In Our Control (26 page)

Emily Martin argues that words like “breakdown” are themselves indicative of how we view the processes of the female body. She points out that looking at the values of words in scientific writings betrays the not-so-objective agendas that sometimes underpin them: “unacknowledged cultural attitudes can seep into scientific writing through evaluative words.”
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Other authors concur with this, noting, “even today, menstruation is a sad story, depicted in the literature as ‘disintegration,’ ‘decay,’ ‘shrinking,’ ‘shedding,’ ‘discharge,’ ‘dribbling,’ and ‘sloughing.’ ”
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By opting to use words that portray this biological process in pathological terms, doctors often indirectly suggest that menstruation is disease.

Metaphors matter, too, and the female body is often described using images of failed production, a factory that has failed to perform its job. This suggests that a woman’s biological purpose is the production of a child, and a period constitutes a missed opportunity. This reflects on society’s definition of the purpose of a female body, a purpose that is seen very differently depending on whether that body is rich or poor, white or black, young or old. Women themselves adopt this sort of language to describe their menstrual experiences—particularly with regard to PMS—favoring images of disembodiment and passivity, saying that they don’t “feel like themselves” or are “out of control.”

And we want to things to be in our control. The experiences that make us feel otherwise contribute negatively to our lives and health. Perhaps without denying the very real physical and emotional pain that women—myself included—often experience, it is possible to suggest that part of the reason women feel “sick” with menstruation is a result of the deeply ingrained notion that periods are evidence of our inability to be autonomous and functional. We know that’s not true: we are great at our jobs, at managing our lives, at balancing an impressive array of commitments, roles, and tasks. We also know that as women we have to work a little harder to achieve all this—we constantly have to prove ourselves. But we convince ourselves that we are in charge. Then, once a month, we are reminded that we aren’t free of inequality, that our identities, accomplishments, opportunities, and ways of relating to other people are constantly
mediated by social forces. We want to prove society wrong, we want to be powerful and accountable only to ourselves, we want to be spotless.

In
The Female Thing
, cultural critic Laura Kipnis’s acerbic, funny treatise on feminism and femininity, the obsession with menstrual management is tied to a larger female anxiety about dirt. It’s not just blood we feel responsible for cleaning—it’s houses, our faces, even our relationships. Any visible blemish on ourselves, our homes, our lives seems to be begging for a good scrub. Kipnis writes, “If women didn’t menstruate … would the cleaning imperative have taken hold a little less successfully, and be abandoned with a little more alacrity? If women didn’t have vaginas, would we take fewer bubble baths, be less susceptible to the newest miracle cleaning product’s marketing campaign, let up on the cleaning standards … and simply not do more than 50 percent of the housework?”
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At least for the time being, she concludes, we will wrestle with these questions. “Cleaning house, cleaning up society, cleaning up sex, scrubbing away at those unsightly nose pores: housekeeping of one sort or another remains a plight.”
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When it comes to sex—an act closely aligned throughout history with dirt—the cultural messages about cleanliness are at their loudest. No wonder, then, that so many modern women are happy to take the responsibility for contraception if it means sex without the mess of latex and spermicide and mutual responsibility. How much easier it is to let the cost of managing the potential messes of unchecked intercourse run quietly through our veins. And if sex and blood are two of the biggest points of anxiety and difference for women, it is easy to see the allure of a drug that promises to control both.

Chapter Six
Spotless: Questions and Controversies with New Menstrual Suppression Drugs

Science may be working rapidly to perfect the human body, but it is certainly not in the image of woman
.
—Kathleen O’Grady

It wasn’t a real advertisement, but it could have been. Smartly dressed women worked and frolicked and practiced yoga as a soothing voice-over asked, “What if you could have your period just once a year?”

“Once a year?” enthused a professionally dressed brunette. “I’d like that!”

The spoof was a
Saturday Night Live
sketch, a fake commercial for a mythical menstrual suppression drug called Annuale. While some of the ad was over the top—a written warning at the end cautioned “do not take Annuale if you plan to ever become pregnant, as it may turn your baby into a fire monster”—the most striking part of the parody was how little exaggeration was required to make a point about the way that pharmaceutical companies use direct-to-consumer advertising to entice and manipulate female consumers.

The fictional pill offered continuous hormones for forty-four weeks with only one week of withdrawal bleeding. As most women have become aware, real pills promising fewer or eliminated periods have become a prominent feature in the contraceptive landscape over the past decade. Far from being completely outlandish, Annuale would actually constitute a middle ground between Seasonale and Seasonique, two products that cut bleeding to four cycles a year, and Lybrel, a drug that completely eliminates withdrawal bleeding.

For many women who deal monthly with pain, mood instability, and the general hassles of managing menstrual blood, the possibility of living without periods holds tremendous appeal. Women reason that if bleeding
has historically been a marker of female difference, an excuse to keep women out of the schools and professions into which they desire entry, perhaps getting rid of it altogether really is the next step in the continuing battle for female equality.

As with every new and potentially profitable pill, menstrual suppression drugs entered the public consciousness armed with powerful scientific and medical rationales. The most provocative was that menstruation itself was unnatural and avoiding it through a constant regimen of pharmaceutical hormones would bring you closer to an evolutionary ideal. Our prehistoric ancestors, argued pill advocates, lived in a state of near constant gestation and lactation during their reproductive years and would have had little opportunity to bleed. Some doctors also suggested that eliminating the period would be a great way to curtail health problems ranging from premenstrual syndrome to anemia, as well as reducing the risk of certain cancers.

Many women, however, were unconvinced. They didn’t really mind getting their periods each month, and felt that the experience, however inconvenient or unpleasant, connected them to other women in a fundamental way. Some felt that there was something strange and distinctly unnatural about stopping bleeds, even if they couldn’t explain why they felt this way. Quickly, women’s health activists and patient advocates took on the role of “loyal opposition,” pointing out that arguments for menstrual suppression played on old ideas about the dirtiness of menstruation, the abnormality of healthy female bodies, and the supposed psychological and emotional burdens of monthly hormones.

Can this “new” contraceptive method really transform women’s lives in a positive way? What are the unique risks and open questions associated with continuous hormone regimens, and how can we understand the cultural conversations that impact how scientific data about them is presented?

John Rock vs. Elsimar Coutinho: A Brief History of Menstrual Suppression

The storm had been brewing since before the Pill was legalized, but it was Brazilian doctor Elsimar Coutinho who tossed the first lightning bolts.
In 1999, Coutinho, a longtime researcher of contraceptive methods and one of the fathers of the injectable progestin Depo-Provera, partnered with Population Council scientist Sheldon Segal to publish
Is Menstruation Obsolete?
This slender volume argues that using and developing available hormonal contraceptives for the purpose of preventing periods would offer multiple boons, including disease prevention and improved job performance.

The book set off a firestorm, polarizing medical and cultural opinion. For some, Coutinho’s work was a revelation and a testament to the promise of modern gynecological science. Contemporary medical technologies could be wed to our evolutionary needs and open up new possibilities for women’s lives. For others, it was sexist medical logic taken to the extreme, attacking one of the most intrinsic processes of the female body. The only marriage here, opponents insisted, was between old ideas about women’s bodies and new drug company interests.

The idea of menstrual suppression—using technology to block periods—was not a new one. Indeed, doctors have possessed the tools to help patients stop monthly bleeding since the legalization of hormonal contraception fifty years ago. Each pack of birth control pills contains a certain number of active pills—generally twenty-one—and a smaller number of sugar pills—usually seven. For decades it has been common knowledge in the halls of college dormitories that if you wanted to skip your period, all you had to do was throw out the sugar pills and skip directly to the next active one.

As we have learned, the bleeding that occurs at the end of the active pills is not the same as natural menstruation. Proponents of menstrual suppression are quick to point out that withdrawal bleeding, essentially a chemically induced period, happens when the progesterone that has been flooding the body stops abruptly.
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While it has many similarities with a natural bleed, it is fundamentally different.

So if withdrawal bleeding isn’t the same as a real period, why do pill packs contain the seven sugar pills? John Rock, that dapper, pious architect of the Pill, wanted to cast his contraceptive drug in biological terms that his church could understand—he wanted to present the Pill cycle as “natural.” A loyal Catholic, Rock believed he understood how to build and explain a drug that would override church objections to birth control.

Malcolm Gladwell writes, “In 1951 … Pope Pius XII had sanctioned the rhythm method for Catholics because he deemed it a ‘natural’ method of regulating procreation: it didn’t kill sperm, like a spermicide, or frustrate the normal process of procreation, like a diaphragm, or mutilate the organs, like sterilization.”
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It was easy to argue that estrogen and progesterone were “natural”—the body made these hormones (forget for a moment that the ones used in the Pill were made in a laboratory). For couples using the rhythm method, progesterone produced a “safe” period; Rock reasoned that his pill worked the same way but extended that safe time to the entire month. It was an adjunct to, not a substitute for, a natural contraceptive method. The pope was initially persuaded by this logic and offered tentative approval in 1958 for Catholic women who suffered from dysmenorrhea and uterine problems. As Gladwell notes, “If Rock wanted to demonstrate that the Pill was no more than a natural variant of the rhythm method, he couldn’t very well do away with the monthly menses. Rhythm required ‘regularity,’ and so the Pill had to produce regularity as well.”
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So for the sake of consistency, Rock convinced Gregory Pincus, the Pill’s co-parent, that despite the fact that bleeding could be completely prevented by continuous hormone use, it shouldn’t be. Instead, a week of placebo pills would be included to emulate the body’s natural cycle. It was an imitation of life, but a symbolically powerful one. Rock felt it would keep the drug in the good graces of the church, and besides, he reasoned, it would create greater psychological comfort for new female patients who would already be dealing with so much change. Having a period, even a chemically induced one, would provide a measure of normalcy.

Imagine John Rock’s heartbreak when after so much chemical and rhetorical maneuvering a new pope ultimately rejected his brainchild: in an official 1968 letter entitled “Humanae Vitae,” Paul VI officially banned oral contraceptives, deeming them “artificial.”

To the minds of many advocates of menstrual suppression, the withdrawal bleed is a relic of a time when science had to bend to the cloth, when appearances trumped good sense. Paul Blumenthal, a professor of obstetrics and gynecology at Stanford University School of Medicine explains, “The fact that birth control pills were prescribed as monthly cycles for all these years is the reflection of what someone thought women would want as opposed to what was physiologically necessary.”
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Many scientists never gave up the idea that women need not go through a week of pads and tampons if they were already taking the Pill. Elsimar Coutinho came to New York in 1959 as a guest investigator at Rockefeller University for Medical Research. It was a heady time in hormone research, and Coutinho had the chance to work with some of the men who had made the Pill possible. He also met Sheldon Segal, an endocrinologist who helped the young doctor begin framing his ideas about the potential of hormonal contraception. Coutinho returned to Brazil but not before beginning work on a new progesterone, medroxyprogesterone acetate (MPA)—Depo-Provera—which Upjohn, the pharmaceutical company, hoped would help prevent late-term miscarriages. While clinical trials proved the drug ineffective for that objective, the doctor found that his progesterone had a powerful effect on ovulation. This research led Coutinho to develop Depo-Provera as the “first long-acting injectable contraceptive,”
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a treatment that had the unintentional side effect of reducing and even eliminating menstruation.