Telemedicine an Appropriate Vehicle for Prescribing Oral Contraceptives

A study of calls made to the direct-to-consumer (DTC) telemedicine platform American Well found the vast majority of reproductive-aged women seeking oral contraceptives received a prescription.

However, only 0.5% of more than 126,700 calls made over a two-year period were related to contraception.

“Previous studies have established telemedicine as an appropriate platform for prescribing hormonal birth control, but use of this particular DTC platform for this reason was uncommon,” says Kathryn Martinez, PhD, a public health researcher in Cleveland Clinic’s Department of Internal Medicine.

As the use of telemedicine grows at an exponential rate, the need to determine suitability for various indications is urgent.

In addition to this study on contraception prescription, Dr. Martinez and colleagues have published results on antibiotic prescribing for respiratory infections, influenza management, urinary tract infections and corticosteroid prescriptions for acute respiratory tract infections.

Filling a Gap

One-third of women who attempt to access contraceptives encounter barriers to obtaining the prescription or refilling it. DTC telemedicine platforms, which offer care via mobile, app-based visits, were developed to address this issue. Because visits are virtual, and insurance is not required, DTC telemedicine was expected to make contraception easier to obtain.

Indeed, DTC telemedicine platforms appeal particularly to young urban residents, who like the convenience of accessing a medical professional 24/7 and obtaining a prescription in minutes. Hospitals also like the platforms, which enable them to provide services at a very low cost.

But since the COVID-19 epidemic is pushing telemedicine to grow more quickly than it might have evolved over time, the most suitable services for delivery through this outpatient care alternative are largely unknown.

“We suspect it is great for some conditions, but less-than-ideal for others,” says Dr. Martinez.

Studying Callers’ Needs

Dr. Martinez and colleagues examined requests for, and provision of, contraception on American Well made by women ages 18 to 50. Unlike DTC telemedicine platform that are contraception-specific, American Well addresses a wide variety of low-acuity conditions using board-certified physicians.

They found 83% of patients seeking contraception accessed the platform only once from July 2016 to July 2018, 12% accessed it twice and 6% called three or more times. The volume of patients seeking contraception during the study period did not change. Specifics about encounter length, charges and insurance are detailed in the study.

Self-reported reasons for accessing care included nonspecific birth control request (58%), request for refills (38%) and request for emergency contraception (4%).

Telemedicine Is the New Norm

Previously published articles in which secret shoppers called different platforms to determine whether contraceptives would be prescribed when contraindicated found this occurred at a very low rate. This information supports the conclusion that telemedicine platforms are a reasonable alternative to access contraception.

“The absolute contraindications to an estrogen-containing contraceptive would be what is listed in the package insert (i.e., estrogen responsive cancer, active DVT, history of stroke, etc). However, progestin only contraceptives can often be started in the presence of various medical conditions (except for women actively being treated for hormone positive breast cancer),” states Pelin Batur, MD, a women’s health specialist working in the Department of Subspecialty Women’s Health within the Ob/Gyn & Women’s Health Institute, and a member of multiple national committees involved in writing U.S. guideline recommendations, including those related to contraceptive access.

“Importantly, the risks of an unintended pregnancy in women with complicating medical risk factors is always greater than the risk of a contraceptive, especially because just under half of pregnancies are unintended. We try to find the most appropriate options available for each individual woman, and most patients can leave the virtual appointment with a prescription, especially if they click into the gynecology section of virtual visits. After women receive their initial prescriptions via virtual visits, women with complicating factors can be referred to Cleveland Clinic’s Medically Complex Contraception Clinic for long-term follow-up,” Dr. Batur continues.

She also notes that there are no medical contraindications that should limit the prescription of emergency contraception via telehealth. “The duration of exposure to emergency contraceptives are too short to cause any significant harm in those with chronic medical conditions.”

“There is no reason not to prescribe oral or emergency contraceptives over telemedicine for low-risk patients, particularly those under age 35 requesting refills,” says Dr. Martinez. “Of course, higher-risk patients and those requesting an IUD must come into the office and be seen in person.”