GETTING SAFE

If you're a Harvard woman exploring the best way to get safe, dependable and convenient birth control, you're likely to end up at the Harvard University Health Services.

There is no doubt that a visit to UHS for contraceptive counseling can be scary, particularly for students who have never had so much as a gynecological exam.

And going to an appointment at UHS without a clear idea of what you want and what to expect can leave you confused and, on occasion, literally sick to your stomach.

One sophomore woman, who spoke on condition of anonymity, says not having a clear idea about birth control and her needs caused her a month's worth of pain and agony.

The woman says she first went to UHS when she "woke up sick in the middle of the night, vomiting."

Although she's sure now that her nausea was not caused by birth control, she received a new prescription from a nurse practitioner, who was concerned that the pill might have been making her sick.

Instead, her new pill made her moody and sad. "I though I was crazy because I cried all month," she says now.

The sophomore says the worst part of that visit was that the nurse practitioner pressured her into taking a pregnancy test, which she found embarrassing and inappropriate.

Although she knew she wasn't pregnant, the sophomore says she did not have the strength or the know-how to counter the advice of a health professional.

The nurse practitioner changed her prescription one more time before the student went home.

"When I went home my doctor said she couldn't believe they changed my prescription," the sophomore says. "She said what [UHS] had done was wrong."

Since that first traumatic experience, the sophomore woman has learned more about contraception, and her experiences with the health service have been better.

Like many doctors and nurses, she now believes that Harvard's student health service is pretty good at providing birth control.

"My impression is that it's actually one of the things they do best," says Melissa Bender '94, who is a counselor with Peer Contraceptives Counseling.

The trick, however, is knowing how to approach a health service that, as numerous students and doctors alleged in a Crimson series last spring, severely restricts student access to doctors.

Getting the right birth control ultimately means asking the right person the right questions.

"The critical issue [in getting birth control] is whether a woman can make an appointment with someone who has the time to talk about all the issues," says Dr. Peter J. Zuromskis '66, former director of UHS' urgent care clinic.

One first-year woman, who also had a prescription for the pill from home, says she got a quick appointment and thorough advice--as well as a pill prescription she calls "an improvement" over her old one--at UHS.

"I haven't had any problems at all," she says.

A Women's Issue

The search for a personalized method of dependable and safe birth control has been a top women's issue since Margaret Sanger, the founder of the Planned Parent-hood movement, crusaded for the legalizations of contraceptives in the early 20th century.

The advent of the pill 30 years ago greatly reduced the risk of pregnancy and made sex more convenient.

For college students, this question is particularly confusing because this is often their first experience with birth control.

"[Contraceptives are] a significant part of what we do," says Chief of Medicine at UHS Dr. Charles H. Weingarten. "[The] clinicians are comfortable with what we do."

Making an Appointment

If a Harvard woman is thinking about using birth control and would like to speak to a professional, she should make an appointment to see a UHS primary care physician, says Andrea Chapin, a nurse practitioner at the health service.

Depending on the problem or concern, a student can make an appointment to see a gynecologist, a nurse practitioner or a physician who specializes in internal medicine, according to UHS nurse practitioner Susan Bowman.

Most people who make appointments to discuss birth control are women, the nurse practitioner says. Several men come in and about 5 to 10 percent of Bowman's patients come as couples.

During the visit, Bowman says she asks a woman about her sexual history, any past methods of birth control and the type of relationship she is in. This provides a "baseline exam so that everyone knows where you're coming from," says Dr. Harris Faigel '56, the director of the Brandies student health service and treasurer of the New England College Health Association.

Even those students with a birth control prescription written by a doctor out-of-state may need to stop by UHS because local pharmacies don't usually honor such prescriptions.

But Weingarten says that if you bring in a medical record, prescription notice or container, UHS can renew your prescription without an exam.

If a student has not previously had a gynecological exam, she will be given one to determine which type of contraceptive is best. The exam includes a pap smear, tests of her cholesterol level and blood pressure, and questions about family histories of breast cancer or diabetes, Faigel says.

The Pill and Its Side Effects

Clinicians at UHS can prescribe most FDA-approved types of birth control.

Bowman says she advises students that their choices are abstinence, the condom or the condom with vaginal spermicides, the diaphragm, the pill or depo-provera, a hormone administered by injection.

Though UHS does not prescribe the IUD or Norplant, Bowman can refer students to hospitals which can insert them.

The most common form of contraception which students use is the condom, followed by the pill, Bowman says. The pill--a daily oral contraceptive made of cycles of cycles of hormones which prevents ovulation--is the number one prescribed form of birth control, Bowman says.

The most common concerns about the pill are its side effects, the nurse practitioner adds. Woman are concerned with weight gain, bloating moodiness, changes in their body and long-term fertility problems as a result of the pill.

But most side effects are not serious, and there is no evidence of the pill causing longterm fertility problems, says Bowman. Also, women should not be concerned about consuming high doses of hormones, since the levels in the pill are "very low," Bender says.

The most common side-effect is break-through bleeding, or spotting between periods, according to Alice Verhoven, director of the Planned Parenthood clinic. Adjusting estrongen levels, however, often relieves this.

"There's a certain amount of being disconcerted when you find out that oral contraceptives are not like popping aspirin," says Faigel, who adds that reactions to the pill vary according to the individual.

"The [current] pills are so remarkably successful, both effective and without a great systemic reaction," adds Dr. Norman Spack, a private physician in Newton and a national expert on college health issues.

Some women fear that switching pills is unsafe, but doctors say there is no cause for concern. "There's nothing unsafe about switching pills," says Spack. "Women should be on the lowest strength pill that works."

In fact, the pill has many benefits, according to Chapin. It protects from ovarian and endometrial cancer and regulates the menstrual cycle, decreasing both cramps and flow. And the pill can sometimes improve acne.

UHS is fastest

If rapid access is a concern, seeing a UHS clinician is easier than going to an outside gynecologist.

While it takes six to seven weeks to see a gynecologist in the Boston area, two to three weeks is the standard wait in student health services, Faigel says.

"[We] see students who are in the beginning of an intimate relationship and they want [birth control] right now," Faigel says.

According to Weingarten, the UHS director of medicine, the health service's fastest exam, performed by a nurse practitioner, will require a wait of one to two weeks.

Though some women might rather speak with a gynecologist, a nurse practitioner is "a terrific way to deal with a large facility [like UHS]," Faigel says.

Appointments can be made more quickly if you already have a primary care physician or if there is an urgent problem, he adds.

In the event of an emergency such as suspected pregnancy, Bowman says a woman can go to the Urgent Care Clinic in the UHS basement and get a "morning after" pill, a high dose of estrogen which induces bleeding. That pill's effectiveness is maximized if used within the first 24 hours sex, and it becomes ineffective at preventing pregnancy after three days.

Peer Groups

Faigel says students seeking contraception will find their college health care system friendlier if they have a peer group to walk them through it.

Bender says peer counseling offered by PCC allows students to talk to someone "less threatening than a nurse practitioner." And if a woman has never had a gynecological exam, PCC counselors can demystify the procedure.

When advising a female student about contraceptives, Bender says PCC counselors first establish how comfortable a woman is with her body and how appropriate a method like the sponge or diaphragm--which both require insertion--would be.

The bottom line for many students, though, is that a condom and foam are safe, cheap and require no contact with the medical profession, Bender says.

PCC counselors can refer people to clinicians at UHS. Bender says the counselors can recommend a physician on the basis of sex or according to the student's medical problem.

Another Option: Planned Parenthood

If students are not covered by the Blue Cross/Blue Shield policy provided by Harvard and are looking for a cheap clinic, PCC counselors sometimes will refer them to Planned parenthood.

Verhoven, the director of the Brookline Planned Parenthood clinic, says that while "we don't see many Harvard student," a Planned Parenthood clinic has certain benefits for college-age women.

All Planned Parenthood clinicians are women certified to prescribe or administer all FDA-approved contraceptives on the premises, Verhoven says. UHS, in contrast, does not insert the IUD or Norplant.

Another benefit of Planned Parenthood is that all of its clinics nationwide share patient information. "You don't have to reestablish yourself as a patient," Verhoven says.

The wait for an appointment at a Planned Parenthood clinic is about the same as UHS and emergency appointments for the "morning after" pill are also available.

Still, a visit to a Planned Parenthood--complete with tests and three packets of pills--costs $70, and UHS insurance won't pay for it. A visit to UHS is free as long as you've paid the annual student health fee of about $600.

Some Tips

Most of the clinicians interviewed say there is only one absolutely effective method of birth control: abstinence.

And they warn that those who use only the pill are not protected from sexually transmitted diseases.

Beyond that, four important tips emerge from interviews with doctors and nurses for getting the birth control you want form UHS, when you want it.

Establish a relationship with a primary care physician or nurse practitioner now, whether or not you are on the pill or have a problem. Doctors and health experts say a close relationship with one health care provider is important for all your health needs, including birth control.

"You have to have a good relationship with your [primary care provider] so the two of you can figure out what you should be taking," says the sophomore who spoke on condition of anonymity. "It's not the kind of thing you do and see what happens because it's very serious for your body."

Whether or not have a primary-care provider, be insistent when calling for an appointment to discuss contraceptives.

"I've heard of people waiting for up to a month" for a routine gynecological exam, says Bender, the PCC counselor. If "[you can convey that you have a pressing reason when you call UHS, they will usually try and squeeze you in sooner."

Be especially careful during the first month on the pill. The pill does not become fully effective until a patient has been taking it for one month, and Faigel warns women to use another form of birth control during their fist month on the pill.

"Be careful [about birth control methods], they're not 100 percent effective," says Faigel. "Get all the information, otherwise you might be surprised."

Be firm with your health care provider. If the pill is what you want, communicate that. According to Bowman, most women who come into UHS with an agenda walk out with the pill.

"Be firm about what you want," says the sophomore who submitted to a pregnancy test she did not want during her first UHS visit. "If you feel you know what you want, be firm."