The right to choose not to have periods

Periods are a normal and natural thing. Few women would describe their periods as joyous as a trip to Disneyland, but they're willing to deal with this aspect of life all the same.

But what if you could choose not to have periods? Just opt out of shark week. The Pill is rightfully recognised as a key part of the sexual and feminist revolution. But there is another part of the feminist revolution that the Pill has enabled: the ability to not have periods. 

For me, the contraceptive pill and the ability to skip periods has significantly enhanced my physical and mental wellbeing. It is an important means of feeling empowered to exercise control and choice over my own body. 

But my goodness, skipping periods is neither cheap nor convenient. We talk a lot about period poverty in New Zealand and the costs associated with periods. But the cost of choosing not to have periods is a bit of a scandal too. That's if women are given the right information about skipping periods at all. It seems like women just can't win.

First up though, here's a little history to illustrate just how poor the advice has been and regarding the Pill. 

Is it safe to skip your period?

Contraceptive pills are organised in monthly strips, with seven placebo pills that allow women to have a monthly period. Since the 1960s up until as late as 2019 (!) women have been advised against skipping their periods when taking the contraceptive pill. 

But here's the thing: those placebo pills that women have been dutifully taking because they were told to don't serve any health function. The placebo pills were introduced in the hopes that, by mimicing a natural menstrual cycle, the Pill would be accepted by the Catholic Church (it wasn't). 

There is no medical evidence to suggest that skipping periods is harmful, or that monthly bleeding is necessary. 

There are several problems with the bad advice in favour of taking the placebo pills:

1) It can actually increase the risk of pregnancy

2) There are significant physical and mental wellbeing costs for some women 

3) It increases the cost of the Pill for women who are skipping the placebo pills, as the six months of pills they are prescribed only lasts 4.5 months.

Family Planning is awesome and has been ahead of the curve in this respect. It has been giving the same advice since 2015: "It’s up to you to decide how you want to take your pill." 

Costs are coming down, but not enough women know about it

There has been progress in this area, but it is slow. In 2017, the Medicines Classification Committee reclassified the Pill from a prescription-only medicine to a restricted medicine, allowing pharmacies to provide the Pill over the counter, provided users meet certain criteria. The changes were likely only made thanks to an application by Green Cross Health who represent Unichem and Life Pharmacies.

The 2017 changes were meant to increase the availability and accessibility of the Pill. But has it? Let's break down some costs based on my own GP and places available to me (so, central Wellington). Costs will likely differ across the country and could be lowered with other subsidies. But annually, it's looking like:

• If I go through a GP : GP visit ($66) + Prescription fee ($5 x 3 = $15) + Prescription renewal fee ($22 x 2 = $44) + Blood pressure test every six months, or every three months based on GP preferences ($12 or more if your GP is cautious). So...around $137 
• If I go to a normal pharmacy: One off consultation and six months 4.5 months supply ($45) +  ongoing supply ($15 x 2 = $30) so $75
• If I go to Chemist Warehouse : One off consultation and six months 4.5 months supply: $19 + ongoing supply ($9 x 2 = $18) so $37

Seriously, bless the Chemist Warehouse and the other discount pharmacies popping up. Those costs really do make the traditional GP set-up seem like daylight robbery. And they're likely bringing down the costs at pharmacies around them. Note that even though the pills the pharmacies sell are not subsidised, they are still cheaper than going the GP route. 

Which brings me to something else I discovered (note I'm entirely relying on what the GP clinic told me, if they're wrong I'd love to know), something that can only be described as a bureaucratic anomaly:

• If you go through a GP, you have to visit annually. 
• If you go through the pharmacy you have to visit a GP every three years.

Why the discrepancy? Because they're covered by different guidance and legislation (I can find guidance for pharmacies but not GPs). The cost of GP visits is by far one of the biggest costs in acquiring the Pill, so the minimum frequency of visits matters a lot. 

It's great that pharmacies have managed to lower the costs, but the problem is that this option isn't well advertised. Despite the changes happening in 2017, neither my GP nor the nurse at my clinic knew that this was a thing. And in a 2020 Family Planning survey the cost of GP visits is still cited as a barrier.

Plot twist: changes to increase accessibility do not apply to simply skipping periods

Perhaps I should have opened on this point, but I wanted to illustrate the relative costs even if you are using the Pill for the reasons it was intended. If you're using the Pill just to skip periods, the costs are even higher.

First, the pharmacy option isn't available. If you go through the pharmacy you have to say that your primary use for the Pill is for contraception. So you better be having sex.

Eligibility for the PHARMAC subsidy is also affected. If you use the Pill for contraceptive purposes, the PHARMAC subsidy is limited to six months supply. Where the Pill is prescribed for non-contraceptive indications, then the subsidised period of supply is only up to three months per prescription. That brings costs up to around $218.

I don't want to get into the notoriously complex ins and outs of PHARMAC subsidisation, but in reality it wouldn't matter if women had other routes to choose from that could offer competitive prices (e.g. the pharmacy).

Why all this matters for the right to choose

Technically, women have the right to choose whether or not to skip their periods.

In practice though, the system seems to be slanted against them. Despite evidence changing around the risks of skipping periods, we still seem to be in the 1960s.  Accessibility around contraception has improved to enhance a woman's right to choose whether to risk pregnancy, but not whether to endure the discomfort and wellbeing impacts they may suffer due to periods.

Even if experts (and by extension public policy and official guidance) were taking a risk averse approach to the evidence, it still doesn't negate the fact that this has taken away the individual woman's right to understand and weigh the evidence herself, and choose whether to take on that risk. 

There seem to be at least some changes that could help improve the accessibility of the Pill:

• Recognise that some women choose to skip the placebo pills, and prescribe accordingly. Better yet, produce ranges so that women have a choice whether to have the placebo-inclusive or exclusive varieties.
• Align the guidance and legislation regarding GP visits. A GP visit every three years seems reasonable. But if that's not palatable, at least apply some risk proportionality so that more at-risk groups might have to visit more regularly.
• On that note, I have no idea whether the status quo is risk proportionate and whether it has been weighed against the costs of making contraception less accessible. If not, do that.
• Let creative destruction run its course: we need a Chemist Warehouse (and its equivalents) on every corner. These discount pharmacies show how low the cost of health products and medicines can be. Did I mention they don't charge prescription fees? Discount pharmacies have shaken the game up, but they're facing a battle against smaller players who cannot compete with those prices.

Women should have the right to make informed choices about their bodies, and the right to choose what level of risk they are willing to take on. Deliberately slanting the system away from the most affordable options undermines that right. 

I just pray someone fixes this mess before I reach menopause, but I'm not holding my breath.