as paying for convenience because it's such a nightmare to get an NHS appointment.

Leah, 35
Increasing the accessibility of contraception can only be a good thing, particularly against the backdrop of increased waiting times. Whether that accessibility should come with a price tag is up for debate. And particularly when it comes to the combined pill – which must still be prescribed – access should be matched with medical monitoring. The RCOG may have lobbied for the progesterone-only pill to be made available over the counter and online but this is not their position on the combined pill. 
The RCOG says it would always encourage women to speak to a healthcare professional if they want to take the combined pill. This is because the small increase in certain health risks with combined hormonal contraception means that it isn’t suitable for everyone.
A quick look at the way certain online pharmacies are marketing their range of oral hormonal contraception begs the question of whether we should be concerned about the privatisation of contraception in England – something which has been free at the point of delivery for years in accordance with the founding principles of the National Health Service. 
Take Hanx, for instance. Its marketing aligns all forms of oral contraception with treatments for cystitis, bacterial vaginosis and vaginal thrush under the banner 'intimate wellness’. As with its marketing of sexual wellness products (condoms and lubricant), it promotes the ease of accessibility of these products as a form of 'feminist empowerment'. The combined oral contraceptive pill is described as "the original diva of hormonal contraception" and likened to a "90s supermodel", while the progesterone-only pill is said to be "mini by name, mighty by nature". 
Is contraception now a sleek, branded wellness product as opposed to something that should be accessible as a human right according to the UN? Hanx’s emphasis on offering choice and accessibility to women and people with wombs, packaged in Glossier-esque branding – from the soft pink and cobalt colour scheme and sans serif font to the consciously casual, overly familiar product descriptions – makes it seem as though being able to buy contraceptives online is radical. This exists in contrast to Superdrug's branding of its online doctor, which is far more matter of fact (oral contraception is only one of the many medications you can access through the store's online pharmacy). In either instance, how radical is the fact that women are now paying for hormonal contraception privately, something that is free on the NHS, because they can’t get an appointment with a doctor or sexual health nurse?

How radical is the fact that women are now paying to buy hormonal contraception privately, something that is free on the NHS, because they can't get an appointment with a doctor or sexual health nurse?

There are (small but significant) risks associated with the progesterone-only pill and, in particular, the combined pill which mean that a doctor or sexual health nurse ought to be available to oversee someone’s use of it if needed. 
On its website, the National Institute for Health and Care Excellence (NICE) has a series of complex prescribing guidelines for the combined pill. These include asking questions about a woman or person with a womb’s family medical history of cancers and blood clots as well as making sure to find out whether they have recently been pregnant, undergone an abortion, missed periods or suffer with migraines with aura, among other things. This is why the combined pill requires a prescription as these questions are vital in determining risks as well as ascertaining which combined pill it is appropriate to prescribe. 
NICE also stipulates that the side effects of the combined pill should be discussed between doctor and patient. As well as discussing the rare but serious side effects listed above, NICE notes the more common adverse effects such as nausea and abdominal pain, headaches, breast pain and irregular menstrual bleeding (which impacts around 20% of combined pill users). 
When it comes to mental health side effects, the NICE website states explicitly that "depressed mood" and "depression" are "known side effects of hormone contraceptive use". It adds that pill manufacturers' summary of product characteristics state that "it can be serious and is a risk factor for suicidal behaviour/suicide" and therefore advises prescribing clinicians to direct women to "seek medical help in case of mood changes" while taking certain combined pills. 
NICE told Refinery29 that it could not comment on the online sale of the combined oral hormonal contraceptive pill when asked whether women and people with wombs would receive the same care when buying the combined oral hormonal contraceptive pill online as they would in a face-to-face appointment. 
There is regulatory oversight of this issue. It is not legal to sell the combined oral hormonal contraceptive pill without a prescription. Private companies who sell it online or over the counter with prescription are providing a remote consultation service. If a prescription is issued as a result of that service, it goes to a pharmacy and can be dispensed in compliance with legal requirements. These providers are regulated by the Care Quality Commission (CQC) and pharmacies which issue prescriptions are regulated by the General Pharmaceutical Council (GPhC).
Lynda Scammell, a policy advisor at the Medicines and Healthcare products Regulatory Agency (MHRA), told Refinery29: "There are strict legal requirements for the supply of a prescription medicine. A POM [prescription-only medicine] must be dispensed against a prescription issued by a relevant healthcare professional."  
To find out whether the same checks and balances were applied when trying to purchase the combined oral contraceptive pill online, Refinery29 went through the process of doing so from Hanx and Superdrug. 
To buy from Hanx you are presented with a choice of 26 different combined pills – we chose Levest. You are told which combination of synthetic hormones the pill is made of, the pattern in which you take them and how much it costs for a three-month course (ranging from £19 to £44), which you can then add to your basket. The website provides information about side effects and who it is best suited for but it is not clear why one brand would be preferable to another unless you have previous experience. You are then asked to "fill in this boring (but important) stuff" where you agree to answer truthfully and will follow the advice on the product information leaflet. You are then asked about key parts of your medical history that could be affected by taking the combined pill: migraine with aura, deep vein thrombosis (DVT), diabetes, smoking and breastfeeding. When Refinery29 answered yes to having migraines or a family history of DVT, a pop-up appeared which read: "Thanks for letting us know. We recommend that you choose the progesterone only pill. If you have any questions, chat to your GP." At no point did Hanx ask about mood or mental health history. 
This questionnaire was then sent to a pharmacist to approve before payment. The pill is then shipped to you with no further questions and no requirement to inform your GP.
In theory, Refinery29 noted that if you wanted the pill anyway you could just go back and change your answers to reflect the criteria, undermining the fact you need a prescription for the combined pill. Leah raised this same concern when telling Refinery29 about her experience of purchasing the combined pill online. "You can obviously just game the answers if it says something you don’t want or tries to deny you the pill you want," she said. "That would be risky and could harm you, though."
This also came up for Emily. "The online questionnaire asked all the right questions, however I could have easily lied if I knew my answer would stop me from being able to get my prescription without needing an in-person check-up," she said. "For instance I could just lie about whether my blood pressure has been measured recently or whether I’ve experienced vaginal bleeding, which I have because I have endometriosis."

The online questionnaire asked all the right questions, however I could have easily lied if I knew my answer would stop me from being able to get my prescription without needing an in-person check-up.

Emily, 29
Emily added that she doesn’t think that buying the combined oral contraceptive pill is safer than being prescribed it by a health professional. "It relies on women being 100% honest," she explained, "but I’m not surprised we’ve turned to this given the state of the NHS and the impact of coronavirus on in-person appointments, which we need every three months given that doctors are so reluctant to prescribe longer courses."
However, Hanx said: "We’ve designed our service as far as possible to mitigate this potential risk with medically backed information across our platforms, including product pages and questionnaire. However, we believe the benefits of being able to access trusted hormonal contraceptive pills do outweigh this risk."
"If women are ‘gaming’ questionnaires, this highlights the broader issues around access to hormonal contraception. This includes the need to swiftly tackle the public health services backlog and make in-person appointments available to all, although this doesn’t necessarily guarantee accurate medical history will be shared by patients," Hanx added.
By contrast, to buy through Superdrug you do not have to self-select a pill. Instead the questionnaire is designed to help you "build a plan you’re happy with", which means asking not only if you have used oral contraceptives before but what side effects you experienced and what problems you are hoping to treat, as well as the same questions about potential concerns like deep vein thrombosis. This means that psychological impact as well as physical side effects is taken into account (which doesn’t happen with Hanx), although current mental health concerns do not form a part of either questionnaire. Once you’ve completed the Superdrug questionnaire, your answers are reviewed by a doctor who sends you a plan suggesting what pills you should take, based on your answers. Based on our answers where we reported low mood, low libido and tender breasts, the doctor recommended a combined hormonal contraceptive that doesn’t contain the progesterone levonorgestrel, "since it looks like some of your problems with your old contraceptive may be due to this". They added that you should continue a course of the pill for at least three months as side effects can settle, before suggesting 16 pills including Gedarel, Mercilon, Yasmin, Marvelon and Cilest. This was followed by details about side effects and another short questionnaire.
It seems that private companies are stepping in to fill the gaps where public healthcare should be. This exposes the impact of sexual health services funding cuts in recent years. The combined oral contraceptive pill is a powerful medication which is vital for the reproductive autonomy of women and people with wombs but it can have serious side effects. With that in mind, should it be sold privately without serious and easily accessible aftercare through the NHS?
When asked what follow-up with a doctor is available for anyone who experiences side effects from the combined pill, Dr Sarah Welsh, founder of Hanx Fix, said: 
"A key touchpoint in the journey is HANX Life, our free digital safe space, a free, anonymous forum for our community for anecdotal peer support and informal contact with myself. We’ve created dedicated topics for our customers to come together and share any concerns or feedback on their experience with their pill. However, throughout our product listings, digital content and bespoke materials included in HANX Fix: Pill orders, we emphasise the importance of contacting a medical professional if they do experience side effects."
Dr Welsh added that Hanx Fix is "addressing a very real need for accessible contraception and tackling the backlog of NHS appointments, but we believe there is still a very important role for health providers in the contraception journey, and this is not something we are replacing by any means – rather enhancing by offering information, access and choice."
When asked the same question, a Superdrug spokesperson said: "All patients that receive treatment from our services are contacted by our clinical team a few days after they receive the medication to check on their progress and are encouraged to message our doctors if they have any questions, concerns or side effects."
"In addition to that, as with all of our services, at Superdrug Online Doctor our patients have access to a private patient portal in which they can ask our doctors free of charge any questions at all to support them before, during and after the use of our services. Our doctors always offer helpful, clear advice and signpost our patients appropriately for further support."
The availability of oral hormonal contraception for private sale raises several vital questions. Who is benefiting from the sale of hormonal contraceptives? Who is at risk and are they being properly monitored? And crucially, why are we paying for contraception in a country where the healthcare system can and should make it free?
Dr Jane Dickson is a spokesperson for the Faculty of Sexual and Reproductive Healthcare (FSRH). She told Refinery29 that the price tag attached to buying the combined pill privately means it is "clearly not an option for everyone". Moreover, she said it should not become the default because "it is a fundamental right for women living in the UK to have access to the full range of contraceptive methods for free on the NHS."
The NHS is aware of this problem. In a pilot scheme, it has recently started offering both kinds of the oral contraceptive pill at community pharmacies in a bid to widen access. Moving forward, it may be that women and people with wombs can have the best of both: free contraception on the NHS and convenient access.
Of the trial, chief nursing officer for England, Ruth May, told Refinery29: "This new pilot is not only convenient for women who will be able to pop into their pharmacy to sort their prescription for the contraceptive pill, avoiding the need for a consultation with their GP or a visit to a sexual health clinic but it is of course also convenient for the NHS."
She added: "High street pharmacies are ideally placed to provide more accessible care for patients and so from next month, it is great news that women will be able to walk into their local pharmacy, have a confidential consultation with a trained pharmacist and pick up their pill."
A Superdrug spokesperson continued:
"At Superdrug Online Doctor we offer doctor-led consultations with our patients aided by questionnaires. Our current Contraceptive Pill Service offers our patients the chance to select their preference of either combined contraceptive pills and patches or progestogen-only pills. The service is designed with the most up to date national guidelines on contraception on which our doctors are fully trained."
"Our consulting doctors review all contraceptive pill consultation requests from our patients and prescribe the relevant contraceptive pills including combined pills only when it's clinically appropriate. The patients who are not medically suitable for the type of pill they have chosen are informed of this and are directed to the right service for them. We then advise them of more suitable contraceptive choices within or outside of our service and encourage them to discuss with their GP or Sexual Health Clinic as needed."
"Our website has a wealth of information on different contraception choices which is regularly reviewed and updated by our doctors. This ensures our patients are well informed of all of their options prior to highlighting their contraceptive choices to us." 
"Our services are regulated by the Care Quality Commission and all of our doctors are registered with and regulated by the General Medical Council (GMC). In line with regulations and guidance, we do not 'sell' medication."
Dr Sarah Welsh, founder of Hanx Fix, continued: 
"The combined pill is incredibly effective (99%) when taken correctly and can also help with managing heavy, painful periods, acne or PMS. There is a small but important increased risk of blood clots in the body, which is why it is not prescribed for certain people."
"Drawing on my background in gynaecological health and our trusted pharmacy partner’s advice, we’ve built a digital process which requires as stringent (if not more) medical history/info as those taken by GPs and sexual health clinics, particularly concerning the blood clot risk."
"During the order process for the COCP, we’ve built in a function which asks customers if they have had their blood pressure checked in the past 6 months. If the answer is no, they cannot proceed with the order, and are advised to try the Progesterone Only Pill instead. This is because there is no increased risk of blood clots with POPs, unlike the COCPs, as they do not contain oestrogen."
Refinery29 has contacted the GPhC for comment.

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