The Pill, Forty Years On

A packet of birth control pills.

Since its introduction in the 1960s, the birth-control pill has been the contraceptive of choice for American women. Corbis hide caption

itoggle caption Corbis

The pill has been the most popular form of contraception for American women for four decades. And just last week, the FDA approved the first form of the pill that completely eliminates a woman's period. Michele Norris speaks with Cynthia Pearson, director of the National Women's Health Network, and Dr. Carolyn Westhoff, medical director of the Family Planning Center at Columbia University, about what has changed since the pill first came on the market, and other contraceptives women turn to.

Take us back to the early 1960s when the pill was first introduced. It was really seen as something that was absolutely revolutionary for women. Why?

Cynthia Pearson, Director of the National Women's Health Network: Up until that time, women and men who were trying to control their fertility were relying on methods that were used at the time of sexual intimacy. They could be effective, but human nature being what it was, they weren't always effective. So there was a big need for more effective contraception that was separate from the time when sex took place.

How was the pill marketed?

At first it snuck in – not that the FDA didn't know what it was going to be used for, but the company's first request was to approve it for menstrual cycle problems – heavy periods, painful periods, and it was to try and kind of sidestep that whole sex thing, to get it out there and get it into doctors' knowledge and experience. But quickly, the pretense was dropped, and it was also approved for use as contraception, and it was marketed in the way that all medicine was in that day — which was strictly to doctors. There was no consumer advertising in the '60s — that's a recent phenomenon. But because it opened up this door to discussion about women's sexuality, it didn't need marketing to be known by consumers instantly — it was the topic of conversation.

The pill has been on the market for four decades. What do we now know about the health risks associated it?

We know two things. We know there are some serious and rare risks of the pill. Blood clots are a real risk. And blood clots — depending on where and how they happen — can cause heart problems and brain problems. The cancer risk is elusive and very small, if real. In some studies, it's associated with a slightly increased risk of cancer in women in the perimenopausal years. But that's not confirmed yet though because that's a relatively new way of using the pill. For quite a long time, there were questions about an increased risk of breast cancer in young women who stayed on the pill for a long time. That seems to be looking like that's not a significant risk with the most recent and the biggest studies.

What about the risk that comes with extended use, people who are on the pill for decades?

That is the question everyone would like better information on. There are women who have been on the pill for 10 years, 20 years, maybe even longer, but they're not in any organized study. We only know what clinicians report, which can be helpful to us because that's sort of an early warning system – what doctors see in their offices. But so far, we don't see problems with women who are long-term users.

There's a new pill on the market that completely eliminates a woman's period. How does the variety of pills that are on the market today compare with what was first introduced?

The most important thing to know about how pills today compare to the older ones is that they are lower dose and safer. It turns out the dose of hormones used in the original pills was 10 times more than needed.

In 40 years, what's changed in terms of cost? Is there insurance coverage?

Yes, and that's a gain we have Viagra to thank. Women in Medicaid were better served, they always had contraception covered. Women who were working, who had insurance, often found that their insurance didn't cover contraception. But when Viagra came on the market and was instantly covered, we were able to get some contraception equity, and now most insurance plans do cover it.

While the pill is designed to be 99 percent effective, that rate drops to the low 90s when you factor in typical use. That's because it's easy to forget to take the pill every day. What other forms of contraception are women turning to?

Dr. Carolyn Westhoff, Medical Director of the Family Planning Center at Columbia University: Sterilization, whether male or female, is overwhelmingly the most popular choice after the pill by people in their 30s and 40s. After that, what we see are a lot of variations on hormonal methods. The vaginal ring and the patch deliver hormones like the pill but don't require daily use. Implants have just come back to the U.S. market so usage is very low now. But these are extraordinarily easy and extraordinarily effective and safe. And then of course we have two IUDs on the U.S. market, and these deserve to be much more widely used because they are so safe and effective.

The IUD is the most popular method used globally, but in the U.S., it's only used by 2 percent of women. Does the IUD still carry some stigma here?

I think women and, in fact, doctors do not realize how very safe the IUD is. We have learned to use it more safely than compared with 30 years ago. We now understand that we need to simply check women for asymptomatic infections prior to an insertion. Under those circumstances, IUDs have minimal risks of infection and, in fact, have dramatic, long-term safety.

And yet when you mention IUD, it often conjures up memories of the Dalkon Shield scare...

Well, the Dalkon Shield was a uniquely poor design. It was created in an era where there was no regulation of medical devices and therefore it didn't have adequate safety and efficacy testing before it was marketed. Now the FDA does regulate medical devices, and we have a lot of information before a new IUD can come to the market.

What methods do we not see on the marketplace that you think are actually needed?

There is certainly going to be room for male hormonal methods. I think it's not something that will sweep the market. But there are now analogs, if you will, for men to the traditional pill that are in clinical testing, and we are getting closer to this. The male pill is not something that will work instantly, nor can it be reversed instantly. Because of the male physiology, it takes about three months for it to start working and three months for it to stop working. So there are people for whom that is not going to be a terrific method, but for couples in longstanding relationships, based on survey data, there are many men who are willing to step up and take the responsibility for contraception.

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