The Pill isn't the perfect solution everyone claims it is.
It was at a medical conference in Orlando, Florida, some years back when I decided I must write a book about, and for, women who have been victimized by the health care system. As a family physician practicing for more than twenty-five years, I’ve had countless women come through my doors with a myriad of gynecologic concerns. At this particular conference, I asked the lecturer—a prominent women’s health physician—to explain why he did not mention the connection between cervical cancer and the use of oral contraceptives in his talk on cervical cancer. He replied (before three hundred other physicians), “Let’s keep that to ourselves.”
Let’s keep that to ourselves? Keep information from patients?
The status quo, it seemed, was this: Let’s keep women in the dark about the risks associated with using the Pill. Women today are prescribed the Pill from a range of doctors—general practitioners, dermatologists, psychiatrists, OB-GYNs, and others. There is an overriding concern in the medical community across all disciplines of preventing unplanned pregnancy. I came to find this thinking problematic because in effect it presumes that women are incapable of making choices about their reproductive health care.
For a physician to think a woman must take a contraceptive pill to avoid pregnancy, especially when she isn’t seeing the doctor for that expressed concern, is for a physician to place his or her agenda ahead of the patient’s best interests. It makes sense for doctors to have an “agenda,” if by that we mean a predisposition to helping patients avoid diseases and inform them of it. But when it comes to the Pill, we’re talking about suppressing not an illness but healthy fertility. It may seem worthwhile in the name of preventing a woman from having an unexpected pregnancy, but it’s up to the woman to make the choice of whether that benefit is worth the risks of the medication.
Still, this “let’s keep information of the risks to ourselves” thinking isn’t isolated to one physician on a panel. Physicians in training during the past thirty years or so have been taught to find any reason to put women on some form of contraception—without mentioning any possible risk associated with these methods. Physicians in the United States may agree on the facts concerning the physical and physiologic side effects of hormonal contraception, yet the vast majority of them still prescribe any and all manners of artificial contraception with little visible hesitation.
So, you may ask, why doesn’t my family doctor, my OB-GYN, my dermatologist, my psychiatrist, and so on—why doesn’t anyone mention the risks? I’ll tell you why—because I used to be a physician who didn’t.
The reason for this peculiar contradiction is that while depression, cancer, stroke, heart disease, and increased risk of blood clots are most certainly problematic, most doctors are trained to see them less of a problem (for women as well as the rest of us) than the overarching “problem” of pregnancy.
For many in the medical community, pregnancy, especially in young women, is considered to be a disease. There's somewhat of an indoctrination that all physicians receive as we go through seemingly endless years of medical training. I experienced it myself going through school. I was taught, as in intern in family medicine, that one of the first questions I needed to ask every woman within the first twenty-four hours of delivering her baby was, "What are you planning to use to prevent another pregnancy?" (Talk about timing—most women will accept any form of birth control after going through a difficult vaginal delivery.) I was instructed that women who have had two or more children should be strongly encouraged to consider permanent sterilization. And teenagers seen for pretty much any concern are to be encouraged to get started on long-acting forms of contraception—regardless of their level of or interest in sexual activity. If pregnancy was a disease, preemptive contraception was the vaccine.
Not only is medical school and residency highly structured and resistant to change, medical students and residents in training are in no position to question the views of their instructors, often for the real fear of losing all they have striven to achieve in a career in medicine.
As a trusting medical student, and then a faculty member who taught other doctors, it took me years to come to the realization that during those years I was blinded by a combination of stubbornness and ignorance.
This discussion surrounding female fertility and family planning is controversial, to say the least. There are many differing opinions, but my own experience has led me to a conclusion that, thirty years ago, I never would have believed.
All physicians have sacrificed a great deal to get to the point in time where they can actually provide healthcare to patients. During the majority of my near three decades in practice, if I was approached by someone trying to tell me that what I was taught to do by my preceptors was “bad medicine” or “harmful” to women, I would reject their criticism outright. I would figure they were just some overly zealous, ill-informed doctor who, though they meant well, was clueless as to how best to treat women. That was my attitude; no amount of factual data on the harms of the Pill, the shot, the implant, the ring, the patch, the IUD, or sterilization could change my mind about how to care for my female patients.
As is often the case in life, it wasn’t until it affected me personally that I changed my perspective.
Close to Home…
After welcoming three beautiful daughters in the first five years of marriage, my wife and I had to make a decision to limit our family size using some form of birth control. That's when the truth about female fertility really hit home for me. Since my wife’s mother had died at the age of 52 from a cerebral aneurysm, we knew that exposing my wife to artificial hormones would place her at increased risk of stroke. We were convinced for other reasons that permanent sterilization was not an option for us either.
Only in later years did I discover that one-third of women who chose Bilateral Tubal Ligation regretted this decision. Further research has also correlated other serious health issues with Bilateral Tubal Ligations, such as an increased occurrence of dysfunctional uterine bleeding.
At that time we were able to find other couples who were learning, and then teaching, natural methods of family planning. Kathleen and I learned of the Fertility Awareness Method (FAM) and ultimately chose to use the Billings Ovulation Method for the rest of our marriage.
The Billings Method allows couples to either avoid or pursue pregnancy by determining the body's natural fertile and infertile periods, based on observing and charting vulva sensations and the discharge of cervical mucus. Couples using the Billings Method to avoid pregnancy then avoid sexual intercourse during the fertile days of the cycle. When we starting using the Billings Method in our marriage, it put the challenge on me as a husband to communicate about and cooperate with my wife’s fertility, rather than ending or altering her fertility with chemicals.
This allowed us to refrain from having kids for a number of years, and then when we returned to seeking pregnancy we had two more children—all while preserving my wife’s health. Because had we gone the route of the Pill, it's exactly that—her overall health—that could have been compromised.
The fact is that the normal human estrogens, progesterone, and testosterone produced by the ovaries do far more than simply help a woman to achieve a normal reproductive cycle and pregnancy. The natural ovarian hormones act on practically every organ system in the woman’s body to ensure optimal functioning. Examples include improved mood (especially during elevated estrogen phases), reduced risk of heart disease and stroke (as compared to men), cleansing of the breast tissue with each normal reproductive cycle to reduce the woman’s risk of breast cancer, and improvements in bone mass to prevent osteoporosis and premature fractures. Not to mention improved libido and overall energy level.
Conversely, women using these artificial hormonal methods may be at increased risk of cardiovascular disease (largely due to the chemicals causing deficiencies of essential vitamins and minerals folic acid, magnesium, and B12). Depression is a common side effect, due to the folic acid deficiency as well as the relative lack of estrogen (a “feel good” hormone). Loss of libido, weight gain, and premature bone loss also frequently occur. One study found that breast cancer rates in women who have used the Pill for more than five years prior to first pregnancy are two to three times higher than in women who have never used the Pill. And women who have been on oral contraceptives for any length of time will find they are at an increased risk of miscarriage within several months of stopping the Pill.
Needless to say, what I experienced in choosing a method to protect my own family forever changed the way I saw my patients. It may sound obvious, but the notion became much more solidified in me: every patient’s life and health should be treated of equal value to my wife’s. But when I returned to my practice to start incorporating FAM and other fertility awareness methods in my work, I faced a well-established rhetoric that proved difficult to overcome.
The Pill That Rules Them All…
The Pill was a game-changing technology when it was invented a half-century ago. During these past fifty-plus years since the discovery of the pill and its widespread embrace in the 1960s, many women have believed that artificial birth control made them more powerful than ever before. The ability to remove the possibility of pregnancy from the sexual act was seen as liberating event.
But the Pill didn’t just provide advancements in what medicine could do; it has also been treated differently than any other medication prescribed by physicians to patients. Unlike other medicines which are usually only prescribed when medically necessary, the Pill is prescribed routinely and by default.
Further, unlike other medications that are prescribed along with a warning of possible risk, the Pill is often prescribed without any sense of hesitation from the prescribing physician—stating risks is viewed as less important than encouraging the woman to take it.
One example of how common this thinking is in the medical world took place at a conference on migraine headaches that I attended. Upon being asked to discuss the increased risk of stroke among women who suffer from migraine headache and use oral contraceptives, the physician speaker answered, to a room of over a couple hundred physicians that it would seem impractical to ask women to discontinue the use of oral contraceptives so as to prevent stroke, for fear of pregnancy. While the facts are what they are, the primary goal of avoiding pregnancy takes precedence.
This thinking, that pregnancy reduction is more important than informing women of the risks of the Pill or other contraceptive medication, is pervasive in my field.
FAM, on the other hand, has been distorted in the medical textbooks, and most physicians still refer to it as the “rhythm method” of ages past. In fact, when taught and used correctly, modern methods of FAM have an effectiveness rate of 99 percent, which is as effective as the Pill for avoiding pregnancy.
Nonetheless, instead of pursuing the natural methods to avoid pregnancy, today's medical community prefers to encourage prescribing stronger hormones and devices, even if it means lessening a patient's agency over her fertility cycle. In recent years, ACOG (American Congress of Obstetricians and Gynecologists), the professional organization representing most of America’s OB-GYN docs, has encouraged women’s health providers to recommend to teenage girls in particular to utilize LARCs (long acting reversible contraceptives), which do a more effective job of preventing pregnancy—though at increased risk to her health. IUDs going by the pharmaceutical names of Mirena and Skyla have highly touted effectiveness, with less than 1 percent pregnancy rate per year of typical use; that high prevention rate, also seen in such implants as Nexplanon and Implanon, and the long acting injection, Depo-Provera, is what makes them so popular today.
The use of these long-acting methods of contraception for young women came to my attention in 1995 when my wife was working toward her master's degree in maternal and child nursing. Kathleen came home one day from a rotation at a county health department in rural Georgia, where she saw many teenage black girls who were lining up by the dozens to receive their quarterly injection of Depo-Provera, which, while preventing ovulation also dramatically reduces estrogen levels to that of a postmenopausal woman and so creates a host of adverse effects in its users. In speaking with several girls, she found that many had not even experienced their first menstrual cycle, and the majority had never been sexually active—they were simply told by their parents, grandparents, teachers, or government agencies that they need these quarterly shots for their own good.
What the general public doesn’t know, and what I detailed in my recent book, The Hidden Truth: Deception in Women's Health Care: A Physician's Advice to Women and All Who Care for Them, is this: Each of these LARC methods dramatically alters the woman’s normal hormonal makeup and replaces it with a host of artificial/synthetic female hormones that, in turn, suppress the healthy function of the woman’s ovaries. Not only do LARCs produce many of the risks as the artificial hormone methods mentioned above, the LARC Depo-Provera for instance makes estrogen levels fall so low that calcium is no longer taken into the bones, creating decreased bone mineral density in many users, not to mention significant weight gain. IUDs, which are abortifacient in that they interfere with formed embryos from implanting to uterus lining, are associated with heavier, more painful menstruation in many women. And while the ACOG stresses that contraceptive implants and IUDs are removable, many young women tell me they are having a tough time convincing their doctors who put them in to take them out. Further, while it is quite an easy procedure, it is often billed very highly. These highly billed patient costs no doubt influence women's decisions.
Changes Unforeseen
Today, I have listened to and served female patients as a physician for almost thirty years, providing prenatal and obstetric care, caring for their gynecologic needs, and caring for their families—their husbands, their children, their parents. This has been my privilege as their family physician. And today, more than ever, I listen to women as they tell me the many ways in which they are suffering—truly suffering—as a result of choices made not only by themselves, but by their parents, their husbands, and their physicians. I too used to be that physician.
But now, it saddens me to see the effects of the Pill at play in unsuspecting lives. How often have I seen one patient after another frustrated by what has come to be viewed as a "necessary evil" for all women, if they ever hope to be a good wife, a good girlfriend, a good sexual partner. What is so "liberating" or "empowering" about feeling miserable, depressed, increasing one's risk of breast cancer, cervical cancer, blood clots, strokes, and heart disease, while the male partner has not a worry in the world?
Take for instance the young women on the Pill for acne who is struggling with depression, taking antidepressants at the same time, having never been told that the Pill is linked to depression.
Or the patient who came in my office who decided the side effects of depression and weight gain she had experienced after receiving Depo-Provera injections wasn't worth the pregnancy-avoiding effects, and signed up to learn more about how to track her fertility naturally.
Or another who I met in the ER who suffered a blood clot in her lungs after being prescribed oral contraceptives. While the Pill carries increased risk of blood clots in all users, it was particularly dangerous for this young woman who, unbeknownst to her, had a condition known as thrombophilia. After treatment with blood thinners for several months and stopping the Pill, she became anxious to learn about natural ways to avoid pregnancy without putting her life at risk.
I’ve also heard from women struggling in their marriages, after the birth of their first child, wondering why after going on the Pill, they have lost energy and libido. Often their husbands do not recognize them as the same women they married. Indeed, the relative absence of normal levels of female hormones can change the woman’s moods and emotions greatly. Simply take a moment to review recent studies on the changes in the limbic system of the brain (the emotional center) in women on the Pill after only three months.
It’s fascinating stuff—yet sobering.
All this explains why, in the middle of a crazily busy family practice, not to mention family life, I chose to write a book about, and for, women. I have seen women, day in and day out, who have made enough sacrifices in life already. Asking these women to make healthcare choices that further compromise their overall well-being is bad health care.
I believe in serving the reproductive health care needs of all women, we should consider more natural alternatives that do not put women at an increased risk of disease and at the same time encourage their male partners to demonstrate equal level of responsibility with regard to the prevention of unwanted pregnancy. As I see it, true equality of the sexes in matters of family planning would not require women to bear the brunt of risks, but one that requires men demonstrate some level of sacrifice as well.
Many couples I meet, once they hear all the information about FAM, prefer to refrain from sexual activity for the seven days or so that the woman is fertile, rather than put the woman at risk with artificial hormones. Couples using natural methods of family planning find that the need to communicate more often about the changes in the woman’s body leads to an increased respect for the woman and increased self-control and maturity in the husband.
Which is why I ask all women—and the men in their lives—to come to a better understanding of who they are, in their natural state, with normally cycling female hormones and to learn natural ways to deal with issues such as family planning and other gynecologic concerns. Female empowerment comes from knowing all the options. When a woman has agency over her health decisions and feels comfortable discussing them with her doctor and her partner, that’s when we’re all better off. Turning blindly to the Pill is not a fix-all; in fact, it’s quite the opposite.
-Dr. John Littell, MD
