“What to Expect When You’re Not Expecting,” Yale Daily News Magazine, February 2007
Not long after Ella started taking birth control pills, a new sensation struck. “I couldn’t feel my tits for a month! It was unreal.” It was unreal. Months into her physician-prescribed course of hormonal contraception, Ella experienced, among other things, a steep drop in sexual interest. She grabs her chest for emphasis. “Can you imagine? You just feel numb.” As if to complicate things further, Ella, a 21-year-old Yale senior, says the pills performed a complete renovation of her personality. Not only did she not want to have sex, “I couldn’t control my tears,” she says. “There were times where there were tears streaming out of my eyes and literally nothing was wrong.” Ella had turned into a weepy, grumpy, spacey, cagey young woman—who thankfully, she says, could not get pregnant.
Countless millions of women in the United States are, like Ella, on some form of hormonal birth control. Eighty-two percent of American females—young single women, mothers, married women and girls barely out of adolescence—will take contraceptives at one point or another. Many of the women who choose the popular and diversifying hormonal methods of birth control—the pill, the patch, the shot, the ring—will use them, off and on, for upwards of fifteen years. Anecdotal evidence and a small but growing body of research suggests that Ella is not the only one with a bone to pick against her meds.
The distance between the pituitary gland, at the base of the brain, and the vagina, a bit lower, is about two feet. This distance represents the female reproductive sequence from start to finish, a chain of events that in fact begins in the brain, where the pituitary, via the hypothalamus, stimulates the ovaries, which produce a monthly egg that initiates the basics of the birds and bees after that. Women who elect to go on birth control traverse this distance in pieces, as hormones, delivered through daily pills, regular injections or other means invisibly disrupt the normal call and response of the brain and body.
Mostly, this small intervention has the desired effect. Hormonal birth control, which introduces synthesized hormones into the body in order to prevent conception, is close to 100 percent effective in preventing pregnancy. It works by simulating pregnancy; a woman taking birth control’s regular doses of estrogen, progestin or both has the brain chemistry of a woman already bearing a child and, as a result, does not think to have one. First her pituitary stimulus, then her ovaries shut down, refusing to relinquish their eggs until the brain decides to reopen the gates. Birth control is fast, relatively easy, relatively inexpensive and almost foolproof.
So what is there to complain about?
The problem, as Yale gynecologist Ann Ross explains it, has to do with feedback systems. All over the body. Estrogen and androgen receptors code much more than the pituitary jump-start required to ovulate. Flooded with the elevated doses contained in prescription birth control, the body may respond with a host of emotional, physical and sexual side effects totally unrelated to the basic desire to plan for pregnancy. Ross cites the more known drawbacks—blood clots, weight gain, nausea—but says that depression and decreased libido are potential problems as well. Yale University Health Services handouts on hormonal contraceptives cite these and other issues, but Ross admits she is not sure that women are fully attuned to this register of responses to birth control. These issues are “probably not so reinforced. I really try not to tell people side effects they may have other than the real serious ones like the blood clotting. Those are the ones we focus on. But the psychological, emotional ones I don’t really go into in detail.”
This makes sense. Doctors, trained to think about what can kill people, tell patients about risks to their body on birth control, but gloss over what can be murder to the mind on the same drug. This is partly because the details are still unclear. We know, for example, that one in 200,000 women on birth control will die from a blood clot, with higher incidence among smokers; however, the prevalence of depressive or sexually disruptive effects is nowhere near fully understood. Not much research has been focused on these supposedly peripheral effects, and the question of how precisely psychology and sexual function can be pegged on birth control has been debated since the initial launch of the drugs into the American market in the 1960s.
When Enovid, the first “Pill,” was introduced, a million women rapidly jumped on board a project that promised to change entirely the way women have sex. Women expected increased personal choice and the freedom to have sex without reproductive concerns—and the pill has certainly lived up to that hype. What was less clear is how generations of hormone use would change the way women think, feel, and behave, in sexual and nonsexual spheres.
Evidence that pregnancy prevention is merely the tip of the iceberg can be found in abundance in apartment 202 of the Oxford Apartments in New Haven. Empty wine bottles and women’s magazines are standard issue accessories for the group gathering. Mary, Nora, Shayla and Tess are senior classmates at Yale, whose chatter in the comfortable living room touches on men, midterms and Thanksgiving break—but I want to talk contraception. Though inserts in every packet of birth control list important health information, including side effects like depression, “anxiety”, or stroke—and birth control remains a medication that must be prescribed by a physician—finding feedback on birth control outside hospital walls is often difficult. For the five of us gathered, one primary feedback loop starts, in fact, among peers.
The swirl of outside variables in the birth control equation quickly becomes clear. Mary, true to demographic projections given by Dr. Ross, started the pill when a serious relationship began in college. Shayla began her sophomore year in high school, Nora and Tess at 17 or so. Nora thought the pill would help clear her skin; hormones in the pill stabilized Tess’s periods and helped with chronic migraines. Shayla says her prescription came “when I was 16, right after I told my mom I was having sex and she was like, ‘Not not on the pill you ain’t.’” Everybody laughs—that much is understood.
Shayla, a New Yorker with long brown hair and eager intonation, says that after about a month of pill use, she began exhibiting strongly depressive tendencies. The crying and listlessness grew into a problem that led her to three different psychiatrists, all of whom recommended Prozac to help with her moodiness and anxiety. The connection with birth control became clear only when the final psychiatrist began questioning other changes in her life, and the issue of sex with a new person arose. Almost as an afterthought, the pill was deemed the culprit and she was hastily switched to a lower dose, the Prozac forgotten.
We are all astonished that no one made the connection for Shayla. I am more astonished that my friend reached a point of such despair just by taking a pill. Birth control, meant to prevent implanting an unwanted body within you, can apparently create an unwanted mind—your own. The woman who, like Shayla, reacts strongly to hormones is merely trading miseries when she goes on birth control. Even now, five years into this new arrangement, Shayla admits she still has difficulty with anxiety and that “honestly I could go off the pill tomorrow and realize that commercials and sad movies don’t make me cry. I just don’t know.”
Tess adds: “I can’t imagine what it would be like not to be on the pill.” A chorus of yeahs, and a thoughtful pause, hit the room.
What imagination can’t effect, going cold turkey can. Nora, who quit the pill in the last year, thinks that without distance there is no way to tell. “I was on it for so long that I don’t think I realized that I was totally crazy on birth control. So I never thought, ‘Aaah, I’m crazy because I’m on birth control’; I just thought I was crazy. You know? But I never thought that switching to a different brand of oral contraceptive would do anything to switch how I felt about life in general.”
My friends get noisy when sharing similar light-bulb moments, when the hormone-mood connection clicked. “I remember when I first was on it I would get horrible mood swings all the time, and I remember sitting at my computer one day, just reflecting about how pissed I was about something and I was like ‘Oh my god, Mary, you’re crazy. Like, seriously, what is wrong with you?’” She turns to Tess, who has lived with her all four years of college. “You remember, I’d be, like, crazy…”
Her roommate chimes in: “Yeah. You were not sane.”
Shayla is laughing, too, but insists, “It’s really hard to explain to someone: Even if you think this is illegitimate, the emotions I am feeling are very real. Even if it’s a chemical, even if it’s this ridiculous thing, you don’t understand how miserable I am right now. It’s like, how can you not get it? And it’s really frustrating because then you really just do seem crazy. But it’s impossible to convey. It’s freaky because it makes you realize how much your emotions are based on chemical reactions.”
The chemicals are everywhere. 16 million American women are said to take hormonal birth control. And these millions, in apartment 202 and countless other bedrooms, offices, kitchens and classrooms across the country, have been truly changed by the pills that they take. The totality of this change has much to do with the basic nature of all medication. The additional hormones, like most drugs, disappear into the body once taken—subject to individual body chemistries, of which no two are alike. But the collateral damage of hormone shifts in particular are almost impossible to measure. Tears are not a rash, numbness is not swelling, yelling is not heart failure. As a result, birth control’s effect on female psychology often flies under the radar, making it easy for doctors like Ross to focus on the physical first.
But a baseline calculation of “reality” or “self” is hard to come by from within one’s own altered brain chemistry. As Nora suggested, understanding a psychological reaction may be possible only after going off of or switching hormonal methods. And as with Shayla, extended use may make a former personality seem inaccessible. This makes responding to adverse effects, by seeking medical or psychological support, less a problem of ignorance than of self-awareness. The millions on birth control have thought to do something about family planning and sexual choice—but if you don’t know who you were, you have little grasp on who you are on birth control. If you don’t know something’s broken, a fix is impossible.
The trouble of not knowing can go beyond the hormonal hijacking of one’s emotional state. Maya, a 21 year old whose name has been changed for reasons of privacy, was put on the pill at 16. It was not for sex. She was flat and boyish well past the age when most of her peers had started menstruating. Her pediatrician clued her into “low estrogen levels in my bloodstream, which meant that I was not getting my period. They were worried that my bones wouldn’t absorb enough calcium and I would get osteoporosis and become a scary hunchback,” she says, in her quiet, offbeat way. To fix the estrogen deficiency, Maya started a course of birth control that, with a memorable three-month exception, has continued unbroken until today.
Dr. Ross has told me that it is not uncommon for birth control to be prescribed as a corrective for conditions, like amenorrhea, that are totally unrelated to contraception. Cramps, migraines, acne, and in Maya’s case, a bashful period, are all acceptable causes for medication. In the five intervening years since her original prescription, Maya has taken nearly the whole catalog of conventional hormonal contraceptives, from high and low doses of Ortho Tri-Cyclen, to Depo-Provera, a progestin-only injection taken four times a year, to Yaz, a low-dose combination pill that shortens the actual period to four days. A bevy of adverse side effects, from raging irritability to ballooning breast size to weeks-long “spotting” fueled the constant search. She has never felt totally satisfied with any method. But while disruptive, none of these inconveniences seemed different from the basics she had observed and heard about from other friends, she says. She filled out, and after they began at 16, Maya’s periods continued like clockwork.
The other shoe dropped three months ago. Maya had gone off the pill at the beginning of last year for a trial period, “to see if my body had caught up with itself”, she says, and could produce estrogen naturally. Nothing doing. “I didn’t get my period for three months. I freaked out and took about four pregnancy tests because for the first time in my life I wasn’t on any kind of birth control.” The tests were negative, and she went back on a low-dose pill to be sure, but months later at the gynecologist, she finally wondered aloud just what the deal was.
A few blood tests later, the low-estrogen diagnosis from her pediatrician in 2000 was revealed to be, in fact, a symptom of primary amenorrhea. Maya doesn’t ovulate. “The birth control has suppressed symptoms of that for six years,” she says matter-of-factly, twisting and twisting her jewelry in her apartment. “Which I just found out means that if I wanted to have a child I would need like, reproductive assistance and hormone therapy and stuff. I was pretty unhappy.”
Maya understates the irony of this. Her perennial dissatisfaction with birth control and the stresses of being vigilant about pregnancy are now moot; instead, a more life-changing problem has sprung its trap. “I was flabbergasted to find that out at age 21 that for almost six years my body had been running amok with no idea what it was doing and I didn’t know about it. And that was really upsetting to me. I felt like my body was dysfunctional and that the birth control had been tricking me for years into thinking that I was just like everyone else, when I’m not.”
Though it still smarts, Maya has come to terms with this diagnosis—and more hormones are in her future. Fifty years ago, her situation would have been hopeless, but fertility drugs, like many facets of women’s health, have improved drastically in the modern era. From the early, high-dose Enovid to today’s plethora of birth control options—different doses of estrogen, progestin-only pills, shorter periods, less frequent periods—increasingly diverse means of administering hormones are available. Yet somehow this burgeoning contraceptive industrial complex still failed her.
So who did this to Maya? Or the other girls, for that matter? I spoke with young women who experienced sudden and debilitating nausea, drastic, unwanted weight gain, flu-like, stress-induced sicknesses, absent libido, strains on personal relationships and oceans of tears. At every turn these women have compromised something critical to their emotional hygiene so as not to complicate their lives with a child. Who could have known better, done better by all these young women trying to stay baby-free?
The issue is that it is about sex and not about sex. “It’s hard to separate them out,” says Marjorie Green, a gynecologist who specializes in vulvar pain, decreased libido and other signs of Female Sexual Dysfunction—a condition defined for the first time in 1997 as difficulties with desire, arousal, pain and orgasm. The American Medical Association says the disorder affects some 43 percent of women in the US. Dr. Green is a member of the advisory board for the Women’s Sexual Health Foundation and one of only a handful of gynecologists in the country whose practice places an emphasis on female sexual medicine and women who, like Ella, find no joy in sex.
The waiting room outside Green’s office, the Mount Auburn Female Sexual Health Clinic in Cambridge, MA, is full of such women, reading Redbook and Metropolitan Home and suffering from a wide range of symptoms that make sex difficult. A certain proportion of them, Green says, experience sexual dysfunction as a result of hormonal birth control. Ella’s old riddle of sexual disinterest straddles psychology and internal medicine. In Ella’s case, her body actually felt deadened, while another senior who used to take birth control claims that the pill affected her mind. “I lost most of my sex drive. I have never had so much sex with hardly any orgasms in my life,” she says. Green explains that the pill and other birth control sucks up free testosterone in the body, which controls the sex drive. For some women the decrease causes vaginal dryness and accompanying pain. For others, the change means a total disinterest in sex.
Whatever the eventual effect, birth control is designed to allow people to have sex more freely, and, if you ask some feminists, fairly—but women taking the pill in order to have sex that is worse find themselves Caught-22. They are trading again, this time forfeiting good sex just to have sex.
Green rightly points out that it is a matter of personal cost-benefit analysis. “Women have to make decisions. They have to decide what they’re not comfortable with. The fear of pregnancy can be greater or worse than the fear of sex.”
Ross made the same point. Worries about getting pregnant can be as much of an obstacle to sex as a hormone-related dip in libido, she said. “A lot of people decide that, okay, so their sexual functioning may be a little bit affected, but they need the contraception.” She is sketching just what I’ve observed, the polar outcomes the medical and social establishment forces a woman to choose between—no baby or no peace, her body or her brain.
Research and discussion of hormonal birth control has lagged behind the rapid expansion of the industry. For something in such ubiquitous use among women 15-44—not to mention its intricate relationship to the way family planning and sexual culture has evolved over the last 40 years—the comprehensive study of birth control has become a matter of scientific inquiry only in this millennium.
Professor Jayashri Kulkarni can’t understand the silence from the medical community on female issues of sex and contraception. A psychiatrist at the University of Melbourne who specializes in mental disorders and their effect on women, she has done some of the only existing research on the connection between hormonal birth control and depression. Searching for other medical practitioners who were studying the mind-body hormone link, she was surprised at the lack of prior research done using a clear, randomized controlled methodology. Such research, she says, is typically the first step in any kind of medical or social advocacy for a condition.
In a pilot clinical trial, Kulkarni tested 62 pill users for symptoms of depression, using a number of conventional psychiatric depression-rating scales that assess anxiety, insomnia, irritability and libido, among other variables. Her results were astonishing. The study showed that otherwise healthy women using the pill were suffering from mild to moderate depression, with an average depression rating of 17.6, compared to 9.8 in the non-user group. The participants on the pill were twice as likely to experience irritability, intolerance, feelings of guilt and general anxiety—symptoms experienced by Ella and a half-dozen other Yale women. “It didn’t reach the point of hospitalization,” Kulkarni says, “but the common symptoms that were described were dysthymia—a low level of sadness that was pervasive, that didn’t really shift no matter what the activity the person was undertaking.”
The complexities persist; the study’s implications are more than strictly psychological. Kulkarni also found descriptors of anhedonia among pill users, which she defined as “the inability to enjoy things to the fullest extent.” This mental numbness corrupts activities that would normally be pleasurable—including, of course, sex. Decreased libido, she explains, is also one of the telltale symptoms of depression, and yet another formulation of Ella’s bad-sex-to-have-sex conundrum.
But more interesting to Kulkarni, beyond a small-scale confirmation of a long-suspected problem, was the social conversation triggered by the trial. Following her study’s publication in November 2005, Kulkarni received a deluge of personal emails thanking her for her work and in myriad ways confirming the results of the trial. She counted 374 separate missives from women “clearly describing when they went off the pill that they felt subjectively more happy. The anhedonia, for example, disappeared, the irritability disappeared, the sense of poor self-esteem disappeared.” Once again, cognitive distance from the “pill self” helped hundreds of individual women see the impact of hormones on their mental state, and, coupled with raw facts, energized a correspondence between doctor and patients that shows the issue is ripe for explosion into the public domain.
Like Green’s pioneering practice in Cambridge, Kulkarni is taking a socially eclipsed part of the women’s health equation and making it medically relevant. She continues to push for a massive double-blind controlled trial to get at the heart of the birth control issue. In the future, she says, “it should be possible for a woman to go to her local doctor and say, this is making me feel terrible, let’s try something else. Whereas that information is not really there for either the woman or for her doctor at this point.”
Dr. Kulkarni’s department at the University of Melbourne champions a quotation from medical Nobel winner Albert Szent-Gyorgi: “Discovery consists of seeing what everybody has seen and thinking what nobody has thought.” What we have seen since 1960 is a booming number of American women, up another 4 million since 2002, taking the pill or other hormonal contraceptives. What we know about the consequences of such a widespread cultural practice are, with work like Kulkarni’s and Green’s, becoming clearer. But what we think about this effortless invader into modern medical and sexual dynamics may make all the difference.
Sex on birth control is, it seems, a mind-body exercise. Maya thinks that familiarity without facts can be dangerous. “I think that people sort of just ‘go on the pill,’” she explains. “They think that it’s like a condom. And it’s not like a condom. It changes your body. Nobody would take testosterone without telling someone that it’s full of testosterone. Nobody takes, I don’t know, insulin, and doesn’t tell you that it’s insulin. Whereas with birth control, they don’t tell you; they don’t always explain well enough what it is and what it does to your body.”
Ritual hormone-ingestion can make a woman oblivious to irregular behavior within her body. Likewise, careless medical professionals who prescribe and re-prescribe hormonal contraception without conversation can contribute to the knowledge gap. Physicians can build a climate of awareness about broader range of side effects, to either guide the treatment of hormone-sensitive women like Shayla, or catch total mismatches, as in Maya’s case. Those who don’t are part of the problem. Annual gynecological exams provide an opportunity for women to check in with themselves and a physician. Both Ross and Green stress the importance of taking a good medical history at these junctures, and encouraging a environment of openness that allows women to really evaluate their reproductive health. Though doctors talk about change and inquire about contraceptive use and habits, Green says, they can’t reach all 82 percent of American women who will try birth control, much less the millions of other women planning families worldwide.
The makers of drugs, however, can and do. And the inserts that accompany all prescriptions for birth control emphasize sexual and psychological factors even less. The low-prevalence blood clots and stroke warnings are there, but the Ortho Tri-Cyclen website provides a handy “Questions to Ask Your Doctor” section that makes no mention of sexual dysfunction or depression as potential side effects—whereas a full section is devoted to their product’s miraculous ability to clear acne.
Ella chalks it up to social engineering. “Depression is never really marketed as a side effect; all of the advertising about birth control is like, skinny women running through flowers because they are so happy about all the baby-less sex they are having.” She is right on about the advertising. Johnson and Johnson’s direct marketing of Ortho Tri-Cyclen as a medication that can clear up blemished skin has been one of the most successful campaigns in medical history—save, perhaps, the Viagra phenomenon. Similarly, a full-page ad in a nationally-circulated women’s magazine shows a woman holding her NuvaRing aloft with a hand accented by a wristful of bangles—the message being that the ring, like a pretty bracelet, is an accessory that comes on and off with ease.
In practice, medicine in America is a top-down process, and it is fairly simple to guess from which end the big decisions come. “The industry won’t support telling millions of women not to take the pill,” Green concludes. And why should it? Based on an average price point of $26 a month, $312 annually, American women on birth control are responsible for a nearly $5 billion payout to the pharmaceutical industry each year. The growing social expectation that women will take charge of their reproductive future has led to an accountability gap on issues like sex and mental hygiene, unrelated to typical industry concerns like safety and accuracy of prevention. Big Pharma has a rock-solid consumer base and, absent widespread awareness and indignation, no incentive to change their imperfect drugs.
If, say, a woeful, weepy patient manages to wade through the sea of evidence that hormones are friendly, that women are naturally moody, that contraception is the best thing since the high heel, that she is just fine—and expresses concerns, sexual or psychic, to a doctor—the solutions are still fairly limited. Gynecologists can fiddle with the androgen and progestin levels in a pill, but to keep her womb empty, this woman will inevitably have to compromise.
It isn’t working. But it is. Reliable hormonal birth control, in its half century of existence, has at once done everything and nothing for women’s health. The incidence of failure for these methods is incredibly slim. Those who take birth control properly almost never experience unwanted pregnancies. But the incidence of failure in psychological, social and sexual arenas should be equally intolerable to a society concerned with a comprehensive picture of women’s health. After all, for women avoiding becoming pregnant in body, birth control functions by making them pregnant in mind. Society tiptoes around pregnant women, pickles and ice cream at the ready, but I now imagine hordes of women wandering “pregnant” and distraught through life, completely unheralded. This is not an apocalyptic scenario, but a persistent worry that may deeply affect not only women but all those who care for them.
The two feet traveled from brain to body has grown longer and harder in the age of hormonal contraception, becoming a marathon distance that encompasses sex, doctors, men and marketing, fear and frustration. The casualness with which women are expected to be on birth control and the concurrent casualness with which we respond to that expectation has produced a host of complications, social and medical, that will take the work of many committed ambassadors to reverse. Fittingly, the aspect of pregnancy is totally divorced from the issue. In the second fifty years of birth control, what will matter are the people, ideas and yes, medicine, that help to bridge that distance.