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When getting birth control becomes as easy as ordering takeout, patients lose

When getting birth control becomes as easy as ordering takeout, patients lose

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Flickr photo

At the 2015 Health 2.0 conference in Santa Clara, Calif., health care startup companies pitched valiantly for investors’ attention. Some were brilliant and some forgettable, but only one was worrisome, and for more than its odd name — Nurx.

Nurx bills itself as the “Uber for birth control.” Answer a few questions on a friendly website, give up your credit card and insurance card numbers, and USPS brings you three months’ worth of the NuvaRing.

Why startups are still using “Uber for… anything” as a slogan befuddles me, given its frequent PR disasters, but prescription drugs are restricted for a reason, and making the procurement of hormonal birth control as easy as ordering Pad Thai on GrubHub begs examination.

I tried out the site. Nurx asked me for my name, age, and whether I have had a few medical conditions, like gallbladder disease or a stroke. I purposely endorsed major red flags like smoking and a recent blood clot and stroke. I indicated my preference for the patch out of three choices (pill and contraceptive ring were the others). I was asked for my height and weight, no doubt to calculate my BMI, or body mass index. Body mass index is notoriously inaccurate as a measure of whether someone is obese — and therefore at higher risk for stroke and heart attack, especially with the help of hormonal contraceptives. The site asked me to list medications and other medical conditions. I could imagine women rushing through this part and possibly omitting important information.

The site allowed me to proceed to checkout, which was a little disturbing. There wasn’t even a heads-up that my recent “stroke” (and current “pregnancy,” added on for good measure) might not make me a good candidate for a prescription. There was nowhere to write anything about a family history of stroke, heart attack, or cancer.

I recalled a 40-year-old patient who has a speech impairment due to a stroke she suffered in her 20s, most likely caused by birth control pills. She has to repeatedly convince people that she isn’t mentally disabled or foreign.

According to the site, Nurx has doctors who review a patient’s responses and then issue a three-month prescription. Insured patients get their birth control free — the Affordable Care Act mandates free birth control for insured women. It’s interesting to note that the company, according to its website, is billing insurance companies for the cost of a doctor “visit”— and likely retaining a portion of that collection. Whether a quick and limited questionnaire, with no eyes or hands laid on the patient, is a billable medical encounter is up for debate. Patients can ask to actually talk to a doctor, but they have to make the request.

A recent study of French women revealed that only 63 percent believed themselves to be well-informed the first time they used contraception, which implies potential problems in terms of the medical safety of Nurx. Without education and guidance, some first-time birth control users might toss the tiny-print instructions away and use the pills only when they have sex, the same way they might pop ibuprofen for headaches. Others might fail to take a make-up pill for a missed pill and end up pregnant. And who does the customer call when she develops vaginitis from her new contraceptive ring?

Women on thyroid medication who take the pill could end up too low on their thyroid levels, and migraine sufferers could experience debilitating attacks because they chose the wrong type of birth control — the pills are offered with quick descriptions, like a takeout menu. Most primary care doctors don’t even pretend to remember which birth control pills have which advantages and drawbacks — we look them up, and we customize our recommendations to the individual patient. The progestin-only pill submenu didn’t mention how difficult that medication is to take: If you’re off by an hour in taking your medication, you may be at increased risk for pregnancy.

Nurx bills hormonal contraception as the quick and easy way to ensure no unwanted pregnancies, despite that diaphragms, IUDs, and condoms work well and don’t carry the same risks, like forgetting to take a pill or replace a patch. Condoms also give the male partner some responsibility in preventing pregnancy. The recent backlash against the Centers for Disease Control, for telling women not on hormonal birth control not to drink alcohol, illustrates this unfairness; women should be able to rely on a responsible partner to wear a condom — and drink a glass of wine if that is what they desire.

As much as women have the right to choose when to conceive children, not every woman should sample every form of hormonal contraception. Given how many patients breeze through in-office questionnaires on medical history and revise their statements upon talking to the doctor, Nurx is taking on a big risk by cutting face-to-face doctor time out of the equation. Other women in more unique medical situations may benefit from their primary care doctor’s knowledge of everything from their medication compliance history to their family history and that questionable breast biopsy a few years ago.

Sound, personalized medical advice is not an inconvenience or a waste of time. In some cases, it prevents unnecessary side effects; in others, it prevents death and disability. Hormonal birth control, while very good at preventing pregnancy, is a prescription medication because it carries risk. Women deserve the time and attention of a real medical consultation, not just a menu. Meanwhile, I’ll limit my own online orders to the vegetarian red curry, no peanuts please.

[Photo by Nate Grigg via Flickr.]


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