“The” Pill: The Good, the Bad, & the Ugly
The invention of “the pill” was a game changer for women in the 1960s and beyond, as it finally gave women a method of contraception that they could use on their own to manage family size or prevent childbearing altogether. There is hardly space here to talk about how important this intervention was, or what a long time it had been in coming– women had been utilizing herbal and other, less effective, and sometimes less safe, methods for many centuries in an effort to achieve this kind of freedom.
The first contraceptive pill, Enovid, was approved for use by the FDA in 1957, but only for heavy and/or painful periods (it carried a warning of its contraceptive effect, but was not meant to be used for this purpose). One can only imagine how many women sought medical help for their periods after this pill was approved– whether or not their periods were a problem for them. In 1960, the pill was finally approved for contraceptive use. However, getting access to the pill was not so easy, and many women were still unable to obtain a prescription. It took a major Supreme Court decision in Griswold v. Connecticut (1965) to guarantee access– but only for married couples. It would be several more years (and a lot more fight) before single women could access the pill. And access remains challenging for some people– six states still allow pharmacists to deny prescriptions based on their personal moral beliefs.
Opposition to contraceptive pill use is still relatively widespread, so I think it is worth talking for a moment about how the pill actually works. Contrary to some people’s beliefs, it is not what is called an abortifacient. In other words, the pill does not interrupt an established pregnancy. Generally speaking, the contraceptive pill works by suppressing ovulation. Consistent use is extremely important, as a lapse in use can trigger ovulation and put you at risk of pregnancy. But again, I think it’s worth restating– the pill does not cause abortion; it prevents the release of an egg so that pregnancy cannot occur. Taking a contraceptive pill once a pregnancy is established will not affect the developing embryo, negatively or positively.
There are now dozens and dozens of pills on the market, but for the average user there are really two categories of contraceptive pills that are worth understanding. The first, most commonly used, and more effective, is the combined hormonal pill, which contains estrogen and a progestin (one of four progestins currently on the market in the US). The other is a progestin-only pill– it does not contain estrogen. While it does not confer some of the benefits of the combined pill in terms of efficacy or noncontraceptive extras, the progestin-only pill is the safer choice for people with certain medical problems or restrictions, such as uncontrolled hypertension or a history of migraines with aura.
Both kinds of pills must be taken daily to work, and should be taken as close to the same time of day as possible to maximize efficacy. This is especially true for the progestin-only pill, which is more likely to fail if not taken every ~24 hours. This is both a benefit, in that the pill is easily reversed if a person wishes to conceive or halt some unwanted side effect– but it is also the reason for the gap between the pill’s “perfect use” efficacy rate (over 99%) and real-life use efficacy rate (closer to 93%).
The pill can cause some adverse effects, most commonly symptoms such as irregular bleeding, nausea, breast tenderness, or mild headache, which most often resolve with several months of consistent use. However, the combined pill can cause very rare, but more serious adverse effects such as blood clots (DVT or pulmonary embolism) or stroke; and chest pain, shortness of breath, one-sided leg pain/swelling, severe headache, or vision changes warrant discontinuation and immediate evaluation by a healthcare provider. To put this risk in perspective, however, the risk of blood clot or stroke is increased by a much greater factor in pregnancy (a 16-fold increase as opposed to about a 2.2-fold increase on average compared with the incidence on nonpregnant, healthy people who are not taking combined hormonal contraception). Still, some health conditions can increase this risk and it is absolutely important to weigh the risks and benefits on an individual basis before deciding on any method.
As far as noncontraceptive benefits go, the pill can offer several. Just like the very first pill that was approved in 1957 for use in dysmenorrhea (heavy/painful/unmanageable periods), the pill can reduce the amount and number of days of bleeding per month, as well as reducing cramping. It can also be used to minimize the number of cycles a person has per year (“extended-cycle” pill packs are available that will reduce the number of menstrual cycles to 4 per year, and this effect can also be achieved by skipping placebo weeks on regular pill packs). Additionally, the pill can provide endometrial protection as well as a more regular cycle for patients with conditions such as PCOS who are not having regular periods and are at increased risk of hyperplasia or cancer. Finally, certain formulations of the pill, especially those that work to suppress androgens (i.e., testosterone), can improve acne.
The pill is an excellent choice for those who want to try an easily-reversible method that they can control, and it provides largely predictable bleeding patterns, which is a plus. Health restrictions and issues must be taken into consideration when choosing a pill, as should noncontraceptive benefits (like reduction of acne) that users are hoping to see. Pill-takers can use apps or alarms on their phones to help with timeliness, which is the biggest barrier to efficacy that we see. And, as always, decisions about contraceptive methods should be made in collaboration with trusted and knowledgeable healthcare providers.
