In Our Control (11 page)

Antidepressants have been suspected in the past of interacting with, and decreasing the effectiveness of, oral contraceptives. Herb-based oral antidepressants like St. John’s Wort have been shown to interfere with the Pill in
certain preparations and dosages but not in others.
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While the Pill is safe to take with many drugs, be sure to tell your doctor if you are taking other medications. Women often fail to think of the Pill as a medicine, probably because we aren’t sick when we take it. Giving your doctor a list of all the drugs you are taking, including the herbal ones, is a start to being safer.

Another thing pills have long been suspected of doing is hurting your sex drive. Many women choose the Pill because of its potential to create an ideal environment for sex, but these freedoms are sometimes undercut by the fact that while they can have sex without advance preparations, messes, and complication, they no longer want to. As with so many posited problems of the Pill, this one is hotly debated. Many doctors and scientists insist that there simply isn’t good science to support the notion that pills kill libido, but generations of women have insisted that this is a potential pitfall of hormonal contraception.
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Rebecca, a thirty-something Philadelphian, admits to suffering these side effects and says, “I don’t know a woman who doesn’t think it is real. The only people who don’t think so are doctors.”

Some doctors and scientists are starting to pay more attention to the problem. Dr. Lorraine Dennerstein, an Australian doctor at the University of Melbourne, has been studying women’s health and sex for a long time. She notes, “About one third of women are having adverse effects on their sexuality by the oral contraceptive pill,”
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adding, “it is rather strange that at the moment we have pharmaceutical companies spending absolutely millions of dollars to try to develop a pill that improves women’s sexual interest or arousal. At the same time, we have freely available the oral contraceptive pill and other hormones which actually suppress women’s sexual function.”
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(In fact, one drug maker, BioSanta, is planning to launch the “Pill Plus,” a contraceptive that supplements with testosterone to try to curtail sexual problems, in 2011.)

Whenever female sexual problems fall under the social microscope, controversy is close behind. The 1990s saw the popularization of Viagra for erectile disfunction (ED) and the medicalization of men’s sexual problems. The drug was a blockbuster, and by the end of the decade, a frantic search was on for a female version to treat was now called “female sexual dysfunction,” or FSD. Since women’s bodies have been medicalized for
hundreds of years, the explosion of classifications for different problems of both desire and sexual function didn’t constitute a new approach to female health, like it did with men. What did change, however, was the way that doctors thought about addressing sexual difficulties. For decades, the answers to women’s sexual problems were thought to be psychological: if a woman didn’t like sex, it must be because of a trauma, or a failure to mature emotionally, or some other problem that existed primarily in her head. Now, increasingly, it seemed possible that drugs could be administered when women expressed sexual dissatisfaction. In 1999, Dr. Irwin Goldstein helped organize a conference in Boston that vastly expanded (and some critics said invented) categories of sexual difficulty and disease. The conference also shot the gun to begin the race for “female Viagra.”

In spite of Goldstein’s hopes—paired with plenty of research and money—there are still no viable female libido drugs on the market. Researchers have begun to realize that, ultimately, we don’t have a very good understanding of female sexuality, and women lack a clear marker (like an erection) to use as a gauge of sexual functioning.

In response to doctors like Goldstein, who insisted that all female sexual problems could be treated with drugs, a group of vocal critics led by NYU-based sexologist Leonore Teifer emerged to reemphasize the role of social and economic factors in female sexuality and to resist the further medicalization of female bodies. They insisted that it is nearly impossible to separate factors like gender inequity, social class, ethnicity, sexual orientation, socioeconomic factors, and experiences of sexual violence and shame from the biological parts that come together to make an orgasm. People—and in particular, women—aren’t that simple.

Understanding that the relationship between bodies, cultures, and pharmaceuticals is rarely clear cut, how can we learn anything about the effect of oral contraceptives on sexual desire? Cynthia Graham, a Canadian scientist, first became interested in how the Pill impacts libido when she was a graduate student at McGill University studying the effect of taking birth control pills on severe PMS. She found that the Pill didn’t seem to help PMS, but what it
did
do was cause sexual side effects for many of the women in the trial.

Graham tells me that part of the problem getting good data has to do with money—“it is very hard to get funding for this kind of research”
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—and part of it is methodological. She believes that many studies in the past that failed to show potential sexual problems were flawed. They looked at long-term Pill users rather than those who were new to the drug. Because of this the group was self-selecting: women who had problems on the Pill got off before they were included in these studies. Another big obstacle has been cultural differences. When Graham worked on a large study that looked at women in both Scotland and the Philippines, problems encountered by the European women weren’t evident in the Filipino population. Because sexuality is such an intersection of culture and biology, assuming that a trial in one population can tell us something about another is risky.

Today Graham is researching the extent to which libido problems lead women to get off the Pill (in which she looked specifically at new Pill users
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) and the role of testosterone in diminished desire.
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Her work is innovative in terms of design: she sometimes conducts placebo-controlled trials (difficult to do with the Pill, but possible if subjects are sterilized or have other protections against pregnancy and can take a sugar pill) and looks at hormone levels side by side with women’s reports of their mood and sex changes. She believes that a small group of women’s sex lives are indeed adversely affected by hormonal contraception, and the challenge for researchers is to understand which factors may make women more vulnerable to sexual problems with the Pill.

One theory about why the Pill might dampen sex drive is that taking it leads to lower levels of testosterone in the body. In 2004, drug maker Proctor & Gamble brought their testosterone-releasing patch to the FDA in hopes of making it the first approved drug to treat FSD. The bid failed, in part because P&G lacked long-term safety data,
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but the idea that testosterone supplementation will boost libido in women persists. In studies of the Pill, women taking OCs did seem to have less testosterone, but there was no clear connection between having a low level of the hormone and diminished libido.
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Other studies found that taking testosterone supplements didn’t seem to improve sexual functioning for women taking the Pill who complained of problems.

Another theory on the link between the Pill and libido relates to the fact that desire peaks in the menstrual cycle with estrogen levels, right around the time that a woman ovulates. Because the Pill can flatten estrogen changes, some reason it could dampen desire. Others theorize that the
amount
of estrogen matters, and that perhaps having too much estrogen in a Pill might cause the problem—though no studies have conclusively shown this to be true.

Some believe that the type of progestin might be the culprit. Depot medroxyprogesterone acetate (DMPA), the progestin used in the injectable Depo-Provera, has fallen under suspicion because of its dramatic effects on male sexual function. While the drug has been used to treat aggression in male sexual offenders, evidence that it curtails desire in women isn’t as strong,
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and there are very few direct comparisons of the effects of different progestins on the sexuality of users.
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Graham’s study of women in Scotland and the Philippines found that while women on combined pills experienced a drop in desire, women on progestin-only pills experienced no sexual change.
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The relationship between changes in mood and shifts in libido remains unclear, but that doesn’t mean you have to live with mood or sexual problems. I asked Graham what she would recommend to women experiencing libido decline, and she believes it is worth trying a switch to a different brand. She emphasizes, though, that there isn’t a lot of empirical data on which to base this change—it’s basically guesswork and experimentation. She also recommends keeping a journal to record what problems you have and when. And, as always, women in these circumstances may want to consider a switch to a barrier or other nonhormonal method.

The Pill may cause sexual problems beyond damaging libido: an unusual study recently examined how it could change women’s sense of smell and alter some of their biological tools for mate selection. The “major histocompatibility complex,” or MHC, is a region of genes that plays a role in the body’s immune system. Some scientists theorize that women, picking up on subtle scent clues, tend to be attracted to men with genetically different MHC, strengthening their potential offspring’s immune systems.
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But when women take the Pill, the preference for difference changes, and
they are attracted to people with similar MHC. This may be because hormonal contraception tricks the body into believing it is pregnant, influencing how companions are selected and prioritized, or because it dulls sensitivity to scent that peaks around ovulation in normally menstruating women. A study published in England in 2008 had female subjects smell the T-shirts of male subjects and rate the scent. Those who were taking hormonal birth control were more likely to rate the scents of genetically similar men as “pleasant and desirable.”
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A team of researchers at England’s University of Sheffield found that because women on the Pill don’t have the shifts of the monthly cycle, they may be disposed to pick mates who are less genetically suited to themselves.
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Study author Virpi Lumma explains, “The ultimate outstanding evolutionary question concerns whether the use of oral contraceptives when making mating decisions can have long-term consequences on the ability of couples to reproduce.”
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Some argue—convincingly—that evolutionary tools isolated in a lab don’t have relevance in the complexity of real-world loves and relationships. And as we will see when we discuss menstrual suppression, it is dangerous to put too much stock in theories of what is “natural” for modern women based on imagining the sexual health of our primitive ancestors. As Alexandra Alvergne, another member of the Sheffield team, notes, “There are many obvious benefits of the Pill for women, but there is also the possibility that the Pill has psychological side effects that we are only just discovering. We need further studies to find out what these are.”
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Inside and Out: Effects on Weight, Skin, Hair, Bones, and Organs

There are so many physical conditions that are known, believed, or suspected to be impacted by Pill use. A comprehensive list of each of these conditions would be long enough to comprise a book by itself. The ovaries impact metabolism, thyroid function, adrenaline levels, glucose regulation, uptake of vitamins, memory and concentration, brain waves, sleep patterns, energy levels, pain thresholds, balance, and even skin and hair texture. Given how many things the ovary effects, you can imagine that the results
of suspending its functions can be far-reaching. Here are a few internal and external issues that have been tied to pharmaceutical birth control.

Weight, Metabolism, and Diabetes

While other potential side effects—like blood clots—may be more frightening, the possibility that the Pill causes weight gain has kept many women from selecting this method. Like sexual side effects, weight is both positively and negatively associated with OC use: some women gain weight on the Pill, others lose it. Older Pills with heavier hormone loads undoubtedly caused more variance, but some women still experience this unpleasant problem with modern drugs. In the case of women whose weight gain is the result of using progestin-heavy pills, which cause people to retain water at different points in the monthly regimen, a lower progestin dose or a different progestinal compound may help. For many, though, the problem is not so easily solved.

Weight gain is a symptom with much anecdotal evidence and little data to back it up.
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A 2007 meta-analysis published in the Cochrane Library combined forty-four studies and found that most didn’t suggest that the Pill caused women to put on extra pounds.
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An article in the
New York Times
, echoing the sentiments of many doctors, explained, “Most women start birth control as teenagers and continue it through their twenties, a period when women naturally tend to gain weight … the link between the pill and weight gain is exaggerated at best.”
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Other research disagrees, finding that all hormonal contraception, including POPS, can cause weight gain.
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For women who experience this side effect, the impact on their lives can be dramatic and devastating. One woman in her midtwenties shared her experience with me: “When I went on the Pill in college, I put on a lot of weight—close to forty pounds. It totally changed my life and limited me in crucial ways. For some reason, I didn’t consider that my birth control was causing my weight gain. When I finally went off the Pill I lost the weight. It made me so angry when I figured it out—I wish I had realized what was going on sooner.”