Some of the most important-and most controversial-health headlines of 2000 have come in the realm of women’s reproduction. Here’s a review-and in some cases a preview-of four developments to keep an eye on.
1. Birth control insurance coverage
Just this month, a federal agency gave support to what many women have been saying for years-that it amounts to discrimination for many health insurance plans to exclude birth control pills from coverage.
If a plan covers prescription drugs and devices, it also must cover contraception-related drugs and devices, the Equal Employment Opportunity Commission decided.
The ruling directly affects only the two women whose complaint about their employer came before the commission. But it could have far greater influence.
About half of large-group insurance plans do not routinely cover any contraceptive, according to a 1994 Alan Guttmacher Institute survey. About 66 percent of plans that cover prescription drugs do not routinely cover oral contraceptives.
Such companies are now on notice to change their plans to conform to the ruling, said Marcia Greenberger, co-president of the National Women’s Law Center, which led a coalition of 60 groups that had asked the EEOC for a decision on this issue before the complaint was filed. “We believe this should serve as a wakeup call to employers,” Greenberger said. If they don’t change their policies, the ruling could provide ammunition for lawsuits.
To exclude a class of drugs used only by women, the ruling said, constitutes unlawful sex discrimination under Title VII of the Civil Rights Act of 1964.
The Pregnancy Discrimination Act of 1978, an amendment to Title VII, specifically prohibits discrimination on the basis of pregnancy, childbirth or related medical conditions.
2. The abortion pill’s distribution
In September, the Food and Drug Administration approved the abortion pill mifepristone, giving women seeking abortions the option of doing so with a drug instead of surgery. Distribution of the pill to several clinics began Nov. 20, said Vicki Saporta, executive director of the National Abortion Federation.
“About 100 facilities across the U.S. are offering it, and more are being added every day,” Saporta said.
In the months since the drug’s approval, opposition to it has continued. Rep. Tom Coburn, an Oklahoma Republican who did not run for re-election in November, introduced a bill that would limit who could prescribe mifepristone. One proposed restriction would require that doctors who prescribe the drug be trained to perform surgical abortions, in case the pill fails. The FDA had considered this contingency before approving mifepristone but decided against it.
If such a bill passes, some abortion rights supporters worry that George W. Bush, whose father banned mifepristone’s import for personal use in 1989 while president, would sign it.
Bush spokesman Bob Hopkins said it was premature to say whether Bush would support a particular piece of legislation. “President Bush would look favorably on regulation that protects the safety of women,” he said.
Abortion rights supporters hope not to have to find out. “The question is whether we can defeat the bill in Congress before it gets to the president’s desk,” Saporta said.
Bush also could appoint an FDA commissioner who would ask for a review and halt distribution, said Julie Piscitelli, communications director of the National Abortion and Reproductive Rights Action League. But during the first presidential debate, Bush said he did not think a president could overturn an FDA ruling.
Eleanor Smeal, president of the Feminist Majority Foundation, doubts that he would try. “It has such support, it is rolling out–it would be unprecedented,” she said.
The FDA action came after 12 years of skirmishing between abortion rights supporters and opponents over the drug’s availability in this country.
“This was a fast-tracked FDA approval,” said Nora O’Callaghan, director of the Respect Life Office in the Archdiocese of Chicago. “Even though the pro-choice people were saying, `It’s taking too long,’ it was much more quickly approved than usual. Some of the long-term effects have not been studied.”
Mifepristone, also known as RU-486, induces miscarriage in early pregnancy. It is administered in a doctor’s office, then followed up two days later with another drug given under medical supervision that causes uterine contractions.
3. AMA support for the morning-after pill
The American Medical Association early this month approved a resolution asking the government to consider making emergency contraception available over the counter, instead of by prescription, which is the case now.
Before the AMA resolution, over-the-counter status had advocates, but none so influential as the members of that medical organization. The Planned Parenthood Federation of America, for instance, has been a longtime backer, estimating that widespread use of emergency contraception could prevent 1.7 million unintended pregnancies and 800,000 abortions a year.
Emergency contraception is the use of hormones, generally two doses of oral contraceptives, within three days of unprotected intercourse. The pills prevent ovulation or, if fertilization has occurred, prevent the egg from implanting in the uterine wall.
They do not work more than three days after sex, which is the crux of the AMA’s support for over-the-counter status. If the pills are not available over the counter, a report by the AMA’s Council on Medical Service suggested, women might not be able to get them in time.
The AMA’s policy-making House of Delegates passed the recommendation without discussion during a convention in Orlando.
Although the morning-after pill is different from the abortion pill mifepristone, some abortion opponents consider it to be a form of abortion, because the egg already may be fertilized.
“Anything that happens post-fertilization is abortifacient,” said Dr. Eugene Diamond, clinical professor of pediatrics at Loyola University’s Stritch School of Medicine and medical director of Birthright of Chicago.
The AMA’s action runs counter to its traditional insistence that serious drugs be given only under the supervision of a physician, Diamond said. A woman who takes morning-after pills without knowing that she was already pregnant before this instance of unprotected intercourse runs the risk of bearing a child with congenital anomalies, he said, particularly heart defects.
Supporters of emergency contraception say it is not a form of abortion, because it does not work once a fertilized egg has already implanted in the uterus, the commonly accepted scientific definition of pregnancy.
The AMA’s support is important, said Gloria Feldt, president of the Planned Parenthood Federation of America, but she does not expect emergency contraception to be available without a prescription soon.
“The FDA is currently asking for input,” she said. “After they receive it, their scientific process moves fairly slowly. You’re looking at a year, two years, three years.”
4. Prozac for extreme premenstrual distress
The FDA in July approved the use of the antidepressant Prozac to treat an extreme form of premenstrual syndrome called Premenstrual Dysphoric Disorder.
“PMDD is considered a much more severe form of PMS, enough that there are both physical and mental aspects–enough to interfere with a woman’s life,” said Dr. Melvin Gerbie, chief of gynecology at Northwestern University Medical School and Northwestern Memorial Hospital.
Women with PMDD suffer extreme and incapacitating mood swings, depression, anxiety, sadness or anger in the one to two weeks before menstruation. It affects 3 to 5 percent of childbearing-age women, or 3 million American women.
Researchers are not sure exactly why these symptoms become so severe in some women, said Dr. David Cohen, assistant professor of reproductive endocrinology and infertility at the University of Chicago Hospitals. The physical aspects are joined by variations in how different women experience and report symptoms, he said.
“There are so many causes and components–cultural issues, dietary issues, activity levels that change between people. It all comes together in a specific person with a specific personality and background,” he said.
“And there is clearly a psychiatric component,” he said. “It doesn’t mean you’re crazy; it just means we don’t understand it.”
The female hormones that fluctuate during the menstrual cycle affect levels of serotonin, a chemical that transmits signals between nerve cells in the brain and affects emotions.
Fluoxetine, the chemical name for Prozac, is part of a class of drugs called selective serotonin re-uptake inhibitors. They block that transmission by preventing brain cells from reabsorbing the serotonin, leaving serotonin lingering in the synapses between cells.
Prozac was found to relieve severe PMS years ago, Gerbie said. But many women were reluctant to take a drug intended for depression.
“Women don’t want to feel, `I have a mental problem; I have to take this medication that other people take for depression; my friends think I’m crazy,'” he said.
Prozac’s maker, Eli Lilly and Co., has renamed it Sarafem to differentiate its purpose from treatment of depression, but the formulation is no different.
Gerbie said he feels obligated to tell patients that the medicine is Prozac.
Lilly recommends that patients take the drug daily, but Gerbie said doctors are experimenting with limiting dosages to the times the symptoms are felt. Patients prefer to take it less often because of side effects, which can include loss of libido, nausea, tiredness, nervousness, dizziness and difficulty concentrating.
