Category Archives: Family Planning

We Must Keep Title X and Planned Parenthood Funding

The House of Representatives will vote this week on continuing resolutions that could end funding for Title X programs and eliminate all Title X Funding going to Planned Parenthood.

Despite the beliefs of their supporters, these resolutions will NOT reduce abortions. In fact, if they pass, abortion rates will surely increase. In addition, vital preventive health services will be cut.

Here are the lies you may have heard about Title X and Planned Parenthood, and the truth you need to know –

Lie #1 : Title X Funding pays for abortion –  FALSE.

It does not, because, by law, it cannot. Here’s what Title X funded for in 2009, straight from the the HHS Website:

  • Contraceptive services for over 5 million family planning users;
  • Over 2 million pap smears, 1% of which had precancerous abnormalities that required treatment;
  • Over 2 million clinical breast exams, 3% of which were abnormal and led to further evaluation or treatment;
  • Over 2 million STD screening tests; and
  • Almost 1 million HIV tests

The majority of Title X funded clinics serve clients with incomes at or below the poverty line, and who have no other funding source for these services. In some states, Planned Parenthood is the only provider of Title X services.

Lie #2 – Planned Parenthood’s Major Business is Abortion – FALSE.

Ninety seven percent of Planned Parenthood’ services are contraception, cancer screening and STD screening and treatment.  Only 3% of the almost 11 million services provided in 2008 were abortions. (Click the pie chart below for detail.)

Lie #3: We can’t afford Title X funding – FALSE.

We can’t afford not to pay for these preventive health services, all of which have been shown to be a cost effective use of federal funds. According to the Guttmacher Institute –

The contraceptive services provided at (Title-X funded) centers helped women and couples avoid 973,000 unintended pregnancies, which would have resulted in 433,000 unplanned births and 406,000 abortions.

By helping women avoid unintended pregnancies, Title X–supported family planning centers saved taxpayers $3.4 billion in 2008—or $3.74 for every $1 spent on contraceptive care.

Lie #4 . Taking Title X funds away from Planned Parenthood will prevent abortion – FALSE.

Loss of funding for contraception means more unplanned pregnancies, which means more abortions.  Without restating the above argument, I’ll state the obvious –

If you want to prevent abortion, you’ll contact your representative and tell him/her to vote against any attempt to eliminate Title X funding.

Take action now.  The threat to funding is real, and the need is urgent.

Clotting Up Office Hours with Talk about Clots

Thanks to the lawyers and the media, this is the conversation I had recently in my practice –

Patient: My mother has been seeing lawyers’ ads on TV about Yaz, and says I should stop taking it. I don’t want to get a blood clot.

Me: Are you experiencing any problems on the Yaz?

Patient: No.

Me: Is there a particular reason why you are taking Yaz vs another pill? (Looking through EMR) I think you had tried another pill and didn’t like how you felt, and wanted to try Yaz, correct?

Patient: Right. My room mate was on it and liked it. But now she’s worried too.

Me: So – let’s run the numbers, shall we?

Patient: OK.

Me: With some variation depending on which study you look at, the background annual risk for blood clots is around 3 per 10,000.

Patient: (nods) OK.

Me:According to one study, women who took Yasmin had a clot risk of about 8 per 10,000. We can probably assume the risk with Yaz is about 20% lower than Yasmin, since the estrogen dose is lower, so let’s call your risk 7 per 10,000. That’s a bit less than a tenth of a percent.

Patient: OK.

Me: Now, if that risk concerns you, we could change you to an older pill containing levonorgestrel. In that same study, women who took that pill had a risk of about 5 per 10,000.

Patient: (silence)

Me: But wait  –  You’ve been on Yaz for what, three years?

Patient: Four

Me: Okay, then, four. Now the biggest risk for blood clots is in the first year of pill use, so you’ve already established yourself as lower risk.  That would lower your risk to around 3 per 10,000. But if we change your pill, your risk will be about 2 per 10,000. So I guess the question is, is the excess annual risk of 1 per 10,000 , or one hundreth of a percent, enough to make you want to change your pill?

Patient: I’m just worried…

Me: Well, you could change to a progesterone only pill, or POP. That has no increased clot risk over the background rate. However, it does have about a 2% higher chance of pregnancy, and is more likely to fail if you miss a pill than the pills containing estrogen. So you need to be pretty perfect taking a progesterone only pill.

In addition, your acne was better on the combination pills – I can’t guarantee it will stay that way on the POP, but we can try. You can always go back. Most patients are pretty happy on POP’s.

Patient: I don’t think I want a POP.

Me: Do you want to go back onto condoms? or be fitted for a diaphragm?

Patient: No way! And I don’t want an IUD.

Me: So what shall we do?

Patient: What do you think I should do? I’m just worried…

Me: Okay, let’s change you to a pill containing one of the older progestins and see how your acne is. It’ll probably be just as good. But if you’re not happy, we’ll change you back.

Patient: (brightens) I like that. My mom will be happy.

Bottom Line

All estrogen containing birth control pills have a small but real increase in blood clot risks. How that risk compares between different pills is complicated, depends on which study you read, and none of the studies are perfect or definitive. In fact, the FDA has yet to make a distinction between standard dose pills (20-35 micrograms) based on clot risk, because the data are so problematic.

Meta-anlayses suggest that pills containing the older progestins such as levonorgestrel and norethindrone have lower clot risks than those containing new progestins gestodene, desogestrel and drosperinone. All of these studies to date have problems, but the data appear to be consistent across analyses. Few of the studies have included norgestimate, but those that have place its clot risk nearer to the older than the newer progestins.

Researchers are now looking at APC resistance as a surrogate marker of clot risk to help us better differentiate pills from one another, but this approach has not been universally accepted.

How to use this information clinically?

We really have no randomized trial data to inform contraceptive choice when it comes to clot risks. All of the studies published to data are problematic in that they do not consistently control for prescribing and diagnostic bias, and varying doses of estrogen between pills, another factor that strongly influences clot risks.

For most women, the choice between pills is made based on factors such as cost, convenience, cycle preferences, side effects and how you feel on one pill versus another. And advertising. At the moment, Yaz is the biggest selling pill, probably due to a large DTC campaign when it first came out.  (Bayer rightly got slapped by the FDA for over-hyping Yaz’s benefits in that campaign.)

If clot risks is your primary concern, there are non-estrogen methods you can use instead – Depo Provera, the IUD, condoms, Diaphragm and implanon. (But even some of these carry clot risk on the package insert, despite clinical trial data to support it.)

The bottom line is that no matter which combination birth control pill you use, you will have to accept a small increase in risks of clots.

What can you do to lower your risk of clots?

Since plane travel and long car rides can increase blood clot risks in anyone, consider wearing knee high travel socks for long plane flights and car rides. Ask for an aisle seat, stay hydrated and move about the plane frequently to avoid clotting. (You can more on avoiding clot risk from plane travel from the CDC.)

If you are at increased risk for clots, you should avoid all the estrogen-containing pills, no matter what dose or brand. 

And by the way, the risk for a blood clot in pregnancy is 1 in every 500-2000 pregnancies.  So it’s pretty much always safer to take a birth control pill than to be pregnant.

Hormonal Contraception Thickens Cervical Mucus – an Under-Appreciated Effect

Ask any third year medical student how hormonal contraception prevents pregnancy, and they’ll probably tell you it prevents ovulation.  What they won’t tell you is that this effect is variable and dose-dependent, and if we depended on it alone, hormonal contraception would be much less effective.

That’s because of the very important, and in my opinion, much under-appreciated effect of hormonal contraception on cervical mucus.

A Cervical Mucus Primer

Fertile cervical mucus – which forms under the influence of rising estrogen levels in the first half of the menstrual cycle and is maximal around ovulation – is thin, watery, clear and easy for sperm to traverse.

Non-fertile mucus – which forms after ovulation and also in pregnancy under the influence of progesterone – is the exact opposite – thick,tacky, non-distensible and impossible for sperm to penetrate. (It’s not called the mucus plug for nothing…)

A Progestin Effect

Cervical mucus during hormonal contraceptive use mimics that of the second half of the menstrual cycle – scant, thick and impenetrable.

The responsible party here is progestin – molecules with names like levonorgestrel, medroxyprogesterone, norethindrone, norgestimate and desogestrel – which mimic the natural effect of progesterone on cervical mucus.  Even in birth control pills that contain estrogen, this progestin effect dominates at the cervix.

This effect on cervical mucus explains why the progestin-only pill, Norplant and Implanon work so well to prevent pregnancy, even though ovulation can still occur during use of these methods.

Mirena IUD thickens cervical mucus

Now, a new study shows that the Mirena IUD also thickens cervical mucus and prevents sperm penetration.

This is not surprising, since Mirena contains the progestin levonorgestrel. But it is important information about how this method works to prevent pregnancy – in addition to impairing ovulation and fertilization, Mirena also prevents sperm from getting into the fallopian tube in the first place. One could argue that in fact, if sperm and egg never meet, the other contraceptive mechanisms of this IUD become unimportant, making the Mirena really mostly a local delivery system for progestin.

This effect on cervical mucus also may explain why users of the Mirena IUD have low rates of pelvic infection, a side effect that doomed the Dalkon Shield. (Of course, the Dalkon Shield also had a multifilament string that allowed bacteria to enter the uterus. Modern IUDs have monofilament strings.)

Could we thicken mucus without hormones?

I think a lot about this contraceptive effect of progestins, wondering if we could find a way to thicken cervical mucus locally without systemic hormonal exposure. The Mirena comes as close to a local effect as we have to date, although its progestin is still systemically absorbed and has body-wide effects.

But if we could develop a locally applied non-hormonal product that does the same thing, wouldn’t that be a great contraceptive option?

The Diaphragm – Now Available at Your Local Pharmacy

7/3/15 UPDATE – THE CAYA DIAPHRAGM IS NOW AVAILABLE IN THE US. HERE’S WHAT YOU NEED TO KNOW TO PRESCRIBE OR OBTAIN IT.

UPDATE  – JANSSEN PHARMACEUTICALS HAS DISCONTINUED PRODUCTION OF THE DIAPHRAGM AS OF FEB 2, 2014. SEE UPDATE HERE.

After a prolonged hiatus, during which diaphragms became as scarce as Elaine’s treasured sponges, the Ortho All Flex diaphragm is back, and it’s now latex-free. The over one-year (at least in my area) shortage happened as the manufacturer transitioned from the old latex to new silicone diaphragms, and suppliers everywhere began back-ordering this important barrier contraceptive.

I called Ortho today, and was informed that the new diaphragms have been available for a few months now. I checked with my local pharmacy, and they advised me they could get a size 75 within 24 hours. At online pharmacies, diaphragms sell for $40-$50. You’ll need to restock spermacidal gel at a price of about $15 a tube – good for 30 or so uses.

Milex also makes non-latex diaphragms (arcing spring and wide seal), but these diaphragms must be ordered by your doctor from Cooper Surgical, as opposed to you filling the prescription at the pharmacy. I’ve been purchasing these diaphragms for my patients for the past year, and will continue to use them for patients whose anatomy calls for the added secure fit of the wide seal or arcing spring.

These days, it seems I rarely prescribe the diaphragm – most women seem to prefer other methods. In my younger years, the diaphragm was a very popular method. It’s a good option if you don’t want to or can’t take hormones. Efficacy ranges from 84-94%, but in motivated couples who use it properly (Mr TBTAM and I were in that group for years), the diaphragm can be extremely effective.  It only works if you use it properly every time you have intercourse, so if that’s not you, then look elsewhere for your birth control.

Don’t use the diaphragm unless you know your partner is HIV negative, since the method requires the use of spermacides, which can increase HIV transmission from an infected partner. Although most women use it without problems, users of the diaphragm have a slight increase in vaginal infections and urinary tract infections.

For more information and to see if the diaphragm is right for you, visit Planned Parenthood’s website.
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More reading on the diaphragm from around the web

Mirena Price Increase

You may be wondering how, in the wake of healthcare reform, Bayer has seen fit to raise the price of a Mirena IUD to over $700.

Some providers are outraged, and concerned that they will no longer be able to afford to provide this contraceptive method for their patients.

But check out this thread on the Café Pharma boards, where drug reps in the know think the price increase came because Bayer got an indication for use of Mirena to treat heavy menstrual bleeding  –

Mirena prices are already high. I assume the increase is do to the MBL indication. I have never seen a forcast but guessing it could add 100 million to the US market.

That seems about right to me. Mirena has moved from a contraceptive market, where it must enter the field in the same price range as its competitors, to the abnormal bleeding market, where its new price compares quite favorably to interventions such as surgery and endometrial ablation.

And sure enough, it looks as if the plans are already buying into the new price –

Due to a recent price increase by the manufacturer, UMP has increased the allowed amount for the Mirena IUD from $515.85 to $742.42, effective March 15, 2010. Claims for dates of service from March 15, 2010 and later will be paid based on the higher allowed amount depending on the network status of the provider (network 85%; non-network 60%).

Wonder when the birth control pill manufacturers will get wise and try the same thing? After all, we’ve been prescibing oral contraceptives to treat heavy periods for years.

And the game goes on. The losers, in the end, will be the uninsured. Oh wait – there will be no more uninsured now that healtcare reform has passed. I think I finally get it…
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Updates

  • It appears Medicaid has also adjusted its reimbursement to match the new price. So relax, everyone.
  • Docs who don’t want the upfront expense of stocking Mirena can have patients obtain it directly from Caremark through their insurers (though I’d always keep a backup or two around the office in case the one the patient brings drops or is defective…)
  • Bayer has a program to assist uninsured women with the cost of Mirena




Gastrc Bypass Surgery May Impact Oral Contraceptive Effectiveness

A review article on the effects of bariatric surgery on reproductive function published this month in Fertility and Sterility highlights two studies suggesting that gastric bypass surgeries may make oral contraceptives less effective. (Note – this does not apply to simple gastric banding procedures that limit stomach size but don’t induce malabsorption.)

The studies are very small, but the findings are concerning.

In one study of 40 women, 2 of the 9 women using oral contraceptives became unexpectedly pregnant after jejunal-ilial bypass surgery, despite having used the same method before without failure. None of the women using other methods got pregnant. The second study, conducted in 7 bilio-pancreatic bypass subjects, found that hormone levels 8 hours after taking a progesterone-only birth control pill were lower compared with normal controls. By 24 hours, there was no difference in levels. No unplanned pregnancies were reported.

The paper’s authors hypothesize that malabsorption due to the bypass may be at work here. I also wonder if perhaps the pill’s “effectiveness” in subjects prior to bypass was really the negative impact of their weight on fertility, since we know bypass can improve ovulatory function.

What do we do with this information?

I don’t think that these data are enough to recommend that all women who have had a gastric bypass avoid all oral contraceptives, though it certainly gives one pause. I think it is worth discussing with your surgeon exactly what areas of the stomach and intestine were bypassed and what your risk of malabsorption is. Certainly if one is having diarrhea induced by a bypass procedure, then one must consider that medications are not being properly absorbed.

What I am doing at this point is avoiding the progesterone-only pill in the gastric-bypass population unless I have to use it, since in general, the efficacy of these pills occurs within a narrower range of serum levels. In women who are taking combination pills, I tell them to be extra careful with compliance, and if they miss a pill, to use back up barrier contraception for at least a week, especially if they notice spotting.

Heading to a standard 35 ug rather than a lower dose 20ug pill would be worth considering in this population. The Nuvaring also seems like it may be a good option, since it does not rely on intestinal absorption. Given that the estrogen exposure in the contraceptive patch is about 60% higher than in pills, I would still tend to avoid this method, even in this group, unless I know I have to use it to maintain levels. But that’s just me – talk to your doctor about what’s best for you.

We definitely need larger studies and some consensus guidance on this issue, since more and more women are undergoing bariatric surgery.

Know Thy Sperm Donor

Uncommon but serious gentically-transmitted diseases are being found in the offspring of children from sperm donors who were unaware that they carried these genes. This week’s JAMA reports on one such donor who unwittingly transmitted a gene for hypertrophic cardiomyopathy to 9 of the 24 children conceived using his sperm. At age 22, the donor was unaware of his condition, which often presents later in life. The article’s authors call for more intensive screening of sperm donors for this and other genetic conditions and increased attention by the FDA to the public health implications of sperm donation.

I know what you’re thinking, because it was my first thought, and that is – So what? All children conceived from human parents are at risk of receiving a previously undiagnosed genetic defect, unless every one of us gets our genes screened at puberty for every known abnormality. Why should donors be held to a higher standard than regular dads?

Here’s why. Most dads don’t have 24 children by age 22. If a guy were spreading his sperm naturally, his diagnosis would likely have become apparent long before kid #24 was concieved.

It’s a brave new world out there folks, and we’re messin’ with the gene pool. Poor Darwin must be turning over in his grave. Instead of “Survival of the Fittest”, maybe we should call it “Survival of the Earliest Donor”….
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Addendum – Nice editorial on this topic in the same issue of JAMA.

Licorice in Pregnancy – Best to Avoid It

Children born to women who consume large amounts of licorice in pregnancy have lower levels of intelligence and more behavioral problems, according to a Finnish study published in this month’s Journal of Epidemiology.

Of the children who took part in the Finnish study, 64 were exposed to high levels of glycyrrhizin in liquorice, 46 to moderate levels and 211 to low levels. They were tested on a range of cognitive functions including vocabulary, memory and spatial awareness. Behaviour was assessed using an in-depth questionnaire completed by the mother.

The results suggested that women who ate more than 500mg of glycyrrhizin per week – found in the equivalent of 100g of pure liquorice – were more likely to have children with lower intelligence levels and more behavioural problems. The eight-year-olds were more likely to have poor attention spans and show disruptive behaviour such as attention deficit hyperactivity disorder (ADHD), the researchers said.

The research comes after a study which suggested that liquorice consumption was also linked to shorter pregnancies.( via the BBC News)

I have to say that while the findings are concerning, the researchers did not control for maternal intelligence or perform psychiatric tests on the mothers in their study. Their surrogate for intelligence was socio-economic and educational status, which is a poor substitute in my estimation.

That said, the findings make sense in terms of what we already know about licorice and its effects on the body. Licorice in large amounts is generally not considered safe in either children or adults, and can induce headache, fluid retention, irregular heartbeat, high blood pressure and potassium loss. The culprit is the root of the herb glycyrrhiza, the component of licorice that gives it its sweet and distinctive flavor. and which has cortisol-like properties. (Licorice actually used to be used to treat Addisons, and licorice craving can be a symptom of the disease.) In pregnant women, excess glycyrrhiza is proposed to inhibit the deactivation of maternal cortisol by the placenta, leading to abnormally high cortisol levels in the fetus.

While the FDA considers licorice to be safe as a flavor but not a sweetener, the European Union advises against consumption of more than 100 grams daily and requires that products containing licorice be clearly labeled as to this constituent.

These findings make it necessary to provide labelling which gives the consumers clear information on the presence of glycyrrhizinic acid or its ammonium salt inc onfectionery and beverages. In the case of high contents of glycyrrhizinic acid or its ammonium salt in these products, the consumers, and in particular those suffering from hypertension, should in addition be informed that excessive intake should be avoided. To ensure a good understanding of these information by the consumers, the well known term ‘liquorice extracts’ should be preferably used. (From the Offical Journal of the EU)

European licorice tends to be much stronger than American licorice, some of which may not contain licorice at all, but is flavored with anise, fruit extracts and corn syrup. (Red licorice is really not licorice at all, just flavored fruit candy.) If you’re not sure what you’re eating, read the label – if licorice extract is listed, you’ve got the real thing.

How much licorice extract is safe? Your guess is as good as mine, since I could not find milligram amounts on any licorice candy products I searched. My advice would be to play it safe and avoid licorice candy during pregnancy. (Hmm… maybe they should change the name from “Good and Plenty” to “Good only in small amounts”…)

This is just one more case highlighting the urgent need for the FDA to be given regulatory authority over herbal food supplements.
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Licorice Plant Image from the USDA website
Licorice image copyright Bert Folsom, via Big Stock Photo

Emergency Contraception Use Does Not Adversely Affect Pregnancy Outcome

Plan B

Pregnancies conceived in a cycle when levonorgesterel emergency contraception (Plan B) was used have no increased risk of adverse outcomes.

In a prospective study, researchers compared the outcomes of over 300 pregnancies in which Plan B was used during the cycle of conception to a similar number of pregnancies in which no exposure to Plan B occurred. Outcomes were the same, with about a 10% miscarriage rate and 1% rate of major malformations in both groups.

The study outcomes are not surprising. Plan B uses levonorgestrel, a progestin component of hormonal contraceptives for many years, long ago shown to be safe if pregnancy occurs despite its use. Despite the fact that plan B uses levonorgestrel doses that are higher than in traditional oral contraceptives, no adverse impact has been reported to date on pregnancies conceived despite Plan B use. Having yet another reassuring study is always good news.

A couple of things to remember when interpreting data from studies exploring the association between exposure to a medication or chemical and pregnancy outcome –

  • The background rate of miscarriage traditionally was thought to be about 15%, but we now know can be as high as 50% if one includes very early miscarriages. Once a heartbeat is established on sonogram, that rate drops to 5% or less. So if you are studying pregnancy outcomes, how you diagnose the pregnancy will affect your miscarriage rate – will you use hcg levels or clinical diagnosis? If you enroll women in your study after 6 weeks, your miscarriage rate will be lower since the early miscarriers will not make it to your study.
  • The background rate of birth defects in the general population is 3-4% – that includes major birth defects like spina bifida and minor birth defects like an extra digit.
  • Subject recall of medication or other exposure can be skewed depending on the pregnancy outcome. If things go wrong, we tend to look back and remember everything that occurred, looking for a possible cause. If things went well, we tend to forget little things like that aspirin we took for that one-day headache. But retrospective studies are much much easier to do that prospective studies. So if you are looking for a link between an exposure and a birth defect, the first step is retrospective cohort analyses. If something comes up there, you need to confirm it in a prospective fashion (if you can).

Family Planning in an Economic Crisis

Cristina Page explains why vasectomy rates are up, and writes one of the best editorials in support of family planning that I’ve ever read.

Family planning is nothing less than a foundation on which many Americans build sturdy, responsible lives. Regardless of political affiliation, that’s exactly what many are struggling to do right now. Those who have lost their jobs and health insurance are in great need of family planning. They’re also, alarmingly, the ones with the least access to it. Meanwhile Republicans openly mock attempts to include family planning as a part of the economic recovery, actively work to defund Planned Parenthood, promote policies that encourage health care workers to deny patients access to contraception, and defend programs that withhold basic information about contraception to sexually active teens. (Then they’re baffled to find the number of teen parents spiked during the Bush years.)

Read it, then send it to everyone you know.

Yaz Makers to Women – “We Screwed Up”

The Misleading Yaz Ad

In a rare move, the FDA has mandated Bayer Pharmaceuticals to run ads correcting misperceptions they’ve created with their ad campaign for Yaz Birth control pills. (via NY Times)

Yaz is FDA-approved as contraception and for treatment of PMDD, a very severe form of PMS that occurs in only about 3% of women. Yaz is also FDA-approved to treat acne. But the Yaz ad targets the common premenstrual symptoms such as irritability, breast pain and bloating – symptoms most women have at one time or another – and implies that Yaz will maintain clear skin. Basically, Bayer is targeting healthy women with typical premenstrual symptoms and no acne.

Think of it as if the makers of Prozac started to target their adertisements to folks having a bad day.

Bayer has taken the same approach in pushing their pill to doctors, assuming we’ll prescribe off label for PMS instead of reserving their pill just for women with PMDD. And in this, they are right. We docs love to find a reason to pick one pill, any pill really, over another. It makes us feel like we’re using our brains and not just blindly throwing a dart at a formulary list. Of course, we have no clinical trial data to support our choice, just a bit of logic that if you want birth cntorol pills and this pill is good for PMDD (and believe me, it does work, though not for everyone), why not try this one? For these patients, the primary indication for treament is contraception, not PMS. The problem with the Yaz ad is that it promotes the non-contraceptive effects of Yaz over the contraceptive effects, and targets them to healthy women.

Unfortunately, we will never know if Yaz treats the milder forms of PMS, because the FDA will not allow clinical trials for PMS – just PMDD. So it’s a bit of a catch-22 for Bayer. I don’t feel sorry for them, though. It’s not like they don’t already have 3 indications for their pill – contracetpion, acne and PMD. They just got greedy for market share. The FDA has very clear guidelines, and Bayer has been flaunting these for a long time now. They deserve this unusual mandate.

What will be interesting is seeing how the new ads affect sales of Yaz. Or how many phone calls I get from worried patients already taking Yaz. Because I’m sure the ad will end with the usual “talk to your doctor” disclaimer.

It will also be interesting to see what the lawyers do with this one. This ad is basically a “Come and get us!” from Bayer to the plaintiffs attorneys. Look for lawyers ads soon.

Need a Diaphragm? Good Luck with That.

UPDATE – JANSSEN PHARMA HAS DISCONTINUED PRODUCTION OF THE DIAPHRAGM. SEE LATEST INFO HERE.

Ortho stopped manufacturing the latex diaphragm in Dec 2007, in anticipation of releasing a new non-latex silicone diaphragm this year. Unfortunately, the new diaphragms will not be available till at least November, according to an Ortho service rep I spoke to today. At this point, I can’t find a diaphragm anywhere for my patients. No other manufacturer’s diaphragms are available from any wholesalers to the pharmacies I contacted.

For now, I’m sending my patients to Planned Parenthood, since they have a bit of a stockpile for now at least. If anyone has any other reliable source, let me know and I will post it here at Diaphragm Central.

Hopefully Elaine’s diaphragm is still in good shape, although she may want to cut back a bit on unnecessary usage so it doesn’t wear out before the new ones are available.

Birth Control Savings Calculator

Virtually 100% of young women in my practice who use birth control pills are filling their prescriptions monthly at a local chain pharmacy, paying anywhere from $25-$50 a month (depending on their copay) for contraception.

In a recent post, I proposed that by changing to mail-order, among other things, these young women could save a lot of cash.

Today, I tried to convince such a woman in my practice to do so herself. She was paying a $25 copay every month for her pills, but was reluctant to change to mail order because she liked the convenience of the corner chain pharmacy. (Here in Manhattan, we have a chain pharmacy on practically every corner. Sometimes, the same chain will have 2 stores within a block of each other…)

To convince her, I suggested that if she put her annual pill savings into a retirement account, it might be worth quite a bit by the time she retired. She didn’t believe me.

So we went into my office, pulled up an online savings calculator and calculated it. And here’s what we found –

If this young lady, who is 22, were to use the pill till her late 40’s (say 46), taking 5 years off to have kids (generous by modern standards), and depost the annual savings (for her, $200) into her retirement account with an annual estimated return of 9%, then at retirement at, say, age 66, she will have (are you ready?)

$68,762!

That’s the magic of compounding.

How much could you save by going mail order?
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To calcuate, I assumed she was adding $200 a year into a tax free account till age 30, stopping contributing for 5 years, then contributing again for another 11 years, then leaving that money in the same account till age 66.

How to Pay Less for Birth Control

Most of my patients are spending way too much money on their hormonal birth control. At close to $50 a month, contraception can eat up as much as $600 a year. Sure, compared to the cost of raising a child, $600 is peanuts. But what if I told you that you could get the same protection against pregnancy for less than $100 a year? That’s a savings of $500 that you can put in the bank, or use to pay off your student loans or credit card bills.

So get smart and start saving money on birth control!

1. Go mail order.

Stop refilling every month at the local Duane Reade or CVS, and go mail order. Did you know that if you use your insurer’s mail order pharmacy, you can get a 90 days supply of birth control pills for a single co-pay? Not only do you save money, but you don’t have to worry about finding a 24 hour pharmacy on a Sunday night when you run out of pills, because you’ll have a 90 day supply in stock all the time.

You’ll need to think ahead, since it can takes up to a week to get your pills in the mail. Solve this problem by asking your doc to write you two prescriptions – a one month supply with 12 refills to keep at the local pharmacy for emergency refills, and a 90 day supply with 3 refills for mail order.

If you don’t know what mail order pharmacy your insurer uses, check you insurance card – it’s usually there. If not, ask Human Resources at your job.

2. Go generic.

Most pills are available in cheaper generic forms that are just as effective and available at much lower cost. If your current pill does not come in generic, ask your doctor if changing to pill that comes generic would be a problem for you. In my experience, a significant proportion of patients can find a generic pill that they will be just as happy with as their brand name.

Check your insurer’s website for a list of preferred generics. Print it out and bring it to your next appointment. Ask your Doctor to see if changing to a pill from that list would be appropriate for you.

3. Get your pills at Walmart, Target or Kroger.

That would mean changing to generic Sprintec (Ortho-Cyclen) or Tri-Sprintec (Ortho-Tricyclen), but at a low cost of $9 a month, it may be worth a try. Ask your doctor if it makes sense for you. (more info here)

4. Get your pills from Planned Parenthood

Even though recent legislation has limited their ability to purchase pills cheaply, Planned Parenthood’s prices may still be cheaper than the pharmacy.

5. Ask your partner to share the cost.

It takes two to tango, so let’s go, gentlemen – Ante up!

6. Take your pills the same time every day, and don’t miss a pill.

After all, if you’re spending money on birth control, don’t take it properly and end up with an unplanned pregnancy, then you’ve wasted your money, right?

7. Use pre-tax dollars for birth control.

If you know you’ll be spending a given amount every year on your pills, put that amount aside in a health savings account with your employer and save on taxes while preventing unplanned pregnancy.

8. Join Planned Parenthood’s Birth Control Now Campaign.

Keep birth control prices low for college students and low income women.

9. Remember birth control pills are used for more than just birth control.

If your insurance won’t cover family planning (and shame on them if they don’t), ask your doctor to submit a letter of medical necessity to your insurer for your use of your pills for treatment of menstrual cramps, acne, or menstrual irrregularities if that’s another reason why you use them.

10. Your turn

Got any other ideas on how to save money on contraception? Share it in the comments section.