The Pill- Same pill, different culture (Based on an article I wrote for Marie Claire Magazine)
In the 1960’s a drug induced social revolution was born - not out of mind-expanding psychedelics but rather a pill that within five years, more than six million women would make part of their daily lives. Only a decade earlier these same women would not have believed that a pill you could take like aspirin would prevent pregnancy.
Herstory-How was the pill developed?
In 1950, when laws criminalizing the sale of any kind of contraceptive were still in place, the Planned Parenthood Federation of America invited a biologist, Dr Gregory Pincus, to develop a contraceptive that would be “harmless, entirely reliable, simple, practical, universally applicable and aesthetically satisfactory.”
In 1954, Pincus joined forces with a clinical doctor, Dr John Rock, to test the drug. Rock and Pincus begin the first human trials (under the guise of a fertility study) with 50 women in Massachusetts, ironically a state with extremely restrictive anti-birth control laws. The drug company Searle provided the pills for the trial and knowing that the pill would be controversial, Pincus pursuaded Rock to use the regimen most likely to be viewed as a natural process rather than “something that interferes with the normal menstrual cycle”. The regimen that was established of administering progesterone for 21 days, followed by a seven-day break to allow for menstruation, is still most commonly used today.
After positive results from tests conducted in Central America, the first commercial contraceptive pill, Enovid-10 was introduced in the United States and by 1964 the pill became the most popular form of reversible birth control. If taken as directed it was 99 percent effective making it the most efficient form of contraception besides sterilization.
By the late 80’s the pill dominated the market to such an extent that many women equated the use of birth control with the use of the pill and an estimated eighty percent of all American women born since 1945 had taken the Pill. In 1990 the annual FDA Consumer report stated that the Pill was considered safe and effective by the government, medical establishment and public.
Despite initial controversy, millions of women found the pill enormously liberating. It allowed them to pursue careers as never before, fuelled the feminist and pro-choice movements and encouraged more open attitudes towards sex. As Loretta McLaughlin recalls in the PBS documentary “The Pill”; “Women became lawyers because law firms no longer had to worry that the woman was going to get pregnant in the middle of a big case. Women became doctors because they could space their children so that they had time to do the internships and the residencies. Women went to work.” You cannot understand modern women's history without thinking about what the Pill did for women and also what the Pill did to women.
How does the pill work?
There are two basic types of contraceptive pill the combination pill and progestin-only pill.
The combined pill, which contains both estrogen and progestin, fools your body into thinking that you are already pregnant and therefore no eggs are released. The cervical mucus, which acts as a barrier to sperm is also thickened and the womb lining made thinner making it less suitable for a fertilised egg to implant in.
Your normal menstrual cycle will stop, but because the pill is being taken for 21 days and then given a 7 day break (during which placebo pills are taken), you experience hormonal withdrawal bleeds which are usually lighter than normal periods.
The progestin only pill or so-called mini pill contains no oestrogen at all. It must be taken at the same time each day even during periods, and preferably no less than three hours before intercourse as it takes two hours for the pill to affect the cervical mucus. It is suitable for older women, smokers and those who are sensitive to oestrogen or are breast-feeding.
Unlike the combined pill, the P.O.P does not stop ovulation but works by thickening the cervical mucus to prevent sperm from reaching the egg and making the lining of the uterus less receptive to implantation should an egg become fertilised. If taken properly it is slightly less effective than the combination pill. It may also decrease the risk of endometrial cancer and does not increase the risk of heart disease such as blood clots.
How safe is the pill really?
Fears about blood clots, heart attack, and stroke, which spurred exhaustive research on oral contraceptives in the '60s and '70s, have largely been laid to rest by the safer, low-dose birth control pills on the market today. Current research suggests that healthy, non-smoking women are at no greater risk of these serious health problems than women not on the pill.
When it comes to the pill’s link with cancer, questions still remain. Certain studies support the hypothesis that the risk of breast cancer increases with the use of the pill but other studies have found no significant increase. No cause-effect relationship has been found between the pill and cervical cancer.
Johannesburg gynaecologist, Dr Jeremy Baker believes “the benefits of the pill still far outweigh the risks especially when it comes to unwanted pregnancies and protection against ovarian cancer.” The pill has also been found to prevent cancer of the ovaries and the endometrium (the lining of the uterus).
The newer generation of birth control pills have lowered oestrogen levels and varied types of progesterones in an effort to improve their safety. Even the risk of a heart attack from current oral contraceptives is still regarded as very slight, adding 25 more heart attacks in 100 000.
Dr Greg Christophers, a renowned gynaecologist, believes that we should evaluate possible risks against those of an unwanted pregnancy. ”It’s essential for prospective candidates to be thoroughly screened to exclude any existing conditions, which may preclude its use” says Dr Christophers. It is essential for doctors to point out the possible contra-indications and side effects even though “the majority are not fatal and the two biggest risks are clotting and stroke -particularly in severe migraine sufferers.”
The Pill + smoking = a deadly combination
Disturbingly, the number of young South African women who smoke has increased in the last decade. As safe as today’s pill is for most healthy non-smokers, the Pill plus smoking places you in a high risk category for heart attacks. If you smoke about 25 cigarettes a day you increase your risk by between 4 and 30 times and the cumulative effect of the smoking plus the pill makes the singular side effect of the pill pale in comparison.
The American Heart Association’s views on oral contraceptives make the point clearly: “If you don’t smoke and don’t have high blood pressure or other risk factors for heart disease, a low-dose oral contraceptive can be used. If you want to use the Pill, or if you are already using it, don’t smoke, whatever your age”.
The Pill and menopause
Seeing that menopause occurs when our eggs are ‘finished’ it seems logical to think that taking a substance that prevents the supply from being used up may affect the onset of menopause. However, Dr Jeremy Baker believes that this is not the case because “the onset of menopause is dictated by our genes and not by interrupting ovulation.” He adds that even when women are taking the pill their ovaries are nevertheless active and there is still egg development but not ovulation. In his opinion, the use of the pill does not significantly affect menopause.
Dr Christophers adds that “In a smoker over 35 her chances of cardio vascular disease increase- so you would generally want to stop her taking the pill but if there are no such reasons a woman could continue to take the pill up till the menopause and then go onto hormone replacement therapy.”
This is supported by a recommendation by an FDA advisory committee to raise the upper age limit of 40 for healthy, non- smoking women.
Should we all be using condoms?
Almost every article we read about the pill reminds us that it does not protect us against sexually transmitted disease and that we should be using a condom along with the pill as a safeguard. In reality however, women who are already taking contraceptive responsibility by being on the pill, do not always want the addded hassle of using condoms. Conversely using condoms alone does not provide sufficient protection against pregnancy. As Dr Jeremy Baker observes, condoms are certainly useful in reducing the risk of HIV/AIDS and other sexually transmitted diseases, but he does not believe they are an effective method of birth control.
In the United States, where pharmaceutical manufacturers had reduced their involvement in contraceptive research because of the threat of lawsuits (and their substantial costs), the HIV crisis has sparked renewed interest in the development of contraceptives that will provide dual protection against pregnancy and STIs.
The next generation - Where are we today ?
Since the pill first became available our needs and expectations have inevitably changed. One such aspect revolves around our perceptions of amenorrhoea- the absence of menstruation. Surveys in the 1970’s and 80’s suggested that women preferred having regular periods because they reassured them of their ‘normality, femininity and the fact that they were not pregnant’. Manufacturers tailored their product around this sensitivity and built a ‘period’ (actually withdrawal bleeding) into the pill-taking regimen.
When taking the combined pill, women do not ovulate and therefore do not build up a thicker uterine lining which needs to be shed along with an unfertilised egg-the purpose of a real menstrual period. The monthly bleeding women on the Pill experience is therefore not a real "menstrual period," but actually a "withdrawal bleed" induced by the withdrawal of synthetic hormones during the Pill-free or placebo week.
In recent years, several reports indicate that women would be glad to have fewer periods. A Netherlands study showed that 31% of women aged between 25 and 34 would prefer to not menstruate at all and in Scotland and South Africa, more than 60% of women were willing to consider a method of contraception that would stop their periods.
These statistics show that women’s attitudes to amenorrhoea are changing. In Western Europe, women are actively avoiding bleeding, and increasing numbers of women manipulate use of the combined pill in order to do so. As Doctor Christophers explains, this involves eliminating the artificially created pill-period; “All it takes is 7 active tablets to suppress ovulation. By tricycling contraceptives you can take away the breakthrough bleeding, which is actually withdrawal bleeding and not a real period anyway.”
Seasonale ®, manufactured by Barr Laboratories, is touted as ‘the low period pill’ but essentially uses the same components as traditional oestrogen and progestin based contraceptive pills. Its major difference lies in the fact that it is taken for 12 weeks (84 days) and then followed by seven days of placebo pills, so it offers four periods a year compared to 13 with traditional oral contraceptives. It gives official FDA endorsement to a regimen that many doctors have been prescribing for years using traditional birth control pills and latches on to the acceptance of the menstruation as no longer inevitable.
Dr David Grimes, a reproductive expert and vice president of biomedical affairs for Family Health International, a non-profit organisation in North Carolina, USA says there's no reason to fear any risk of gynaecologic cancer or threat to fertility from Seasonale, based on what is known about oral contraceptives. If there is an element of fear it revolves around the idea that if we do not menstruate “it isn’t natural”, however regular menstruation is in fact a modern phenomenon and in the past women spent much of the time either pregnant or breastfeeding and having far fewer periods.
Dr William Parker, a California gynaecologist at Santa Monica-UCLA Medical Center says some women worry that it's unnatural not to have a monthly period because they think toxins will build up in the uterine lining, which is sloughed off during menstruation. Actually, he says, the progestin in the pill thins out the lining, so the toxin fear is unfounded. He says that a similar regimen has been used for years, with no ill effects, in patients with endometriosis - a condition in which uterine tissue grows outside the womb.
Unlike with early contraceptive trials, nowadays, women’s health advocates and potential users are involved in contraceptive research and development, helping to identify the needs and views of consumers and guide the studies accordingly. While the pill is today considered to be safe and effective, the search continues for improvements such as an estrogen free oral contraceptive without the side effects of progestin only pills. Contraception remains a personal, social, cultural and political issue and the developments around the pill will continue to reflect these dimensions.
Marina Green 2005