In Our Control (13 page)

If the body is unpredictable and sometimes painful while it is winding
up, reproductively speaking, in the first few years after menarche, these problems can also arise while it is winding down before menopause. A host of potentially unpleasant and life-disrupting side effects are associated with this time of life, including heavy and unpredictable bleeding, and many consider turning to the Pill for relief. But, as Jerilynn Prior notes, estrogen levels are often quite high during perimenopause, and when women gain weight during this time, they can get even higher. High estrogen levels compound the already elevated risks of cardiovascular problems that women experience with hormonal contraceptive use after age thirty-five. Adding the Pill could put women at an increased risk for blood clots, strokes, and heart attacks.
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For these reasons, she recommends against using the Pill for contraception in this stage of life.

Fertility

It has always been difficult for patients and scientists to believe that taking hormones over time has no permanent effect on fertility. Dr. John Rock, who co-parented the pill into existence, was a fertility specialist who was originally interested in the ability of the progesterone to
increase
the likelihood of conception when withdrawn. In the 1960s and ’70s, Pill critics worried that the opposite was true: that shutting off the ovaries for years or even decades would lead to sterilization in some women. The truth, it seems, is somewhere in the middle. The majority of women regain fertility after OC use in about one to three months,
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a time frame that is similar to other contraceptive methods.
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Remember, though, that your regained fertility after going off the pill will be similar to the average fertility of a woman your age who has never used hormonal contraception. So if you are forty when you go off the pill, you will not regain the fertility of a twenty-year-old.

For women over thirty, the process of regaining fertility can generally take longer, and one study suggested that it took half of the participating women a year or longer to get pregnant than women who were using barrier methods before trying to conceive.
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Another study concludes, “A significant reduction in fecundity occurs after COC, IUD, or injectables,
which is dependent on the duration of use.”
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There are two important points here: the first is that almost all women do regain fertility. The second is that for those over thirty and those who have been using the Pill for many years, it may take longer to do so.

For everyone who knows a woman with a horror story about failing to get pregnant after dropping OCs, there is someone who gets pregnant the first month that she doesn’t take her pills. Both experiences are real, and highlight how much we still don’t know about the effects of hormonal contraception on fertility.

Even if women aren’t seeking pregnancy, they may be eager to know that normal cycles have resumed after Pill use stops. Women who had normal cycles before taking OCs will usually get a period within five weeks. It can take longer for women who were irregular before hormonal contraceptive, typically three months or more.
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If your period doesn’t come back within expected time frames, you should probably take a pregnancy test to make sure that that isn’t the reason for your missing menses. If you are perimenopausal, you may not resume bleeding. Those who are perimenopausal should also be aware that high levels of LH during that time can cause false positives on a pregnancy test, so be sure to consult with your doctor if you experience this problem.

Getting Off the Pill

In the fall of 2009 I received an e-mail message from a friend of mine, Michelle. Michelle had been on the Pill for six years. At first she was happy, but in the past year had started to have problems. She started to spot and have more erratic bleeding. Her moods had gotten worse, and she said she just generally felt sort of sick all the time. “It’s like having a perma-cold,” she told me. After much thought, Michelle had decided she wanted to off the Pill. When she did, though, she started having other problems. Her skin broke out and she started feeling more easily run down. As Michelle described her problems giving up hormonal contraception, it got me thinking: In a society where such a high percentage of women take this
powerful drug for years at a time, how many women have trouble giving up hormonal birth control?

Many women—myself included—have no problem giving up oral contraceptives. Others struggle. Jane Bennett and Alexandra Pope note that because the Pill affects nutritional balance, it is more important than ever to make sure that you are living a healthy lifestyle (including exercising, sleeping, and eating a nutritious diet) when you decide to ditch the Pill.
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In addition, make sure to take a multivitamin and perhaps extra vitamin C. Ask your doctor about nutritional changes—such as cutting down on sugar and some carbohydrates—that may make the transition easier on your body. Periods may take several months to adjust, and may not immediately start occurring on a regular schedule. When periods do start coming, they may be heavier than previously experienced.

Remember to be patient and expect some shifts in how you feel. You may notice changes in your skin and hair, and changes in mood are normal. Giving up daily hormones is a massive change, and you need to be patient with your body as it adjusts. Be careful not to get immediately scared by changes and rush back to the doctor’s office for a new prescription.

Some adjustments after giving up the Pill are psychological. Holly Grigg-Spall, who movingly describes her experience letting go of oral contraceptives in an excellent blog, Sweetening the Pill (
http://www.sweeteningthepill.blogspot.com
), tells me that since finally going off six months ago she has been jumpy with her new contraceptives. “When anything goes wrong, I run to get Emergency Contraception. I mean I’ve probably done that three times now. It’s hard not to be scared.”
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For women who are thinking of stopping hormonal contraception, there are a few practicalities to consider. Women on a combined Pill (with estrogen and progestin) and those using the contraceptive patch and ring can stop taking their pills at any point (bleeding within a few days of stopping pills is to be expected).
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Women may find it easiest, however, to wait until the end of a pill pack to stop taking their pills. If you are using progestin-only pills, you should wait until the end of a pack. In all cases, use backup contraception to be on the safe side. If you have been getting Depo-Provera shots, simply stop going for your regular injection. Hormonal
IUDs should be removed just before a period is expected while other implants can be removed by a doctor at any time.
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Parting Thoughts on the Pill

When Barbara Seaman took on the Pill and its safety problems, she made the point that these medical hazards didn’t exist in a vacuum. The dangers of the Pill were permitted to exist, and they were hidden and exacerbated by unequal power relationships. This started when doctors testing the Pill decided to do so on poor Puerto Rican women in part because it was a population that didn’t have as many medical ethical and legal protections. It was made worse by pharmaceutical companies who valued profits over the health of people using their products. It continued in a society where women were prescribed the Pill by doctors who treated them like children and often suggested that side effects were “all in their heads.” And it was perpetuated by male partners who were happy to let women bear the burden of contraception in every organ of their bodies.

These injustices weren’t separable from the medical facts of the Pill. In fact, the physical dangers and social problems created and compounded each other. “Fixing” the Pill meant working to alter inequalities in power between those promoting and those consuming the drug.

Today, much has changed, but more than we would like remains the same. It is still important to be conscious of social factors that can both make the drug itself more dangerous and limit the ability of women to use it in safest and most effective way possible.

Think about these two things. 1) The Pill is one of the most-studied drugs in the world. 2) There has never been a long-term, randomized, double-blinded trial of Pill use on the scale of the Women’s Health Initiative. What this means is that we have a
lot
of information on hormonal contraception, but not the best, most conclusive kind of research. It is impossible to perform such a trial for many reasons. The most basic is that it would be impossible to enlist a large group of women willing to remain on contraception for a large portion of their reproductive years.
Pill use is dictated by life. Relationships end, children are born, things change. This does not good science make. What we have for the most part, then, are observational trials, meta-analyses and shorter, smaller placebo-controlled studies. The limitations of oral contraceptive research mean that there are certain questions that will, at least for the foreseeable future, remain open.

The Pill offers many benefits to women, but it is far from perfect. If you are one of the millions who use oral contraceptives, be a smart consumer. Keep a journal of any side effects, problems, benefits, or other bodily changes. Don’t be afraid to tell your doctor if you are having problems, and don’t let anyone tell you that the things you are experiencing are “all in your head.” Likewise, if you are happy with the Pill, don’t let anyone make you feel bad or unnecessarily scared to use a drug that has been such a useful tool for so many women. For those of us who use and love hormonal birth control, and for those of us who have had bad experiences and don’t like it, let’s work to understand, respect, and empower choices that are different from our own.

In the next chapters, we will look more specifically at different types of hormonal and nonhormonal contraception and ask how our experiences, risks, and potential benefits change with age, biological development, race, ethnicity, economic background, and geographic location. Birth control pills, like all available contraceptive methods, are not “one size fits all.” Let’s begin asking the complicated question of how we may find the best fit for us.

Chapter Three
Hidden in Plain Sight: Nonhormonal Contraceptive Options

I know everyone says “out with the old, in with the new.” But after six years on hormones and one on a diaphragm, all I can say is “in with the old.”
—Amy, age 27

This story is a mystery and we are the detectives. We have been called to investigate a disappearance: a once ubiquitous, very useful birth control option has vanished, and it is time to get it back. We must unravel the case of the disappearing diaphragm.

In today’s contraceptive landscape, female-controlled barriers are almost completely absent. Other nonhormonal methods such as IUDs are growing in popularity, but they account for a tiny fraction of total usage in the United States. The vast majority of young couples today use two methods of birth control: the Pill and condoms. Older couples (over thirty-five) opt in significant numbers for either tubal ligation or vasectomy. Given that many women find they are unable—or unwilling—to use hormones to control fertility, and many more will grow dissatisfied with the Pill and its cousins as they age, it is striking that alternative methods are so underutilized. While condoms are without peer for STI prevention, it is worth asking about women-controlled contraceptive options that don’t involve taking drugs. Are methods like diaphragms really obsolete, or have they been too quickly pushed aside because, among other reasons, they aren’t significant moneymakers when compared with pharmaceutical methods? Why have diaphragms disappeared, and is their disappearance really the best thing for women?

Barriers to Knowledge: Vanishing Diaphragms and Cervical Caps

When Wilhelm Peter Johan Mensinga, a German gynecologist, created the first modern diaphragm in 1842, it was an invention that slowly and quietly shook the world. The mid-nineteenth century saw an outpouring of contraceptive creativity in Germany that included not only Mensinga’s creation, but an early modern cervical cap as well. Mensinga was a vocal advocate of contraception, which he said was useful for political as well as medical reasons.

What distinguished Mensinga’s product from the others was its consistency and reliability. Science had finally begun to play a role in assessing how well a contraceptive functioned. The doctor conducted small informal tests on a dozen patients from various social groups. Contraceptive Historian Robert Jütte notes, “Mensinga’s work thus marks the beginning of an era of comparatively ‘reliable’ knowledge about contraception that is substantiated by both statistics and case histories. From this point, it is not far to the clinical studies of the 1950s.”
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In choosing to compare the success of working-, middle-, and upper-class women, Mensinga was already acknowledging an issue that continues to surround the diaphragm (and many other contraceptives) to this day: the extent to which economic status and lifestyle factors play a role in the appeal, efficiency, and usefulness of a method. Mensinga insisted, in contrast to later commentators, that even women with limited access to education and sanitation could successfully choose a diaphragm.

Following in Mensinga’s footsteps, other inventors and entrepreneurs, including many Americans, rushed to develop diaphragms and cervical caps. Edward Bliss Foote was one of these enterprising people, and after graduating from the Pennsylvania Medical College, he created his own version of the cervical cap called the “womb veil.” He marketed the device in a book,
Medical Common Sense
, which he published in 1864. The device cost six dollars and, Foote enthused, it put “conception entirely under the control of the wife, to whom it naturally belongs.”
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