Categories
Public Health Women's Issues

Tackle the Pink Tax

            We’re all aware that the role of women has changed in the last centuries, but probably less aware that their biology has also changed. Together, these changes have helped change society.

            Currently an average girl in the USA undergoes menarche (starts to menstruate) before age 13. In the 19th century a girl was 4 years older before reaching that landmark. We aren’t sure why girls are maturing earlier, but there are probably multiple factors. Better diet is definitely a contributing cause, as is obesity. Chronic stress may also be a factor, and endocrine disrupting chemicals such as BPA probably have an effect. Interestingly, menopause (the permanent cessation of periods) may occur slightly later than a century ago.

            Menstrual problems may come along with menarche. Usually this is just cramps that are controlled with over-the-counter medication. Because girls often don’t ovulate for the first months after menarche, a girl may have heavy and/or irregular periods that may lead to anemia. These problems can interfere with the young woman’s life, causing her to miss school, sports or other important activities.

            Interest in boys usually follows menarche. The same hormones that cause a young woman to menstruate also affect her libido. Since girls are maturing earlier, it follows that they will also be interested in sex at an earlier age. On the other hand, the average woman’s education lasts many years longer than it did a century ago. Our mores are still based on the way people lived in the 19th century, when it was common for a woman to wed shortly after graduation from high school, or even to drop out to marry. Her husband was usually the breadwinner and she stayed home to care for the children—the first of whom was born not long after marriage.

            One of my heroes, Dr. Malcolm Potts, has observed: “…the modern woman can have 300 or more menstrual cycles. Given a later puberty and pregnancies separated by long intervals of ovulation-suppressing breastfeeding, women in the few surviving hunter gatherer societies, may have as few as 60 life time cycles.”

            Can “the pill” safely help young women? Oral contraceptives are the most effective way to regulate periods. They decrease blood loss and reduce cramping, plus they make periods predictable. It is even also possible to skip periods by changing how pills are taken. For some, oral contraceptives will help with the moodiness (PMS) that may come before a period.

            Young women may benefit from other good side effects of “the pill”, including improving acne, decreasing the risk of anemia or ovarian cysts, and later decreasing the chances of a woman developing ovarian or uterine cancer.

             Menstruation interferes with the lives of many women. In less developing countries girls often miss school when menstruating, or drop out entirely—especially if they cannot afford pads.  That is also true for some girls in the USA: Chicago Public Schools have a policy which “…requires that schools provide free menstrual products in bathrooms to improve gender equity for people who miss school because they don’t have access to these products.” Denver Public Schools and some other Colorado schools also provide easy access to free menstrual products. Scotland has gone a step further—menstrual products are free to all who need them.

            Another problem in developing countries is that many schools lack clean and private washrooms. “Days for Girls”, an international nonprofit organization, provides help to many young students. In addition to making and supplying reusable pads and ways to carry and clean them, instructors go to schools and talk to young women about menstrual care and staying safe.

            The cost of menstrual protection can add up, and it is an expense that boys and men don’t have. To make things worse, in many states (including Colorado) these products are taxed because they are not considered “necessities of life”. Organizations such as Period Equity are tackling the “pink tax”. In Colorado, House Bill 1127 was introduced in the Legislature in 2017 to do away with this unfair tax, but the bill was postponed indefinitely. The City of Denver has already stopped taxing these necessities for women; isn’t it time that the whole state follows along?

© Richard Grossman MD, 2021

Categories
Population

Liberate the Pill

            Do you think that a medication that kills more than 3000 people in the USA should be available without a prescription, even though it has health benefits? What about another medication that has many health benefits but doesn’t increase the risk of death?

            The first drug mentioned above is aspirin and can easily be bought without a prescription. The second is “the Pill”, or Oral Contraceptive Pills (OCPs), which need a prescription now. In the past women needed a yearly Pap smear which meant a visit to a doctor (or other health care provider) with the expense and embarrassment of a pelvic exam. As the amazing safety of the pill has been recognized, laws have been changed to allow women to purchase their OCPs in some states from a pharmacist with minimal hassle–and they can keep their clothes on!

            Perhaps you noticed that the first paragraph of this essay was making an unfair comparison. The people who die from aspirin are usually older than the women taking oral contraceptives. Furthermore, the study that found no increased mortality among women who had taken OCPs, found that there was an increase in deaths from breast cancer, but that was counterbalanced by a decrease in ovarian cancer and other causes of death.

            I had the unusual experience of getting a package OCPs for an elderly nun. Our Catholic hospital had a committee to consider requests for tubal ligations–usually women undergoing repeat Cesarean sections. The sister, a member of the committee, didn’t understand that a tubal ligation could be life-saving. Apparently, she wasn’t aware that women die from pregnancy complications. I showed the nun the insert accompanying every package of OCPs, which has information about the risks of dying with various contraceptive methods, or with none. The most dangerous was not using contraception, since every pregnancy carries a small risk of death. She was convinced of the importance of tubal ligations for women who desired no more children.

            When OCPs first became available 60 years ago they were quite different. Then the level of estrogen was more than twice what it is now. Over 50 years ago my wife and I visited a college classmate in the hospital where she had been diagnosed with a blood clot from OCPs. It took years to recognize that estrogen in OCPs increases the risk of clots–the more estrogen, the higher the risk. We now know that pills with less estrogen are safer, but still effective.

            Fortunately, there are already several ways OCPs can be bought without an examination. They include Planned Parenthood, where answering a questionnaire and blood pressure check are all that’s needed. In Colorado and some other states, a pharmacist can prescribe them. Also, there are Internet sites that provide prescriptions and sell OCPs inexpensively. Why not reduce the restrictions to make it easier and less expensive to get OCPs?

            Perhaps you remember a similar situation with Emergency Contraception Pills. It took years to convince the Food and Drug Administration of their safety. ECPs can now be bought in a pharmacy or even from Amazon without restrictions. Because ECPs are most effective in preventing pregnancy if they are taken within 12 hours after unprotected sex, it is suggested that people who are at risk keep a pack “just in case”.

The “Oral Contraceptives Over-the-Counter Working Group” advocates for OCPs to be available without prescription. They have worked for years to reduce hurdles for women. They have looked at pills’ safety record in other countries, where one can purchase OCPs without a prescription. Social scientists have been developing easy-to-understand wording to go with the pills since no provider will tell the woman how to take the medication.

Well, England has beat us to it! This month Progestin-Only Pills will be available without a prescription, after a brief consultation with a pharmacist. Since POPs have no estrogen, they are safer than the usual combined OCPs and can be used by many people who should not take estrogen.

Making contraception more available is not just a matter of convenience. Studies show that access to contraception increases young women’s chances of graduation from high school. Facilitating access to safe OCPs can help change teens’ lives for the better.

© Richard Grossman MD, 2021