In Our Control (7 page)

As we approach this new anniversary, however, there are rumblings of discontent, signs of change. New chemicals and ways of distributing hormone drugs have led to a new batch of lawsuits. A new series of blood clots and strokes have replayed the avoidable tragedies of the 1960s and ’70s, and once again, women have begun to ask whether or not the Pill should always be our first line of contraception. For the first time in many years, Pill prescription leveled out instead of growing in Canada.
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Two Australian health writers, Jane Bennett and Alexandra Pope, published
The Pill: Are You Sure It’s For You?
, a startling book that examines many of the potential health dangers of prolonged hormone use. And I have received e-mails from and had conversations with women around the country—women of different ages, races, and religions with different educational backgrounds and economic resources—detailing negative experiences with hormonal contraception that ranged from slightly annoying to life-threateningly serious. I am invigorated by this new engagement with contraceptive options and renewed willingness to question the Pill. All I can say is, “It’s about time!”

I believe that the Pill represents something rare: a truly “new” thing in
the world. It has changed women’s lives unimaginably for the better. I also believe that we live in a culture that doesn’t tolerate critical outlooks on hormonal contraception. If you ask questions, you must be a crazy conspiracy theorist, an opponent of “Western medicine,” an unrepentant eccentric.

I am none of those things. I often take pharmaceuticals and am happy to take risks to reap drug benefits. My story is that of a skeptic who changed her mind, a person who took the Pill because, well, it’s what you do, and who went on to believe that that sort of unquestioning allegiance is a mistake. Blindly worshiping at the church of the “magic bullet” is never the best thing for female consumers. If we are to truly value the gifts of hormonal contraception—and there are many—we must also be willing to ask tough questions about its risks, inconveniences, and unknowns. Many women will have no side effects at all with pill use, and there are many voices ready to educate women about the benefits of the Pill. On the other hand, women who struggle and have bad experiences lack strong, secular, feminist voices to illuminate their experiences.

When Barbara Seaman was writing in the 1960s, her goal was to warn women about a dangerous drug. My goal is to help women gain a more comprehensive and holistic knowledge of a drug that is generally safe. I also hope to give women who find that the Pill isn’t right for them the confidence to stand up to a medical hegemony that insists that taking hormones is the only smart way to go. You need not believe that the Pill poses a serious threat to your health to simply not want to take it. It’s your body, and your reasons are valid. While we can dream of a future with better, safer contraceptives, women are best served when they have good knowledge of those available to us today.

Hormonal Contraception Yesterday and Today

An Oberlin College graduate with a fondness for the poetry of Yeats, Barbara Seaman never intended to write about women’s health; she wanted to pen song lyrics, or maybe novels. At first her weekly magazine column about sexual health was just an outlet to write and a way to pay the bills.
But as Seaman began receiving letters detailing the terrible side effects of the Pill, she realized her column was a serious tool that could be used to address women’s concerns. Chronicling the drug’s dangers in
The Doctors’ Case Against the Pill
transformed her into a passionate crusader against the excesses of the pharmaceutical industry and the potential dangers of hormone drugs.

The original 1969 edition of
The Doctors’ Case Against the Pill
outlined several potential problems that were being understudied and underreported. They included increased risk of blood clotting, stroke, cardiovascular disease, certain types of cancer, diabetes, sexual and mood side effects, gall bladder disease, weight gain, liver tumors, and reproductive tract infections with Pill use. Perhaps the best way to start asking questions about today’s pills is to look back and compare them with yesterday’s. Which concerns have been disproved, and which remain the same? Which problems have been alleviated in the five decades of chemical tinkering, and what new issues, unforeseen the 1960s, are we dealing with today?

What’s In the Pill?

Before we begin talking about what can go right and wrong with the Pill, we must first be aware of what’s inside it and how it works. The majority of oral contraceptive pills (OCPs) are made of a combination of synthetic estrogen and progestin hormones. Most contain an estrogen called ethynil estradiol at doses that vary from 50 to 20 mcg. Compare that to the world’s first birth control pill, Enovid, which had 150 mcg of the synthetic estrogen mestranol.

As estrogen drugs have fallen under scrutiny in recent years, there has been a push to move patients toward using “natural” hormones. Qlaira, a new Pill introduced by Bayer-Schering—the company that brought us Yasmin and Yaz—uses a compound called estradiol valerate instead of ethynil estradiol. But if a hormone isn’t made by your body, it isn’t natural. As one writer on hormones explains, “It’s like saying that a Twinkie is
natural because it contains high fructose corn syrup.”
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At the end of the day, all chemicals are “natural,” and this sort of language shouldn’t be a determining factor in your decision to use hormonal contraception.

Progestins
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are much more varied in dosage (although all are now well below the original Enovid load of 10 mg of norethynodrel), chemical structure, and safety profile than estrogens. They can be more and less progestational, estrogenic, and androgenic, depending on the formulation. Some progestins are older than others, and scientists often think of different compounds as falling into a first, second, third, and now fourth generation category. The problem with this breakdown is that no one understands exactly what constitutes a certain “generation.” A less historically pleasing but more accurate way of thinking of today’s progestins is to group them by chemical structure, but because studies and news articles continue to refer to “generations,” I will explain which compounds generally fall into these groups.

First, the C-21 progestins (pregnanes) group includes medroxyprogesterone acetate (MDPA), the hormone used in the injectable contraceptive Depo-Provera. A second big group is the 19-nor testosterones. Older members of this group (sometimes called estranes) include norethistrone—the original progestin that Carl Djerassi struggled to make in his Mexican lab in the early 1950s—and norethynodrel, the progestin in Enovid. It also includes a number of compounds present in today’s Pills, including norethindrone, norethindrone acetate, and ethynodiol diacetate.

Together these compounds are often called “first generation” progestins, although the last two compunds are sometimes called “second generation.” Early female hormones were made by chemically altering the structure of other steroids, such as androgens (male hormones), which the body turns into estrogen and cholesterol. While the earlier progestins were miracle drugs in their way, they had a lot of unpleasant side effects, many of which were androgenic, such as skin problems and weight gain. Over the years, scientists have subtly tinkered with the formula, trying to maximize the benefits and minimize the problems. Today, most progestins are made from androgens and contain residual amounts of male steroid compounds, but have been engineered to curb earlier side effects.
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The second group of 19-nor testosterones makes up the majority of progestins in today’s pills and include norgestrel, levonorgestrel, norgestimate, desogestrel, and gestodene. Norgestrel and levonorgestrel are often called “second generation progestins.” Desogestrel, norgestimate and gestodene are frequently called “third generation progestins,” and these newer compounds have been causing controversy in recent years as a result of serious side effects, as we will see later.

Further controversy surrounds a progestin made in a completely different way, drospirenone. This compound, used in the popular pill brands Yasmin and Yaz, is made from altering an antihypertensive compound instead of androgens. It is associated with higher potassium levels, making it a bad choice for women with kidney, liver, or adrenal problems. Sometimes called a “fourth generation progestin” or simply lumped in with other “third generation” compounds, drospirenone has also been associated with elevated blood clotting risk.

While pills with different progestins can be equally effective at preventing pregnancy, they have very distinct effects on each individual’s body. Different pills are, to some extent, different types of drugs. This fact complicates both patient prescribing and the process of getting good data on oral contraceptive side effects. Most doctors experiment when it comes to choosing which brand of pills (and consequently which combination of hormones and doses) will work for individual women, but some doctors are coming to believe that testing hormone levels will help to predict who will do well on particular pills.

Combination pills (containing both estrogen and progestin) typically come in “monophasic,” “biphasic,” and “triphasic” formulations. A monophasic pill provides a steady dose of hormones throughout the month. A biphasic has two different doses of hormones, and a triphasic has three. Qlaira, Bayer-Schering’s new pill, has four different hormone doses.

Pills that change hormone dose throughout the month do so because there is some thought that it more closely mimics the body’s natural hormonal changes during a menstrual cycle. Studies have observed differences in the tendencies of these different pills to cause various side effects. Some women do better on monophasics and others prefer a pill with varying
hormone doses. If a patient struggles on one type of pill, her doctor may suggest a switch to the other.

In addition to the differences in pills caused by various combinations of estrogen and progestin and differing hormone doses, many brand name pills are also available in generic form. These generics must be chemically similar enough to brand name versions to qualify as the same drug based on FDA’s standards for generics. It is said that even small chemical differences can have a big effect on a person’s body, and many women report that they feel different on generic birth control. Be aware that some states require specific instructions from a doctor for a pharmacy to provide a brand name product if a generic is available.

How Does It Work?

Pills work in three major ways. The female reproductive system is triggered when the hypothalamus (part of the brain) sends chemical messengers to the thyroid telling that gland to release hormones to the ovaries. Follicles in the ovaries slowly mature and release an egg, along with more hormones that eventually either nurture a pregnancy or lead to a period. The first way that birth control pills suspend this process is by blocking the surge of luteinizing hormone (LH) that would normally lead to ovulation. Sometimes ovulation happens anyway; no one is sure exactly why an egg will occasionally sneak through, but we do know that with lower-dose pills, it probably happens more often.

Second, pills lead to the thickening of cervical fluids. Over the course of a normal menstrual cycle, cervical fluids (sometimes called cervical mucus)—the moisture that starts at the gateway to the uterus—change. Around the time of ovulation, fluids become particularly hospitable to sperm in order to help them make the difficult journey through the cervix and uterus. When these fluids get too thick they can actually hinder, instead of helping, fragile sperm.

Third—and most controversially—the Pill can inhibit sperm and egg motility. That means that it becomes harder for sperm to swim up the fallopian
tubes, and (this is the controversial part) it may become difficult for an egg that has been fertilized to implant in the uterine wall and begin to grow. Scientifically, a woman is not considered pregnant until a fertilized egg is implanted in her uterus, and the Pill does not affect eggs that have already been implanted. But some people believe that life begins with the fertilization of the egg, and since the Pill may affect a fertilized egg’s ability to implant, some see it as an abortifacient.

In sum, the Pill works by stopping the production of an egg, blocking the sperm at the gate to the uterus, slowing sperm down as they move toward an egg, and if all else fails, preventing the egg from implanting. While this system is highly effective, the Pill isn’t
quite
as good at preventing pregnancy as we are led to believe. We are used to seeing “typical use” failure rates for barrier methods—that means how often the contraceptive actually falters—but we see “ideal use” rates for hormonal contraception. However, even “typical use” failure for the Pill is quite good, and only six or seven women out of 100 who use the Pill as directed for a year will get pregnant, no matter what brand they use.

An important point to emphasize is that the Pill does not regulate a woman’s menstrual cycle. In fact, it suspends the menstrual cycle and flattens a woman’s natural hormone shifts. Doctors are often quick to rhapsodize about the potential health benefits of the Pill, but they are less willing to admit that there may be many health benefits to having normal menstrual cycles. We live in a culture that imagines that monthly cycles are useless outside of allowing pregnancy, a bad attitude that has resulted in a dearth of good research and information about this very basic part of female biology. Making the Pill the preferred contraceptive discourages women and health care providers from engaging with and learning from the menstrual cycle.

POPs

A newer and less frequently prescribed alternative to the standard pills are progestin-only pills (POPs). Originally marketed to menopausal
women, these drugs—sometimes called “mini-pills”—have been shown to be useful for preventing pregnancy as well. They work slightly differently than pills containing estrogen, preventing ovulation only about 50 to 60 percent of the time.
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They rely more heavily on other methods, such as thickening cervical mucus, to ultimately prevent pregnancy. It is even more important to take POPs at the same time each day than their combined counterparts; if you miss a pill by more than three hours, be sure to use back-up contraception until forty-eight hours after resuming pill use.
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