Female contraception: The pill laced with indifference

Contraceptive pill being taken by a woman

Exploring the overlooked complexities and health risks of oral contraceptives for women, and the urgent need for more comprehensive medical guidelines. Image credit: Danilo Alvesd, via Unsplash.

Every year about 1.9 million women contact the NHS regarding contraceptives, resulting in 28% of women in the UK between the ages of 15 and 49 using the pill. While doctors would not prescribe statins without first taking a patient blood test, when it comes to birth control, most women are not tested for hormone imbalance prior to receiving a prescription.  

In line with the ethos of the NHS, to provide a comprehensive service in physical and mental health to all, protocols for prescribing widespread medications, such as contraception, must be as time and budget friendly as possible. Thus, women are regularly told to find the contraceptive that works best for them, even if that means trying several different methods before committing to one. However, this guinea pig approach has numerous pitfalls. Though the first ever over-the-counter birth control pill has recently been approved by the FDA for use in the USA, the mini-pill has been selling over-the-counter  in the UK since 2021. While such news is being hailed as a game changer for women’s autonomy over their own bodies, it comes with a little-discussed but potentially devastating caveat: birth control may not be as liberating as it is made out to be.

Female oral contraception has been linked to a plethora of physical and mental side effects, which range from migraines to cancer, mood swings to suicide. More dangerously, we still do not fully understand how birth control affects a woman’s body, including her reproductive and non-reproductive organs. So, while contraception is inarguably vital for women, the potential damage it can cause needs to be elucidated and discussed more openly. To reduce the risk of involuntarily debilitating women any further in society and health, the way oral contraception is trialled and distributed must be reviewed.

While doctors would not prescribe statins without first taking a blood test, when it comes to birth control, most women are not tested for hormone imbalance prior to receiving a prescription.

In most cases for a woman to receive a prescription for the pill in the UK, she must undergo a consultation with a general practitioner to discuss factors such as age, weight, blood pressure, smoking status, and medical and familial history. The GP then suggests on an approach best suited for the individual, taking into consideration any anecdotal information about the patient’s menstrual cycle and associated symptoms.

For example, a patient who smokes, has high blood pressure, or a family history of stroke will be advised against the combined oestrogen and progesterone pill. However, such a shallow assessment is not enough to indicate the correct contraception for an individual. Periods and hormones commonly differ from person to person and can even change within one’s lifetime due to internal and external factors, such as stress or diet. Therefore, it is no surprise that certain modes of contraceptives are not one size fits all (and no, we are not talking about condoms). Yet, looking at the clinical trial documentation for Opill, the first over-the-counter contraceptive pill pioneered by HRA pharma in the USA, we see that the drug was only trialled in a sample population of 53% Caucasian and 47% African American women.

So, what about other minorities? Latinas made up 18% of women in the USA in 2019 and women of Asian-descent made up more than 5%. Based on this statistic alone, the Opill trials failed to account for a quarter of the US’s female population. This could have dangerous repercussions as individuals not of Caucasian or African-American decent may experience different symptoms. Moreover, they may be dismissed when reporting such instances to local practitioners due to underlying bias since the pill was deemed safe enough for over-the-counter sales. 

To add to the complexity of contraceptive use, its side effects often overlap with symptoms of various reproductive disorders, mental illnesses, and hormone imbalances. Thus, the use of contraception confuses further detection of such conditions. For instance, endometriosis, an oestrogen dependent disease, is often misdiagnosed for other physical and mental maladies. Endometriosis occurs when endometrial-like tissue grows outside the uterus causing pain, psychological and physical dysfunction, and even infertility if left untreated. Yet, one study found that 75.2% of patients suffering from endometriosis were misdiagnosed, leading to an average diagnostic delay of 8.6 years. 

Birth control can drastically help ameliorate or aggravate symptoms, depending on the underlying problem and the hormones involved. For example, birth control can be prescribed as treatment for endometriosis and Polycystic Ovary Syndrome (PCOS). However, in the case of PCOS, oral contraception may heighten the risk of certain PCOS related maladies such as diabetes, cardiovascular issues, and obesity. Though the origins of PCOS and endometriosis are still unclear (despite 10% of women suffering from PCOS in the UK and 10% of women world-wide from endometriosis) , endometriosis is thought to be caused by a hormonal imbalance. Thus, while contraception may help with its treatment, exposure to excess hormones from contraception pills could also increase the risk of worsening the condition. In addition, about a third of endometriosis patients do not improve with contraception treatment. Should we not ask ourselves why that could be the case?  

Yet, one study found that 75.2% of patients suffering from endometriosis were misdiagnosed, leading to an average diagnostic delay of 8.6 years.

Contraception also negatively affects women without underlying reproductive disorders. Aside from immediate side effects (nausea, weight gain, migraines, blood clots, stroke, yeast infections,  fatigue, decreased libido, gut inflammation) very little is known about its long-term impact on women. Even the copper IUD, a non-hormonal contraceptive option, can still cause irritability, mood swings, brain fog, spotting, and depression. While the copper in the coil kills sperm, it is toxic for the thyroid, an organ vital for hormone production. Hormones are important regulators of not just physical physiology but also brain function and emotion. Recently the use of birth control has been linked to mood disorders with higher rates of depression, suicide, and stress amongst users. Premenstrual Syndrome (PMS) is highly linked to severe mental health problems and affects 90% of women; However, there is five times more research on erectile dysfunction (which affects 19% of men) than PMS, alluding to a jarring disregard for female health. The hypocrisy continues, with many clinical trials for male contraception halted as a small percentage of participants were unwilling to tolerate the emotional side effects of the treatment- the same symptoms associated with clinically approved female birth control.  

Additionally, there is a large social aspect to contraception.  No doubt, the ability to control child-bearing has opened up a new opportunity for women in the career ladder, but preventing pregnancy is not enough to give woman an equal stance at success. What are the drawbacks for professional women on the pill? Many types of birth control lead to weight gain, which could affect their careers, as a recent study demonstrated  thinner women are more financially successful. Mood swings due to hormonal fluctuations may affect a woman’s professional success, particularly if they are in positions of power. A recently recognised, more extreme, version of PMS, Premenstrual Dysphoric Disorder (PMDD), comes with all the usual symptoms and more: fatigue, apathy, poor concentration and memory, stress, hopelessness, anger, and insecurity. Symptoms which could negatively impact a woman’s workplace performance and their image. Another form of PMS, premenstrual exacerbation (PME),  can even aggravate underlying mental or physical conditions at certain times of the month. How can a career woman juggle such symptoms while staying on top? The right birth control can limit the amplitude of these swings, while the wrong contraception might amplify them, further showcasing the importance of matching women to the right contraceptive measures.  

There is five times more research on erectile dysfunction (which affects 19% of men) than PMS, alluding to a jarring disregard for female health.

Moreover, some employers are also making female reproduction their business. Nowadays, certain companies boast fertility benefits to attract female employees, yet at times these benefits fronted as “perks” are forms of masked coercion which convince women to put off motherhood. As a society we love the idea of children, yet we give very little leeway to the people who rear said children. Interestingly, it was not always like this. Recently it was revealed that prehistoric women were just as much hunters as gatherers, and when they hunted their young children participated! During the industrial revolution, when the male forces were drafted and women took over their jobs, children were brought along to the workplace. These practices serve as striking contrasts against the current expectations and demands that women can seldom choose both career and family. Career aside, research has even shown that birth control can alter mutual perceived attraction and play a role in the success of physical and romantic relationships. Overall, it seems, on many fronts, society can influence a woman’s reproductive choices. Yet, it appears women are often left to their own devices when trying to regulate their own reproductive health. What could healthcare systems do to help women gain reproductive independence without compromising their own well-being?  

The menstrual cycle is, well, a cycle, with a delicate balance of fluctuating hormones dictating a natural course. For example, during ovulation, progesterone starts to rise while oestrogen drops. One discrepancy, due to excess or lack of one hormone, and the whole cycle is offset. All these considerations are ignored in current clinical protocols for prescribing oral contraception and will be further undermined as the pill sells over-the-counter.  Using contraception to regulate hormones, whether for family-planning, hormone imbalance, or to alleviate maladies, is great if done correctly. This means identifying which hormones are compatible with an individual, the right dosage for the person, and monitoring the pill’s impact on their health long term. Yet this data is missing, possibly due to lack of interest from gender-bias. Even what has been studied often alludes to conflicting conclusions (i.e. The effect of the pill on cancer development). Therefore, it is essential that better and more thorough statistics should be compiled on day-to-day effects of birth control on women.

Though there has been increased conversation in these areas, given that side effects of birth control have recently been trending on Tik Tok, the fact that non-medical professionals (i.e. Influencers) are giving advice may spread more confusion and mistrust. Honest conversations about side effects of contraceptives should be discussed between a doctor and their patient. Blood tests should be carried out to aid birth control selection for, at the very least, first time users of contraception. Blood tests are expensive but can pay off in the long run as identifying the correct contraception for a women from the start may improve their overall health and decrease the number of reoccurring clinical visits due to misdiagnosed, or ignored, symptoms from the wrong contraception. Not only would that improve individual quality of life, but it could ultimately prove financially beneficial for the healthcare system.

It is undeniable that birth control was both monumental for women’s rights, and a revolutionary treatment which could act as a powerful mitigator of maladies for some women.

Recently, fertility tracking kits have also been breeching the market whereby tools such as urine tests can measure fertility hormones from the comfort of one’s own home. Based on this, the user can input their data into an app which tracks their personal hormone profile throughout the month. However, these tests are still expensive, limiting the availability of these trackers amongst the wider population. Additionally, sensitive information regarding fertility should not be exploited for market research but guarded under the realms of HIPPA or the data protection act. Overall, in the hands of healthcare systems, these tests could prove cheaper than blood tests but still an effective way to track patient cycles.  

It is undeniable that birth control was both monumental for women’s rights, and a revolutionary treatment which could act as a powerful mitigator of maladies for some women. This piece does not work to undermine such facts. It only serves to remind, that like progesterone and oestrogen, there is a dichotomy to everything. Until we have comprehensive answers to how birth control and hormones may affect all types of people, stigma about women being hormonal will propagate, leading to even less willingness to understand their needs as equals in society, and leaving women to bear the heavy physical and mental burden of bias.