January 13, 2020 at 07:38PM by CWC
The creation of the birth control pill in 1950 is largely considered a watershed moment for female reproductive freedom. For the first time in human history, there was a reliable, relatively safe contraceptive method that allowed people to have more control over when they got pregnant and with whom. While some at the time clutched their pearls about the implications of being able to have sex without the consequence of pregnancy (gasp!), usage of the Pill (and later, other forms of hormonal contraception) became widespread and highly accepted… until, it seems, right now.
The number of women using hormonal birth control pills is on the decline—per the CDC, 12.6 percent of women using contraception were on the Pill between 2015 and 2017, compared to 18.9 percent of women in 2002. While some of the decrease can be explained by increased use of other hormonal contraceptive methods (including a rise in IUD use from 1.3 percent to 7.9 percent, and an increase in implant and patch use from 0.8 to 3.5 percent), there is a small but growing movement of women (currently representing 5.4 percent of women using contraception, per CDC data) who are shunning hormonal contraceptive options altogether in favor of more “natural,” hormone-free options.
Among them is Ashley*, who was 17 when her doctor diagnosed her with polycystic ovarian syndrome (PCOS) and wrote her a prescription for birth control pills—a common treatment for the hormonal disorder to help regulate periods and hormone levels. After about eight years on a low-dose pill without any noticeable side effects, a new OB/GYN hypothesized that Ashley may not actually have PCOS. At the same time, a specialist in Arvigo abdominal therapy (a type of bodywork focused on improving reproductive and digestive health) with strong opinions against hormonal birth control encouraged Ashley to learn more about her cycle. So, at age 26, Ashely decided to stop taking the Pill.
“If I did have PCOS, I wanted to find out early enough in my fertile window to make any necessary adjustments,” she says. Her new OB/GYN supported the decision, and determined once her period came back that she had indeed been misdiagnosed. Ashley, now 34 and a clothing designer in San Francisco, says quitting birth control has helped her to feel more connected to her natural cycle. “I feel like I can use my period as another indicator of my body’s health. I notice changes in cycle length, duration, bleeding color, and consistency,” she says.
While Ashley’s decision to stop taking the Pill was carefully considered (and has so far worked for her), there is a vocal and highly visible segment of this movement that relies on fear and extreme views to convince women to make this highly personal choice—and that can make it difficult for the average person to see where the facts end and the fear-mongering begins. When that happens, people may miss out on the very real potential benefits of hormonal birth control.
The history of the birth control backlash
A lot of the current conversation about the Pill is shaped by an influential 2013 book, Sweetening the Pill: Or, How We Got Hooked On Hormonal Birth Control. The book’s author, Holly-Grigg Spall, makes dubious claims that the Pill is an “addictive” drug that supports patriarchal capitalism and is comparable to “female castration.” (It should be noted that she is a consultant for several natural fertility-tracking technologies.) Another early leading proponent of the anti-Pill movement, holistic psychiatrist Kelly Brogan, MD, argued that the Pill can cause depression in women and has voiced fringe opinions on other health topics, including vaccine skepticism and an (incorrect and dangerous) belief that the HIV virus does not lead to AIDS.
This Pill skepticism didn’t stay confined to the distant corners of wellness. In 2016, the hashtag #MyPillStory lit up social media, with people sharing stories about the side effects they say they experienced when taking the Pill, including low libido, anxiety, depression, and brain fog. Cycle-tracking apps flooded the market, many marketed as effective, hormone-free alternatives, and in 2017, Natural Cycles became the first natural family planning app certified by the European Union as a form of birth control.
The debate over the Pill has since reached the mainstream: In 2019, articles in media outlets such as The Washington Post and New York magazine featured women voicing concerns about the side effects of hormonal birth control and claiming that many are even dropping birth control altogether. A 2018 online survey of more than 2,000 women by Cosmopolitan found that over 70 percent who have used the Pill said they stopped using it or thought about quitting in the past three years.
“I think what’s happening is women are walking away from the birth control pill because of what they don’t know about it.” —Sarah Hill, PhD
Of course, the Pill has been around for nearly 60 years—so why are people turning their backs on it now? “I think what’s happening is women are walking away from the birth control pill because of what they don’t know about it,” says Sarah Hill, PhD, an evolutionary psychologist, professor at the Texas Christian University College of Science and Engineering, and author of the recent book This Is Your Brain on Birth Control. “Women are more in tune with their health and are becoming increasingly wary about putting things in their body they don’t understand.”
“My patients are more informed about their choices and more involved in the decision-making about what type of contraception is right for them,” says OB/GYN Nora Doty, MD, who is on the faculty at Hackensack Meridian Health Jersey Shore University Medical Center and a spokesperson for the American College of Obstetricians and Gynecologists (ACOG). “They ask really good questions about their health and how birth control may impact it, which I think is due to greater availability of accessible medical information as well as a culture shift that empowers women to be advocates for their own health.”
The legitimate concerns about birth control
While the claims of fringe health experts can be extreme and overblown, there is some truth to the cautionary tales regarding hormonal birth control such as the Pill. “These are real concerns based in evidence. It’s just that the evidence isn’t consistent and can’t help guide us in a neatly organized way to make changes,” says Marra Ackerman, MD, the director of NYU Langone Health’s reproductive psychiatry program.
Part of the challenge in understanding the effects birth control pills can have on patients is that there isn’t just one uniform type that everyone takes. There are many different formulations that have different amounts and combinations of synthetic progesterone and estrogen (which work to stop ovulation and thus prevent pregnancy). Because of this variety, the Pill can affect everyone who takes it a little differently, says Gillian Dean, MD, Senior Director of Medical Services at Planned Parenthood Federation of America. This can explain why some people experience side effects like headaches, spotting, and decreased sex drive—or even the more anecdotal, less-understood side effects like mood swings and brain fog—while others don’t.
Additionally, the same hormones used in the Pill and other forms of hormonal contraception are also signaling software that your brain uses for numerous mind and body functions, says Dr. Hill—which means that altering them may impact how your body and brain behave. She says she experienced this after she quit birth control in 2011 after her husband had a vasectomy and noticed a dramatic change in her mood. “It felt like I woke up, like I crawled off a two-dimensional page in a black and white drawing. I felt more vibrant and alive,” says Dr. Hill. This experience, and a subsequent deep-dive into the research about the effects of birth control on women’s psychological functioning, led her to write her book.
“When we look at the data, there aren’t clear guidelines about how to choose birth control based on how it will affect mood, because there’s so much individual variability. It’s more individual trial and error, and that’s frustrating.” —Marra Ackerman, MD
However, the actual research into the effects of hormonal birth control on mood is less than clear. A large 2016 study made waves for linking birth control to depression, but the actual increase in new diagnoses of depression and new antidepressant prescriptions among women taking birth control was very small, notes Dr. Dean. Other research, including a 2016 review of all studies on hormonal contraception use and mood over the past 30 years, found that most women on the Pill experience no changes or a positive effect on mood, she says. “Mood changes and depression are highly prevalent in women, and it is difficult to identify a causative factor in these types of population-based studies,” adds Dr. Doty.
“When we look at the data, there aren’t clear guidelines about how to choose birth control based on how it will affect mood, because there’s so much individual variability,” says Dr. Ackerman. “It’s more individual trial and error, and that’s frustrating.”
Other research has found that birth control may decrease sex drive in some women, because the estrogen in the Pill can alter testosterone levels in the body, says Dr. Dean. “There is some subset of women who have diminished libido and increased pain with sex. We have seen that discontinuing birth control will get rid of the problem. It’s a genuine concern,” says Alyssa Dweck, MD, an OB/GYN in New York and assisting clinical professor at Mount Sinai School of Medicine.
As for more vague concerns about hormonal birth control “messing up” your hormones or future chances of having children, Dr. Dweck says changes in fertility after birth control pill use are linked to age (which is the biggest factor in infertility) or other conditions birth control might be being used to treat, like endometriosis or PCOS—not the use of synthetic hormones itself.
Sorting fact from fiction
Like any medication, there are certainly legitimate potential drawbacks of the Pill for some people. But experts caution not to throw out the baby with the bathwater. “I think that the birth control pill is getting a bad rap right now,” says Dr. Dweck. “For medical problems and gynecological concerns, the Pill is a godsend for my patients.”
Further complicating matters is our current political climate, where access to contraception and abortion is increasingly at risk. The Trump administration and certain federal judges have proved hostile to the birth control mandate in the Affordable Care Act, which could affect people’s future access to affordable contraception; the Supreme Court will hear a challenge to Louisiana’s restrictive abortion ban this year that may shape the future of Roe v Wade, the landmark ruling that established abortion as a constitutional right; and women’s health centers that provide contraception and reproductive health services are closing because of proposed draconian abortion bans. Could this backlash against the Pill—only some of which is rooted in truth—make accessing safe, effective birth control even harder for people?
Several experts interviewed for this story are concerned that the current skepticism about the Pill presents information (only some of which is credible) out of context—which could cause legitimate confusion for patients. Dr. Dweck says that the question of whether birth control is right for any one person is extremely subjective and can only be determined by an individual and their healthcare provider. “[Doctors] have to be treat people as individuals and put the risks versus benefits side by side. It will become clear who will benefit and who will not,” she says. “This is a weighing game, and it’s not a black or white answer.”
Dr. Hill, on the other hand, sees her place as simply educating patients about their options. “I’m giving women more information to make more informed decisions,” she says. “I think giving access to information might bring women back to the Pill in many cases. It gives women an explanation about things they’re experiencing.”
What everyone interviewed for this story can agree upon: While hormonal birth control methods, including the Pill, patch, and ring, have been studied for over 30 years, bigger and better studies are needed to answer the questions that patients and practitioners have. “We really need more data to help guide us,” says Dr. Ackerman. For example, Dr. Hill says that most birth control studies don’t separate out the type of Pill women are using—and, as discussed, different formulations can have significantly different effects on the brain. But we may be waiting a while. Scientific research is highly competitive and funding is limited, explains Dr. Hill; there is a well-documented gender gap in research today benefitting men, who are easier and cheaper to study than women because their hormonal systems are less complex (and thus easier to control for in a study).
For now, doctors and patients are left fumbling with a rather unscientific personal experiment to find a solution that works. “These are common questions that come up and women face. These choices can be very impactful, and we’re in the realm of trial and error,” says Dr. Ackerman. Right now, that means testing out the many different kinds of contraceptive methods until a person finds what works for them. Hardly an ideal system, which potentially requires several different OB/GYN appointments in a year for consultations and prescriptions—which can get costly, fast. Regardless of some of the hype and overblown critiques of hormonal birth control—particularly the Pill—it’s clear that people with uteruses deserve more answers, and more options, when it comes to safely preventing pregnancy.
*Name was changed to protect the privacy of the source
Speaking of birth control, here’s why the IUD suddenly became the queen of the contraceptive world. And for more intel about fertility, hormones, and everything in between, you should probably check out the biggest questions about fertility answered by OB/GYNs.