Plan B is Over the Counter, why not Plan A?

The work to move birth control over the counter must be done in parallel to the work advocating for legal abortion. Both are equally important, and neither negates the other.

On July 11, France-based HRA Pharma submitted their Prescription-to-Nonprescription (Rx to OTC) Switch Application to the FDA, hoping to be the first providers of an over-the-counter oral birth control in the United States. The drug is currently on the market as OpillTM and requires a prescription, whereas the company’s UK version, under the name Hana, is available without a doctor’s order. 

OpillTM is a progesterone only pill or “minipill”, rather than a combination of progesterone and estrogen. The active ingredient is a synthetic progesterone called norgestrel, which works to prevent pregnancy by preventing ovulation and thickening the cervical mucus. During the normal menstrual cycle, fluctuations in estrogen and progesterone signal to the body that it should either prepare for a pregnancy or reset the cycle. 

These hormones communicate through a negative feedback system with other parts of the body, including the brain. This system is called the Hypothalamic-Pituitary-Gonadal (HPG) Axis.. In this process, the hypothalamus signals to the pituitary, which in turn communicates to the gonads (in this case, the ovaries), which produce estrogen and progesterone. When the body senses these hormones, it signals back to the hypothalamus  to stop signaling the pituitary, hence the name negative feedback. 

By adding exogenous (“outside the body”) progesterone, the feedback loop that exists between the brain and the reproductive system senses the presence of progesterone and downregulates the actions of the hypothalamus. In doing so, it also downregulates another important hormone called luteinizing hormone (LH), which is responsible for ovulation and ovulation is blocked.

Oral birth control has been around for over sixty years, and progesterone only pills are safe for the majority of reproductive-aged patients, including those who should not take the combination, estrogen-containing pill. This may give HRA Pharma an advantage in the approval of their application, which is expected to be under review for the next ten months.

HRA Pharma’s application followed on the heels of the Supreme Court’s June 24th ruling in Dobbs v. Jackson that overturned federal protection of abortion. With abortion now restricted or banned in many states, the potential for over-the-counter birth control is certainly invigorating news in the push for reproductive justice. However, improving birth control access will not negate the need for comprehensive, safe, and informed sexual healthcare, including abortion. 

The pill’s 91% efficacy in real world use is great. But what about the  9% of people who have a birth control failure? The work to move birth control over the counter must be done in parallel to the work advocating for legal abortion. Both are equally important, and neither negates the other. As one of my previous professors said, “As long as people are having sex, we will need abortions.”

That being said, moving OpillTM and other pills over-the-counter is an important step in achieving accessible, equitable health care. Eliminating barriers to using the birth control pill will empower people to control their own fertility. Historically, contraception, and the pill specifically, has been used to suppress vulnerable populations. Shifting oral contraceptives over-the-counter can alleviate hesitation in seeking a prescription and having to juggle a provider’s prejudice. It also reduces barriers such as taking time off work or finding alternative family care arrangements that are necessary when making an appointment at a physician’s office.

There is so much to benefit from OpillTM potentially coming onto pharmacy shelves, and we hope that HRA Pharma’s data, collected with help from Ibis Reproductive Health and others in the Free the Pill Coalition, will be enough to prove the safety and efficacy to the FDA. 

It’s Done.

Somewhere a woman is lying in bed right now, learning that she is unable to terminate the pregnancy that is robbing her of her ability to mother her children, be a partner to her spouse, or maybe even keep her job.

This morning Roe v. Wade was overturned. In my state, abortion is still legal, but is likely to grow less accessible as more states pass restrictions. This critical healthcare will be in higher demand from those who must travel here from someplace less safe.

I asked a lot of people what to do and how to prepare for this day. The usuals, support your local abortion support network, go to the protests, etc. came up a lot. I have done those things, and I am glad I did, since today is not the day for clear thinking.

About a month ago, I procured abortion pills from Aid Access, and several boxes of Plan B from my local pharmacy. (Note aidaccess.org crashed this am, but I am sure they will be back online soon.) I have two 15 year olds, and my house is often full of young people. From talking to them, I know $50 for Plan B is inaccessible for many, let alone the process of obtaining abortion pills to have on hand (you need ID and a credit card, computer access, and a way to receive the pills safely). I know I am not the only mother in my community who has prepared this way.

But I want to talk a bit about why this is less about practicality for me this morning and more about emotions. First, as someone who dealt with infertility and repeated miscarriages, I know that fundamentally first trimester abortion is the SAME THING as the procedure to remove the products of conception during a miscarriage. Second, as someone who had an abortion when I got “miraculously” pregnant at 43, I can tell you that the thought of having my bodily autonomy stripped away is visceral.

Quite literally, for me, being pregnant is a fight with constant nausea and vomiting. I am certain of this, since I have been pregnant many times. The last time I was pregnant, I really thought I could tough it out and make a go at having the miracle child. But biology stepped in and I had to decide between my existing children, my career, my other relationships and 9 months of incapacity. The hyperemesis treatments that worked for me before no longer made a dent in the crippling vertigo.

I couldn’t get out of bed, and I couldn’t work – because that required standing up, or at least sitting up. My gracious coworkers took over for me during this time, and no one asked me any hard questions. In other words, they respected my autonomy and privacy. They gave me space to get back on my feet. I am forever grateful. Not everyone has this kind of support network at home, much less at work.

There are women all over the country and maybe in your life dealing with similar situations. Somewhere a woman is lying in bed right now, learning that she is unable to terminate the pregnancy that is robbing her of her ability to mother her children, be a partner to her spouse, or maybe even keep her job. Maybe someone from the clinic has called to tell her that the appointment is cancelled.

It is for these women I grieve, and tomorrow there will be more.