The past, present and future of birth control

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Jordan Heath-Rawlings I want you to stop and think for a moment about all the medical breakthroughs and advances that we’ve made over the last six plus decades. I’ll help you with just a few measles, mumps, polio and meningitis vaccines among others. The eradication of smallpox, human heart transplants, sequencing the genome about an extra 13 years of life expectancy in Canada, and too many effective pharmaceuticals for me to list here, including refinements of those drugs that eliminated side effects and increased efficacy. But you know what? Drug has barely changed and still has almost all the side effects that it came with 60 years ago, and in fact now actually has more side effects than it did when it was introduced because we simply keep discovering new ones. You probably guessed it’s the birth control pill. The pill changed. Society gave women the freedom to control their own bodies, to time their pregnancies to focus on careers. It dramatically changed the workforce and the economy. It changed everything. It also sucked to take for many people, and 63 years later, it still does. But why are we still figuring out what hormonal birth control does to people who take it? Why haven’t we made it better or at least found some workable alternatives with fewer side effects or even heaven forbid developed a working contraceptive for men? I am Jordan Heath-Rawlings. This is The Big Story. Nicole Schmidt is a Canadian writer and fact checker, currently based in Berlin. She wrote this piece for the Walrus. Hello, Nicole. Thanks so much for finding a little time for us.

Nicole Schmidt: Thanks so much for having me.

Jordan: The first thing I want to ask you is to start where your story does. Who is Allie Little and what happened to her?

Nicole Schmidt: Yeah, so Allie Little is a 30-year-old woman that I connected with a Facebook support group for women going off of hormonal birth control. She had been on various types of birth control starting from the time that she was 15, and she just experienced this crazy cocktail of side effects. So everything from migraines, she gained 70 pounds in just a few months. She had bouts of depression, and after a few years she finally found a pill that seemed to be working for her, and she was on that for over a decade. And so during that time, she developed some other health problems that neither her or her doctors attributed to the pill, including this heart condition that made her heart beat abnormally fast. And then as those problems worsened, a naturopath suggested that she try going off the pill. So that is what she did. And in those first five months, things improved for her heart condition, just like miraculously disappeared. She felt more like herself. There were some other subtle changes as well. She described food tasting different, her body hair growing back thicker. And then around the six month mark, things took a pretty drastic turn again. So she started to feel dizzy, tired to the point where she couldn’t get out of bed. And then eventually she was actually hospitalized and they determined that she was experiencing some really rare complications from hormone withdrawal, and it took her months to recover. She told me that in those months, no one could have convinced her that she wasn’t going to die. Wow. Yeah. So I ended up speaking with her on her one year anniversary off the pill, and she said she’s doing a lot better, but she’s still recovering. So it’s been a crazy few years for her for sure.

Jordan: How common are side effects like that? I know you mentioned that particular outcome might be rare, but really complicated stuff among people who take the birth control pill.

Nicole Schmidt: Yeah, so Ally’s story is extreme. Things like developing a heart condition or having to go to the hospital because of the pill are quite rare. But a lot of the other side effects that she experienced, the weight gain, the headaches, the depression are quite common. So we have the most comprehensive study into the link between depression and birth control, which was conducted in Denmark back in 2016. And it looked at health records of more than a million people between the ages of 15 and 34. And that study found that those who took the pill were twice as likely to be diagnosed with depression. So were kind of just starting to understand how vast the side effects really are.

Jordan: So when did the pill first come on the market and how is it that many decades later? We are still discovering new side effects of it.

Nicole Schmidt: So the pill first came on the market in 1960. That’s when it was approved by the FDA with the side effects. Part of the problem there is how the healthcare system treats women. So we have studies that have found that women are more likely to have their concerns minimized or dismissed by medical professionals. So one issue is simply that we’re not being listened to, and I think that is the biggest thing at the center of why we haven’t really seen any improvements.

Jordan: How prevalent is the pill? How many people are taking it, or what percentage, I guess, of people who menstruate in Canada worldwide, what do we know about how popular it is?

Nicole Schmidt: So the pill is most common among young people. So between the ages of 15 and 24 in Canada, 50% of that age group actually relies an oral contraceptive, and then that figure starts to decrease with age. But because the pill is quite inexpensive and it’s convenient compared to something like an IUD or an implant, that’s why it’s still an appealing option for a lot of women.

Jordan: Are the risks always communicated to people who are going on the pill and are they understood? This

Nicole Schmidt: Is a hard question to answer. I mean, I can talk a little bit about myself here because this is actually the thing that kind of got me thinking about this story. So I started on the pill quite late by comparison. I was 20 years old when I got on it. After a really brief conversation with my doctor, I kind of went in to talk to her and she had asked why I wasn’t on the pill and just kind of wrote me a prescription. And that was the end of the conversation. There wasn’t really a lot of dialogue, not a lot of questions were asked. And when I was reporting this piece, that story seemed quite common among a lot of women that I spoke to. But of course, it’s hard to speak for everyone here. Some people have really great gps and I’m sure that there is a lot more room for that dialogue. But based on my own experience, and again, people that I spoke with for this story, it seems to not always be the case

Jordan: In terms of the side effects we’re talking about how does the pill work and what causes them?

Nicole Schmidt: So most birth control pills rely on synthetic hormones, specifically progestin, which mimics the body’s naturally occurring progesterone and also estrogen. And what that does is it suppresses signals in the brain that tell the body to ovulate. The issue is that hormone receptors are present through your entire body, not just in your reproductive system. So the synthetic hormones in the pill are really being picked up everywhere, including the brain. And that’s why the pill has the ability to affect everything from digestion to sleep, to metabolism to sex drive to skin, really so many different things. And we just haven’t quite figured out a way to target it specifically to the contained area that we want it to.

Jordan: What are we learning about its effect on the brain as we go

Nicole Schmidt: A lot, actually, this was my favorite part of writing the story as I just mentioned, hormone receptors, they’re present through your whole body, including your brain. So it makes sense of course that some of the side effects that the pill would affect how we think and feel. Depression is something we’re hearing a lot about now, but there are more subtle ways birth control can affect the brain too. One of the most surprising examples that came across in my research is actually attraction. And so biologically, we’re sort of pre-programmed to reproduce, and there is some evidence to suggest that we’re attracted to people, different types of people throughout our cycle. And this is not bulletproof, but the idea is that when you’re at high fertility, you tend to seek out someone with the type of genes and characteristics that you’d want reflected in your own offspring. So maybe you’re looking for someone who’s a little more attractive, who has, again, the type of jeans that would make a good fit. And then at low fertility, the brain switches into long-term partner mode where maybe you’re more likely to prioritize qualities like kindness, loyalty. And when you’re on birth control, you don’t have a cycle, and that means you’re more likely to get stuck in that latter category. And there have actually been documented instances of people who meet their partners when they’re on the pill and were less attracted to them after going off of it. I read one book that was really helpful for this piece, and there are a few women who talk about how they actually got divorced from their partners. They’ve gone off the pill initially to try to have children with their partners, and then they realized that they weren’t attracted to them and it ended in divorce,

Jordan: And that sucks.

Nicole Schmidt: I know these poor partners.

Jordan: I want to rewind a bit. You mentioned that the pill’s been around for almost 80 years now. What kind of safety testing was done on it at the time? What did we learn about it before putting it on the market if we’re learning all this stuff now decades later?

Nicole Schmidt: So the first large scale clinical trials of the pill were actually conducted in the fifties, so in the decade before it came out on women in Puerto Rico. And there were fewer regulations there. So several US officials supported eugenics theories and they believed that poor and racialized people shouldn’t be able to procreate. And so many of the women involved in those studies didn’t even know that they were participating in a trial and they weren’t given any proper information about the risks. And there were so many because those pills had way higher levels of hormones. So the side effects that we talked about earlier, just imagine those amplified tenfold.

Jordan: So how do the pills that people take today differ from those original ones that were first tested? How far have we come?

Nicole Schmidt: Yeah, so there’s a much lower dose of hormones in today’s pills. The first contraceptives on the market had as much as like 98.5 times the amount of progestin and 7.5 times the amount of estrogen, which is just, it’s crazy. So we’ve managed to reduce that and only include kind of the necessary amount. But in terms of the science itself, the technology is the same. We’re still using the same hormones, it’s doing the same thing. So yeah, there’s been very little innovation.

Jordan: What impact did the adoption of the pill have on women in society?

Nicole Schmidt: So there were a lot of really positive things that came from the invention of the pill. What it did was start to break down some of those traditional gender roles that expected women to stay home and raise kids. And the result was really more women in university, more women in the workforce. And also what you got out of that was a more casual approach to sex since it was no longer by default affiliated with having babies. So the pill really did spawn an economic revolution, a sexual revolution, and there’s no denying it was a really good thing for women.

Jordan: Why hasn’t anything replaced it?

Nicole Schmidt: So to talk about this, we kind of have to understand how the market works. And even though a lot of women may not necessarily be happy with their birth control, a lot of people still need to choose an option. You’re kind of just picking of the worst ones available to you. And so there hasn’t really been a drastic enough reduction in the sales of oral contraceptives to warrant any real innovation. When you study women, you need to account for changes throughout their hormonal cycle, whereas you don’t have to do that with men. So a lot of times that means you have to spend more time on them, and of course, more time equals more money. A lot of biopharma companies just don’t want to spend money on it.

Jordan: Well, that explains the difficulty in coming up with alternatives for people who are menstruating. But for men, where’s our birth control? How are we coming along with that? I feel like I’ve seen stories here and there over the past decade about a male pill or various types of birth control for men, but none of them ever seem to make it to trials or to the market.

Nicole Schmidt: Yeah, I mean, this is super interesting because there’s definitely been more interest and conversation around male birth control over the past few years. But the issue there is that studies have shown that it’s just not something that a lot of men are interested in. And why should they have to be, if women are going to shoulder the burden of birth control or people who menstruate are going to shoulder the burden of birth control, why should they have to worry about it? And I mean, I guess that’s an interesting question for even you and the men in your life too. If there was a male birth control pill available, would you take it?

Jordan: It would depend on the side effects.

Nicole Schmidt: Yeah. I mean, that’s a great answer. Right? But because there’s not a lot of interest, this isn’t something that drug companies are lining up to poor money into, right? Because they want a return on their investments,

Jordan: And they know that men by and large are just going to skate on it and aren’t interested in it, so won’t buy it.

Nicole Schmidt: Yeah, pretty much. I mean, I would love to see an alternative world where more men are interested in it. I think that would be very cool. But I do remember reading about one form of male birth control that had gone pretty far in the clinical trials, actually, but the side effects were kind of too much and they ended up pulling it. I

Jordan: Remember that one too. Wasn’t it though that the side effects were deemed too much, even though they’re like one third or whatever, the number of side effects of the actual pill?

Nicole Schmidt: Yeah, I mean, if you read the media reports, that’s what they said. But if you look a little bit closer into the study, there were some actual problems with it. But I mean, at the end of the day, I feel like the problem is the same is that we need birth control regardless of what gender it’s for that is safe and that we shouldn’t have to compromise on

Jordan: What kind of scientific advances are happening in terms of creating, again, for whatever gender, some sort of non-hormonal birth control. I think lots of pills will have side effects, but it’s the hormonal stuff here that as we discussed in the brain and that we don’t clearly totally understand.

Nicole Schmidt: So there’s some stuff that’s currently on the market and some stuff that is still being developed. The two options that are on the market, one, a lot of people are probably familiar with it’s cycle tracking. So you have an app you plug in when you have your period, and then you also can take your temperature every morning, and that can basically help determine the fertile window. But the cool techie thing that’s happening with that is a lot of the companies that have these cycle tracking apps are partnering with wearables companies. So for example, there’s a thing called an aura ring. It’s like an Apple watch, but you wear it on your finger and in your sleep, it tracks your temperature, it tracks your heartbeat. And again, it can kind of accurately determine that fertile window. You can really only get pregnant for a few days each month. I feel like a lot of people don’t know that. But some other cool things, like last year, a new product hit the market. It’s called fxi. I hope I’m pronouncing that right. But it lowers the pH balance of vagina and it makes it more difficult for sperm to swim. It’s basically a gel, but the issue with that is it’s so expensive, it’s like 200 USD for a pack. So that kind of is a barrier for a lot of people who can’t afford that. And

Jordan: In terms of the trackers, that sounds, I mean an awful lot, not too far removed from, I guess what they used to call the rhythm method, right?

Nicole Schmidt: Yeah, exactly. I mean, that’s been around for, right? It’s just we’re getting better at making it a little bit more precise because the rhythm method is really tailored to people who have a normal cycle, but not everyone does have the normal 28 day cycle. Right. One technology that’s still being developed that I’m really interested in is by this Danish fem tech company, and they’re working on what they call mucus engineering, which just sounds hilarious when you say it out loud. But basically they’ve found a way to change the cervical mucus naturally to make it temporarily impenetrable to sperm. And I think that’s really cool. So a few companies are working on things like that, and they’re in various stages of clinical trials, so they likely won’t hit the market for at least a few years. But it’s nice that we’re starting to have these conversations and see a little bit of progress.

Jordan: It’s good that options may be available soon. It’s good that we’re refining, I will say, I guess earlier options, but what is this whole saga and reporting on it? Tell us about the way the health of people who menstruate is taken by medicine and what options are there?

Nicole Schmidt: Yeah, I mean, I think the whole thing shows us that we don’t take women’s health as seriously as we should. Like you said, it’s been almost 70 years since the pill was invented, and we’ve seen little to no innovation why? It’s because we don’t listen to women. We don’t care as much as we should. And yeah, I really do think that this is a field that we should be a little bit more focused on because you could just improve the quality of life for so many people. That was the whole point of the pill to begin with, was to improve the lives of women. And I feel like if we had better birth control, we could do the same now, and that’s what we’re owed and that’s what we deserve.

Jordan: That’s a perfect place to end it. Nicole. Thank you for this. This is a lot of fun.

Nicole Schmidt: Thank you.

Jordan: Nicole. Schmidt writing and the Walrus, that was The Big Story. For more, you can find them at The Big Story podcast.ca. Or of course, in any podcast player like the one you’re probably in right now, you can send us suggestions, criticism, praise, whatever you like on Twitter at The Big Story Fpn in an email to hello at The Big Story podcast.ca, or in a voicemail that you can leave by calling 4 1 6 9 3 5 5 9 3 5. The Big Story available absolutely everywhere. You know that by now, wherever you are. If you haven’t done it yet, please do take the time to rate us, to review us, to tell us what you really think, and most importantly, to put something there so that others who are checking out this podcast for the first time know that it doesn’t suck. That’s always helpful. Thanks for listening. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.