Contraception 73 (2006) 372 – 375
Original research article
Over-the-internet availability of hormonal contraceptives regardless of risk factors Lisa M. Memmel a, Leslie Miller a,4, Jacqueline Gardner b a
Department of Obstetrics and Gynecology, University of Washington, Harborview Medical Center, Box 359865, Seattle, WA 98104, USA b Department of Pharmacology, University of Washington, Seattle, WA 98104, USA Received 17 August 2005; revised 14 October 2005; accepted 14 October 2005
Abstract Objective: The purpose of this study is to measure the accessibility to purchase oral and transdermal contraceptives over the Internet for lowand high-risk individuals. Methods: The Internet was used to search for and order both oral and transdermal contraceptives. Using the bGooglekQ search engine to locate online pharmacies by entering the term bpurchase contraception,Q we proceeded to purchase either oral contraceptives or contraceptive patches without a prescription. We first posed as a healthy 25-year-old woman, then as a 35-year-old woman who was obese and a heavy tobacco user, and finally, as a 35-year-old smoker on an antihypertensive medication. Results: Our attempts to order both combination oral contraceptives, as well as contraceptive patches, over the Internet without a prescription were successful for all three risk profiles. We ordered from three different Web sites, two within the United States and one international site. The two U.S. Web sites required us to complete a medical questionnaire to obtain a prescription from the site provider, but the foreign site had no questionnaire or risk information posted on the Web site. Despite entering known risk factors for estrogen use, we received all the medications. There was no medical follow-up to these sales except for offers to sell more products. Conclusions: Both oral and transdermal contraceptives are easy to obtain over the Internet without a physical appointment with a health care provider to obtain a prescription. D 2006 Elsevier Inc. All rights reserved. Keywords: Hormonal contraception; Internet pharmacy; Oral contraceptives
1. Introduction Prescription medications are typically obtained by an old-fashioned trip to the doctor’s office and dispensed from a pharmacy located in an actual building. With the Internet, our lives and purchasing habits are changing, including the purchasing of pharmaceutical supplies. There are now hundreds of drug-dispensing Web sites in business, and issues of the quality of the medications and regulation of these prescriptions at the state and federal level are being debated [1,2]. Fatalities after taking sildenafil purchased over the Internet [3] and counterfeit medications such as contraceptive patches from overseas [4] have been reported. There can be advantages to purchasing prescription medications online, including contraceptives [5,6]. The
4 Corresponding author. Tel.: +1 206 731 3228; fax: +1 206 731 5249. E-mail address:
[email protected] (L. Miller ). 0010-7824/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2005.10.001
Internet has the ability to improve accessibility in remote or rural areas without a provider and/or pharmacy, it is available 24 h per day, it provides an easy price comparison and it allows the purchaser the privacy of his or her own home. The disadvantages of Internet dispensing include the high cost, the lack of regulation, possible compromise in the actual quality of the products, the drug information provided and the absence of medical consultation prior to obtaining prescription medications [1,2,7]. Although contraceptives with estrogen are safe for the vast majority of women and can provide significant health benefits, they are not without risks. Providing medical consultation in order to obtain contraceptive pills or patches can give providers an opportunity to screen women for pregnancy and other medical contraindications to estrogen use. We wished to determine and evaluate the availability of hormonal contraceptives for both low- and high-risk women and to assess whether there appeared to be adequate safety barriers for Internet purchases.
L.M. Memmel et al. / Contraception 73 (2006) 372 – 375
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2. Materials and methods
3. Results
The Internet was used in 2004 and 2005 to search for and to order specific brands of oral and transdermal contraceptives. The bGooglekQ search engine was used to locate online pharmacies by entering the term bpurchase contraception.Q We assessed the number of bhitsQ registering from the key words bpurchase contraception,Q bbuy birth control pills,Q and bbuy birth control patchQ (Table 1). The authors then posed as three different women with profiles as follows: (1) a 25-year-old with no significant medical history, (2) a 35-year-old with a weight of 200 lb who smoked one pack of cigarettes per day and (3) a 35-year-old smoker with hypertension on the antihypertensive medication lisinopril. We then attempted to purchase from sites either oral contraceptives or contraceptive patches, first, as the healthy 25-year-old and then, as the other risk profiles. Data collected for each selected online pharmacy Web site included the uniform resource locator; the presence and requirement of a medical questionnaire, including history of smoking, weight, medication use, blood pressure, cervical cytology testing and possible pregnancy; the presence of a consent form, if there was information posted regarding side effects and risks; the time taken to complete a purchase; and whether a Verified Internet Pharmacy Practice Sites or bVIPPSQ seal or logo was present on the Web site. The VIPPS seal was developed by the National Association of the Boards of Pharmacy and is used to display a bseal of approvalQ for Internet sites that apply and meet State licensure requirements and national standards [1]. Specific contraceptives sought included the NordetteR oral contraceptive, the YasminR oral contraceptive and the Orth-EvraR patch. We specifically chose the drosperidone-containing product YasminR because lisinopril use would be a contraindication without monitoring potassium levels in the user. When the contraceptives were received, we documented if there was a prescription from a medical doctor on the package, whether side effect information and warning signs were included, time to delivery and the location the contraceptives were shipped from. A pharmacist evaluated the product packaging, labeling, expiration date and appearance, but chemical testing of the medications was not performed. We also collected information on the costs of similar contraceptives at a local for-profit pharmacy by asking at the retail counter.
Entering the selected search phrases produced an astonishing number of b hits,Q which increased over time (Table 1). The results from our product purchases are presented in Table 2; hormonal contraceptive purchases were successful for all three women with the differing risk profiles. Despite the seal of approval on the U.S. sites, not one site displayed the prescriber’s credentials or name. Questionnaires were minimal, but most did ask about weight, medication usage, history of high blood pressure, possibility of pregnancy and last pelvic examination. At the sites with a consent, it was required to click byes Q in agreement that the buyer had read and agreed to various statements, such as b Patient Responsibility Statement,Q the bWaiver and Consent Agreement, Q the b Notice of Privacy Policy Q and that ball questions were answered truthfully.Q Yet it was not required to actually view or scroll slowly through these documents in order to check off these boxes and one could just scroll and click rapidly to get to the purchase page. Neither of our higher-risk bpatientsQ received further questions regarding her stated tobacco use or hypertension history, and they did not receive any follow-up questions to verify compliance with blood pressure monitoring. If a prescription label was provided, a specific physician name was often given, but in two cases when we checked the state medical licensing board, the physicians were not listed and did not appear to have a current state license. Another prescription had a New Jersey address for the prescription, but the contraceptives were shipped from Alabama. All packaging appeared legitimate, and products were within the expiration date but patient education materials did not always match the product. For example, an oral contraceptive handout was enclosed with contraceptive patches. One site queried the bmoderate riskQ profile patient with an e-mail stating that the physician needed more information before proceeding. The information required was the most recent blood pressure and if her physician approved of her taking this medication. We did not respond to this e-mail, and the contraceptives were received anyway. Our high-risk profile patient also received an e-mail asking, b Why have you chosen NordetteR?Q The patient’s reply was that it is a low-dose birth control pill and her friends liked the pill. This patient received the pills with that response. The international Web site had absolutely no medical questionnaire or history taken. It took only two clicks to reach the order form, with two more clicks to complete the order. No information about the product side effects was given, and these pills arrived 12 to 14 days later in brown envelopes with handwritten addresses with no return address and a postmark from Greece. These were the least expensive of the contraceptives, costing only $25 per pill package, including shipping. The retail price for similar contraceptives to those we bought over the Internet were quoted by WalgreensR in Seattle, WA, March 2004, as
Table 1 Internet hits using search phrases over time Search phrase
b Buy b Buy b Buy b Buy b Buy
birth control pills Q birth control patchQ YasminQ NordetteQ OrthoevraQ
Number of hits May 5, 2004
November 5, 2004
June 16, 2005
4110 438 25,100 14,200 10,300
11,400 847 58,100 61,100 33,700
797,000 958,000 1,110,000 846,000 1,030,000
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Table 2 Data collected for hormonal contraceptives purchased from different Internet sites Patient profile
Contraceptive purchased
Rx by MD
Consent and side-effect information present
Minutes to purchase
Monthly cost
Days to delivery
Healthy 25-year-old
Patcha YasminRa NordetteRb YasminRc Patcha NordetteRb Patcha Patchd NordetteRb YasminRc
Y Y Y N Y Y Y Y Y N
Y Y Y N Y Y Y Y Y N
3 4 3 2 5 5 5 4 6 3
$74.95 $104.95 $101.00 $25.00 $74.95 $101.00 $74.95 $83.99 $101.00 $25.00
4 7 11 12 10 12 5 2 3 12
Obese 35-year-old smoker 35-year-old smoker on lisinopril for hypertension
a b c d
Purchased from www.pillvault.com. Purchased from www.planetpills.com. Purchased from europeanpills.com. Purchased from www.pillstocker.com.
follows: a package of YasminR was $33.59, NordetteR was $31.49 and Ortho-EvraR was $37.99 for three patches. Three of the Internet sites used for our purchases (Table 2) were dead links at the time of manuscript preparation, but it only took 4 min to find a new site and to purchase patches as the high-risk profile patient from www.pillstocker.com, June 2005. We used this same site at September 2005, and this time, patches were delivered the next day from a Nebraska pharmacy and a bHome Oxygen ServiceQ was listed as the prescribing physician. 4. Discussion Unlike a few years ago, it is now possible to easily purchase estrogen-containing hormonal contraceptives over the Internet if one has a credit card [6]. We were successful for not only a low-risk profile, but also a woman with estrogen contraindications who could easily get these products. Purchasers are not required to actually click links to view any safety information. We could simply scroll down quickly to check these bsafetyQ boxes without having any idea of what the consent or waiver documents actually stated. Some concerns should be raised by the results of our study regarding the ease of the accessibility of hormonal contraceptives over the Internet. Although the higher-risk women were queried sometimes regarding medical history, suggesting that the responses to questionnaires were being read, both of our higher-risk patients were still sent the contraceptives despite their stated risk factors. No site later contacted these women in follow-up to ascertain if any health problems had developed and/or if blood pressure monitoring was performed. The only follow-up contacts were e-mail offers and home phone calls to sell more products. The costs of these contraceptives were significantly more expensive than the costs quoted by a local pharmacy for similar products. However, depending on the insurance coverage for an office visit, the elimination of a visit to the health care provider could be a cost saving for a contraceptive prescription. But what cost should be assigned
to safety? Our cursory study reveals there are no real barriers to the market forces, and efforts to regulate Internet pharmacies are not working [7– 9]. The U.S. Government Accounting Office was also able to obtain many prescription drugs from a variety of Internet pharmacy Web sites, without providing a prescription, and the drugs obtained included those with special safety restrictions, such as highly addictive narcotic painkillers [10]. In comparison to these medications, contraceptives pose much less of a potential risk to the consumer. In 1938, medications were first required to be proven safe and to be labeled for the consumer [11]. But it was not until 1951, with the Durham–Humphrey Amendment, when many medications changed status from being dispensed at the pharmacist’s discretion to being obtainable only by prescription [11]. The only truly essential elements to providing hormonal contraceptives safely are medical history and blood pressure, so is it ethical to b hold women hostage Q and essentially force them to obtain a medical office visit in order to obtain certain types of contraception? Or, should all types of contraception be made available without a prescription, but with regulation of the screening, consent and education for selection of a method? In summary, it is evident that the Internet is rapidly breaking down the safety barriers between prescriber and patient if one has a credit card.
Acknowledgment This work was supported by an NIH grant 1R01HD4242701.
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