The Pill: An Education
Justus von Liebig, a nineteenth-century German scientist, popularized the idea that growing healthy crops required just three chemicals in the soil: nitrogen, phosphorous, and potassium. Contemporary science solves the complex process of plant growth: We’re good here!
Reading about von Liebig’s theories made me think, Wow, this feels like the same development process hormonal birth control probably went through. Give women ethinyl estradiol and some form of progestin and…contemporary science solves the complex process of menstruation: We’re good here!
Hormonal contraception is on my mind a lot these days—I started taking a version of it this year for the first time in decades. I have mixed feelings. On the one hand, I try to fix or at least ameliorate any health concerns with changes in food or exercise (and by “health concerns” here I mean things like feeling unusually tired or having back pain, not breaking an arm). On the other hand, even my most intense food/exercise changes were alarmingly ineffective when it came to my battle with chronic hives.
And on both hands, women historically have been fucked over when it comes to medicine made only for “female problems.” Birth-control pills are not entirely an exception there. I certainly had my share of truly awful experiences with them in my twenties. And that was before I knew how they were developed and what the research is like on their non-contraceptive effects (minimal).
Still, these days I’m taking Lo Loestrin (nickname: Lolo), an ultra-low-dose combination pill, to alleviate perimenopause symptoms. It was a big deal for me personally to give hormonal contraception another shot, and it took having violently itching bumps for months on end to convince me to do it.
Even now I have questions. Like, Lolo gives me a low dose of the estrogen ethinyl estradiol, but why is a low dose better than a medium dose? My first instinct with medication is always to take the smallest effective amount. But hormones don’t necessarily follow that logic, and there isn’t a ton of guidance about which meds will work best for which person…or even why there are different dosages. They all work as effective contraceptives, after all, so after that you’re at the mercy of your doctor’s competence/interest/awareness.
My life on Lolo led me to take a deep dive into hormonal contraception’s history, current state, and potential for helping people through perimenopause. I learned things I probably should have known years earlier. The birth-control pill (and sibling treatments, like the NuvaRing) has given us the remarkable benefit of reliable contraception—but that’s not all it can do.
Especially as we head into what looks like a total shitshow of right-wing efforts to reduce or eliminate access to hormone-based contraception, each of us should take some time to understand the history, impact, and future of these drugs. Even if you’ve never taken them. Even if you never plan to take them.
When I gave up on using hormonal birth control twenty years ago, I stopped paying much attention to hormone-based contraception. Not that I’d ever paid a lot of attention to it? I didn’t grow up in a family that vilified birth control, and by the time I was interested in BCP (the birth-control pill), it had already been in regular use for forty years. So I never spent a lot of time thinking about what an incredible effect BCP has had on women’s progress over those decades—or what other uses it might have beyond contraception. I was privileged enough not to have to care and I, like millions of other people, am often bad at being aware of stuff that doesn’t directly affect me.
A Complicated History for a Revolutionary Product
The first hormonal contraceptive pill was approved in the U.S. in 1960, branded as Enovid, and contained 10,000 micrograms of a progestin (norethynodrel) paired with 150 micrograms of an estrogen (mestranol). From what I’ve read, its creators figured they’d err on the side of a bigger hormone dose rather than determine what the smallest effective dose was. To give you an idea of where we are now, my Lolo contains 1,000 micrograms of a progestin (norethindrone acetate) paired with 10 micrograms of an estrogen (ethinyl estradiol). I think my reaction to hearing the difference in these dosages was, “YIKES.”
(I should note here that Lolo and Enovid use different estrogens and progestins and the amounts aren’t exactly comparable…but it’s still fair to say that the amount of hormones in each dose of any BCP is significantly lower these days.)
The development story of oral hormonal contraceptives is troubling; it involves a horrifying disregard for consent from study participants, an arrogant and patronizing dismissal of side effects women reported, and an elitist disinterest in the human costs of drug trials. If you want to read more, the history has been covered by The Harvard Crimson, The Washington Post, and Planned Parenthood (a laudable but imperfect organization that is still contending with founder and early birth-control advocate Margaret Sanger’s racism and ties to eugenics). I understand that it’s tempting to paint the original BCP creators as brave and ethical. But often our world is gray murk, sadly.
For all the medical missteps its creators made, however, The Pill (as it’s been called practically since its inception) has provided significant force in pushing forward women’s independence, autonomy, and liberation—in those terms, it’s a triumph in the same vein as the nineteenth amendment. It’s become part of the women’s health landscape and, until recently, I assumed it (or some form of it) always would be. Now, with reproductive rights under attack every minute these days, that assumption may prove to be upsettingly incorrect.
The Pill’s Evolution and How It Works (and Which Ones I’ve Tried)
In their first twenty years or so on the U.S. market, birth-control pills were monophasic, meaning every pill had the same dose; the composition included both a progestin and an estrogen, with the exception of a week of non-active pills. These inactive pills were put into the package as a sort of psychological thing, I’ve gathered.
You don’t actually ovulate when you take hormonal contraceptives that contain both an estrogen and a progestin, so during that week of inactive pills you’re just bleeding a little bit as your body adjusts to a sudden cessation of hormones. Again: No menstruation is involved. The inactive-pill week was conceived as a way to make BCP feel less “unnatural.” And, according to many sources, it’s medically unnecessary. I haven’t had any bleeding at all since my second month of continuous Lolo. I skip any pill that doesn’t contain exactly the same hormone composition and it’s amazing; getting that regular and unchanging dose appears to make a huge difference with the perimenopause-induced hives.
In the 1980s, motivated in part by a desire to reduce the overall hormone dosage levels, scientists came up with mulitphasic BCP options, which they thought might also more effectively mimic a typical menstrual cycle.
The first BCP I ever tried was Ortho Tri-Cyclen, a triphasic pill (meaning in each pack there are three different types of pills with different dosages, plus that inactive-pill week). It gave me acne so severe it distorted the shape of my face; ultra-bleak depression of a sort I’d never before experienced (which was, I found later after kids, very similar to postpartum depression); and inescapable nocturnal vomiting sessions around 2 a.m. For months.
Next, I tried a monophasic pill (Alesse, since discontinued), followed by a different monophasic pill (Yaz), and both times experienced weight gain, depression, and a complete lack of interest in sex. Which, since I was mostly taking the pills as contraceptives, seemed hilariously ironic in the Alanis Morissette sense.
After the Yaz, I was done. I decided fucking around with my hormones was Not For Me. I turned instead to condoms, which have the additional benefit of STD protection and are a lot harder to forget than taking a pill at the same time every day is.
Periodically I would consider things like a copper IUD and then be terrified by the stories of people subjected to painkiller-free insertion (while being shamed for wanting a painkiller during an invasive operation involving something pushed up into the cervix), only to have the IUD take a little unscheduled walkabout inside their reproductive organs later.
I thought I’d made peace with living a life absent artificial hormones. Then, well, the hives.
Three BCP Side Notes Before the Next Tangent:
1) I learned when I started Lolo that part of the reason side effects are so pronounced in the first couple of months on BCP is because you’re basically doubling up on hormones. The ones your body’s already producing with its menstrual cycles and the ones you’re introducing via pill. Eventually your own cycle-related hormones are suppressed and you rely on the ones from the pills. Until then…not great. I wish someone had explained this to me earlier. It would have aided me emotionally in getting through the initial adjustment period.
2) Hormonal contraception, generally speaking (there’s the mini-pill and others that are progestins only and don’t always operate quiiiiite this way), works by halting ovulation. It doesn’t, as popular mythology would have it, convince your body you’re “already pregnant.” You are not busily building up a home for an embryo. You just aren’t getting the signals to ovulate anymore. Your body is sort of arrested at a specific point of the menstrual cycle and continues to get the same hormones that tell it, “We’re cool. We don’t need to stimulate the production of more or different hormones. Shhhhhh, steady on, all good.”
3) Anyone who’s said, “It’s just water retention!” when you tell them you’ve gained weight on BCP is full of bullshit. Per a 2002 study in Fertility and Sterility, the journal of the American Society for Reproductive Medicine, different progestins were developed over the years in part to help BCP users avoid “cosmetic effects related to androgenicity,” which is a way of saying, “the older progestins gave people acne, made them put on fat, and sometimes led to extra hair growth in unexpected places.” It turns out that when you deal with those side effects, you might not take your BCP as directed. Drug makers wanted people to keep taking the drugs, of course, so they cast about for progestins with fewer “cosmetic side effects.” The earlier progestins (one of which Lolo still uses, I was kinda bummed to discover) also can alter lipid and carbohydrate metabolism, according to multiple studies. Which, ominous.
The Part Where I Suggest You Explore Your (Hormonal) Options
So, anyway, maybe you, too, dismissed The Pill from your life once you passed thirty-five or were done having kids (post-kids vasectomies are A+++). Maybe you tried one or two methods of BCP in your twenties, had a bad experience, and figured something else was an easier way to go.
But now, maybe, your hormones are on a terrifying journey into the unknown and you’d like them to just calm the fuck down. You don’t need to replace them yet with hormone-replacement therapy (HRT) so much as get them to regulate themselves. I, for one, do not need to add more estrogen into the mix at this point.
Consider talking to your OB or GP. See what your personal options are if you’re struggling with perimenopausal symptoms (the BCP dosage is lower and the online support, if nothing else, is better these days). I’ve been surprised at the number of postmenopausal people who said they started low-dose BCP in their forties then moved into HRT and had an easier time of it than they might have otherwise.
Ideally, your OB or GP would bring this up to you if you mentioned perimenopausal symptoms (ideally those medical professionals would bring up perimenopause to you proactively!) and go over your individual risks and potential rewards. Because there are risks, and you ought to be made well aware of them.
I wish there was better public education about hormonal contraception. It can and does do so much more than simply enable penis-in-vagina sex without fear of pregnancy. It’s used to treat a variety of conditions, including but not limited to: polycystic ovarian syndrome, painful menstruation, premenstrual dysphoric disorder, and perimenopause. It’s often the first recommended course of action in those cases.
Given that, it's frustrating that there are still an unsettling number of unknowns about these drugs—potentially significant ones, like the recent study published in Behavioural Brain Research that found certain birth-control pills may negatively affect women’s ability to process stress. A review of sixty years’ worth of studies on brain effects of hormonal contraception, published in Frontiers in Neuroendocrinology last year, concluded that brain changes from these drugs have been well documented and “many questions remain and more studies are needed.”
To improve female reproductive-system health, if nothing else, we ought to put more effort into making these types of hormonal treatments safe and effective and put less effort into demonizing and attacking them.
A Quick Detour: The Infuriating Anti-BCP World (or: I’m Shoehorning This Section in, Sorry)
There’s a growing number of people in the wellness space who are trying to seed distrust of BCP, citing health concerns that aren’t always justified (though some, of course, certainly are). If you’re getting medical advice from a wellness influencer, see if you can figure out where their funding comes from and what their agenda is. Look, I’ve worked in healthcare-research jobs, and I know the safety records of drugmakers are far from spotless. Like any drug, BCP will cause side effects. Hormonal contraceptives are not a high priority for further development and improvement. And there’s financial shareholder pressure on drugmakers, which can lead to, well, the situation Boeing finds itself in: all quantity no quality.
But if you’re truly committed to living a medication-free lifestyle, don’t refuse to consider BCP and then embrace a substance sold online that the FDA has never seen and that has zero clinical trials recorded in any respected medical journal. Be safe with your body in a consistent way. If you’re super cautious about pharmaceuticals, be equally cautious about shit you buy from the internet. And, just as you must advocate for yourself at the doctor’s office and urge lawmakers to prioritize reproductive-health issues, you should also question what an influencer or company has to gain from criticizing one product as they promote another.
And in a different corner of our burgeoning dystopia: A few of the concepts pushed by religious anti-contraception zealots are…sure something.
Like the idea that contraception is tantamount to abortion, because what if a person would have conceived that one time but there was no egg for the sperm and good grief it’s like outright murder to have been absent an egg when the sperm came to call. Well, if that’s what someone truly believes, then that person should not take BCP. Problem solved. What does it have to do with everyone else? (Yeah, yeah, I know. Here we are in a post–Fall of Roe country.)
Also, hormonal contraception isn’t, as those more fanciful and fear-mongering segments of our population would have it, a gateway to sin and licentiousness. It’s a medication that enables people to stop ovulation—for a variety of reasons. Sometimes because they don’t want to (or can’t, due to health reasons) be pregnant. Or because they don’t want their hormones to swing wildly in perimenopause. Or because menstruation causes them extreme pain and discomfort. Or because they simply don’t want to menstruate, whatever their motivation might be. And there are a lot of potential motivations. Plenty that have nothing to do with sex, even (!!).
We take medication to reduce cholesterol, to lower blood pressure, to increase energy, to inflate penises, to balance brain chemicals, to stimulate, to calm, to save lives. To make life worth living, sometimes. And if stopping ovulation makes life worth living? Well, we have a medication to do it. Surely that’s no more immoral than Viagra.
When was the last time you saw a big-name, anti-contraception conservative really going after Viagra politically? I mean, by the logic of anti-contraceptive enthusiasts, if that dick doesn’t get hard, it’s between you and Jesus, right? No need for unnatural, immoral medication. If you’re meant to impregnate, then the lord will provide. Also, if you use your penis for sexual purposes outside of procreation… Satan has some great lava-front property for you, I guess.
Joking (?) aside, we need to move into improving these hormone treatments and optimizing them for the many conditions and symptoms they treat—and we need to stop giving political and mental space to regressive arguments that aim to curtail or forbid BCP.
Back to the Main Post: But Seriously, Educate Yourself About Hormonal Contraceptives
I’m not saying everyone going through perimenopause ought to take some kind of hormonal contraceptive. Far from it! There are risks and side effects; the cons will always outweigh the pros for some people. You don’t have to want or need to take it to support it, though. Eroding access to medication that helps so many women—that already has helped women join the workforce, escape poverty, achieve independence—leads to bad situations that are everyone’s problem. Let’s improve it, not eradicate it.
I have a lot of thoughts about this topic, and, for all that I believe in the social good of BCP, I’m still wrestling with the fact that I take a hormonal contraceptive every day (I can be an annoying pharmaceutical skeptic). Reading about the history, development, and power of hormonal contraceptives, however, feels like an important action we should all take.
It’s easy if you grew up in the 1980s (and later) to take for granted readily available hormonal contraception. And if you take something for granted, you probably don’t know much about it. How many people still think Plan B somehow forces an abortion?
It does not, in fact, have anything to do with shedding a fertilized egg. If you take Plan B and you’ve already ovulated, you’re out of luck. But because there’s so little education about how hormonal contraception actually works, it’s easy for people in the anti-reproductive-rights camp to spread misinformation.
Everyone should be invested in these kinds of hormonal medications sticking around. They’re imperfect and inadequately studied, but they’re the foundation of our reproductive freedom, an existing treatment for many hormone-related conditions, and an avenue of relief for the perimenopausal that’s still largely unexplored. Anything that does so much deserves educated attention.
Yours in a feeling I can only describe as white-knuckled optimism,
That Hag
Two Things to Learn About in the Week Ahead:
1. Women’s suffrage in the U.S. This movement had a massive and lasting influence on women’s lives, yet not many people know much more than the very broad strokes. The U.S. National Archives has an overview to get you going. It took a long, complicated fight for women to gain the right to vote. Some of the movement’s most visible figures didn’t always live up to our expectations (spoiler: racism, elitism). But understanding what’s gone before us that made our modern lives possible is so vital to avoiding complacency. Poke around a little online or at your library. There’s more to the eventual nineteenth amendment than Elizabeth Cady Stanton and Susan B. Anthony (justifiably famous though they are).
2. The history of your favorite dessert. Because learning about drug development and voting rights can be emotionally exhausting. Take a research trip down a sweeter road and investigate the origins of your No. 1 postprandial pleasure (the edible kind). Although I rarely turn down frosted cake and champagne, I think my top dessert spot is reserved for baklava of the pistachio variety…and I’m about to read an article titled “The Sticky History of Baklava.” I have to admit, that doesn’t sound uncomplicated. Ah, well. At least it’s a break from the medical journals.