Missed period pills could be a new option for fertility control : Invisibilia This week on Invisibilia, could the rebrand of a familiar pill open up a new way to control fertility in a post-Roe America?

A Little Bit Pregnant

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KIA MIAKKA NATISSE, HOST:

From NPR, this is INVISIBILIA. I'm Kia Miakka Natisse. And with me today is producer and reporter Abby Wendle.

ABBY WENDLE, BYLINE: Hi, Kia.

NATISSE: Hello.

WENDLE: So I had this interesting conversation with a woman the other day named Allison Coffman, and she told me about this experience she had that complicated the old saying, you can't be a little bit pregnant.

NATISSE: And are you saying you can be a little bit pregnant?

WENDLE: So let me just, like, tell you what happened for Allison.

NATISSE: OK.

WENDLE: It was a few years ago. She and her husband were trying to get pregnant, and it took them a little while. But after several months, Allison missed her period. So she tested, and it was positive.

NATISSE: Nice.

WENDLE: Over the next few weeks, Allison says she started to feel pregnant.

ALLISON COFFMAN: Some nausea, definitely some fatigue, just overall icky, but also very excited.

WENDLE: Eight or nine weeks in, Allison and her husband, they go for their first prenatal exam. And the ultrasound technician is, like, doing the exam, taking measurements. But at some point, Allison starts to realize something is not right.

COFFMAN: The ultrasound technician was not finding the heartbeat. So they finish up the ultrasound. And then she informed us that because of the fact that there is not fetal cardiac activity, that the pregnancy is not viable.

NATISSE: Oh, no.

WENDLE: So the doctor told her the pregnancy wasn't progressing, but her body hadn't realized it yet, so it was still acting as though she was pregnant.

NATISSE: Is that unusual, what happened to her?

WENDLE: Well, it's not super common. The doctor called it a missed abortion, which is like a type of miscarriage. But miscarriages in general are, like, quite common. Doctors think between 1 in 5, maybe even 1 in 4 pregnancies end in miscarriage.

NATISSE: OK.

WENDLE: And later that day, Allison got a procedure called a D and C, a dilation and curettage. And almost immediately, she stopped feeling pregnant physically. The nausea, fatigue, ickiness - all of that went away. But it took her a long time, she said, to stop feeling pregnant emotionally and mentally.

COFFMAN: It's hard not to inevitably be like, OK, I'm pregnant this date. I'm going to give birth on this date. You know, like, what's my next year going to look like? You don't want to get ahead of yourself, but you also - I think, naturally, as human beings, we start thinking, you know, about the future life that could be.

WENDLE: While she's dealing with all of that, she gets a bill from her insurance company. And she was like, what? You know, my insurance is supposed to cover all prenatal care. Why are they making me pay this bill? So she calls up the insurance company.

COFFMAN: And, you know, whoever was trained on the other end for the insurance company was like, oh, you know, we don't consider you pregnant until you have the first positive ultrasound that detects fetal cardiac activity. So according to the way we, like, determine pregnancy as an insurance company, you were never considered pregnant. It was incredibly upsetting. It felt very much like an erasure and very much in contradiction with, like, what I had lived.

NATISSE: Wow. That sounds so hard and messed up.

WENDLE: Yeah. Yeah - like insult to injury, you know?

NATISSE: Yeah.

WENDLE: So she pays the bill, basically, just to, like, move on with it. And she and her husband get back to trying to have a baby. And they were successful. She just celebrated her son's first birthday.

NATISSE: Oh, nice. Congratulations and happy birthday.

WENDLE: Yeah. But the whole experience - I mean, it left her with just a lot of questions about pregnancy and, like, the different ways that we define it.

COFFMAN: In the 15 minutes prior to the ultrasound, was I pregnant? And then the second the ultrasound happened and we found out that it was not viable, was I no longer pregnant?

WENDLE: Was she never pregnant, like the insurance company said?

COFFMAN: Because it was never going to be a full-term pregnancy.

WENDLE: You know, when Allison took that first pregnancy test, saw the line on a stick, it seemed really simple and straightforward. But, like, she realized pregnancy isn't just a test result. It's a process and a pretty ambiguous one at that.

COFFMAN: We want a binary, right? There can be comfort in being like, am I pregnant? Am I not pregnant? And a test can tell you your body is responding to, like, fertilization, maybe implantation. You know, like, your body is acting as if it's pregnant, but it can't tell you that the pregnancy is viable.

NATISSE: Yeah. I can only guess at how hard it is to be, like, sitting with that uncertainty, especially when you're trying to have a baby.

WENDLE: Absolutely. I mean, it seems hard as hell.

NATISSE: Yeah.

WENDLE: But there are situations where this ambiguity could be useful. That's actually the story I have for us today. It's a thought experiment I stumbled across about how embracing ambiguity could help a person maintain control of their body in a post-Roe America.

NATISSE: I love a thought experiment. We'll be back with Abby's story after the break.

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WENDLE: At the center of this thought experiment is the pregnancy test.

UNIDENTIFIED PERSON #1: Pregnancy tests have come to define what is pregnancy.

UNIDENTIFIED PERSON #2: You're either pregnant or you're not.

UNIDENTIFIED PERSON #3: That line on a stick - is the line there or is it not?

WENDLE: If the test is positive and you're trying to get pregnant, congratulations. This proposal is about those times when the test is positive, and you do not want to be pregnant. When the plus sign isn't a joyful rush but instead is an unnerving result that in many places is getting increasingly difficult to do anything about. Like, if you live in Oklahoma and you want an abortion, you'll have to travel out of state to get one. Or you might order pills online to perform your own abortion at home, which, though medically safe and effective, can be very risky legally - in extreme cases, could even result in criminal charges. And a lot of the time this terrifying trajectory begins with that pregnancy test, the cheap piece of plastic we pee on. So what if when you went to the doctor...

WENDY SHELDON: What if they didn't have to take the pregnancy test? Like, what if there was just no confirmation?

WENDLE: This is Wendy Sheldon, a researcher who's been part of the reproductive health and justice movement both internationally and in the U.S. for the past 20 years. She first articulated this question back in 2014, spit balling with a coworker.

SHELDON: It was just in a conversation with a colleague in the office.

WENDLE: What did the - how did the colleague respond to you?

SHELDON: She said that would be amazing. Why not? (Laughter) Why can't we do that?

WENDLE: Wendy's thought was simple - prescribe people who have missed a period and don't want to be pregnant pills to bring their period back. Call them...

SHELDON: ...Missed period pills or period pills or late period pills.

WENDLE: What Wendy is suggesting is a rebrand because what she's calling period pills are actually the very same pills prescribed to induce a medication abortion, typically misoprostol and mifepristone or misoprostol alone. Wendy is working on this concept with nearly two dozen collaborators known as the National Working Group on Period Pills in the U.S. They're working to develop period pills into another option on the spectrum of fertility control, falling somewhere between emergency contraception like Plan B and abortion.

SHELDON: So essentially, the same service that you would get for an abortion but without a confirmation of pregnancy.

WENDLE: For many people because you'd take them without that confirmation, there would be no abortion. What you have instead is a practice Wendy first became aware of years ago while working overseas called menstrual regulation, MR for short. MR is not a new practice. It's existed for a very long time, informally, outside of the medical establishment all over the world in countries like Indonesia, India and Myanmar.

CARI SIETSTRA: They would start by taking what was called Kathy Pan, which was this mixture of herbs, sort of, like, hot herbs to try to warm up the body enough to bring on bleeding.

WENDLE: There's documentation of women doing things to bring on a late period in Afghanistan, throughout Africa and Latin America. In Brazil, they say...

JACQUELINE PITANGUY: (Non-English language spoken) which means for the menstruation to come down.

WENDLE: In Peru...

UNIDENTIFIED PERSON #4: (Through interpreter) Menstrual regulation is a practice sought out by many people to see their bleeding.

WENDLE: Menstrual regulation has existed here in the U.S. as well. Historically, women used herbs like black cohosh and pennyroyal to get their period back. And in the 1800s, female monthly pills were advertised in newspapers. With the formation of the American Medical Association and the onset of laws banning abortion. These practices started getting forced underground. But MR didn't ever go away. It just became a kind of wink wink way around the law. Michelle Drew understands the need for this kind of wink wink.

MICHELLE DREW: I am a certified nurse midwife and family nurse practitioner. And I am a full spectrum reproductive health provider.

WENDLE: Michelle's grandmother was also a midwife. She treated patients at her home in rural Virginia in her kitchen.

DREW: Someone would come in, and it would be around, I'm late. You know, my courses are late and her eliciting, well, when's the last time your courses came on? Was it last month? Was it the month before?

WENDLE: Conversations would go on like this, sometimes a physical exam, until Michelle's grandmother was satisfied she knew just how many courses were late. But at no point during any of this would anyone ever mention pregnancy.

DREW: And then she had herbs, her big bag of plant medicine or - and then her - you know, her garden in the back for the things that would have still been fresh. And she would make someone a tea or give someone a tincture.

WENDLE: Michelle's grandmother was doing this work in the mid '70s. Roe v. Wade had recently been decided legalizing abortion nationally but only for certain doctors to provide who were mostly white men. Being a midwife, Michelle's grandmother could have been accused of practicing medicine without a license. So when she gave people herbs to treat a late period, it was for just that - a late period. So for Michelle, Wendy's proposal to formalize menstrual regulation as missed period pills gave her a bit of deja vu.

DREW: We're back to my grandmother's kitchen. Let's just say that you've missed your period and put that power back into your hands to be able to self-determine your own fertility. It's crazy to me that that's genius. It's crazy to me that that's revolutionary. It's crazy to me that we haven't been doing this the whole damn time.

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WENDLE: Despite the prevalence of menstrual regulation throughout history and geography, when the period pill working group first presented the idea of missed period pills to their colleagues working in reproductive health in the U.S., lots of them just did not get it.

SIETSTRA: The initial reactions we tended to get from folks in the U.S. were not super positive.

WENDLE: This is Cari Sietstra. She's got a background in law and is also part of the period pill working group. She says some common responses have been...

SIETSTRA: Why wouldn't you just have a medication abortion?

WENDLE: When they talked with doctors and other medical providers about it, Cari says many were very confused.

SIETSTRA: But if I can tell someone if they're pregnant or not, shouldn't I tell them?

WENDLE: She recalls some journalists getting indignant.

SIETSTRA: Like, oh, my God, like, this is a lie. This is just abortion. Like, why would you say this?

WENDLE: Cari and Wendy got resistance from inside the abortion rights movement, too.

SIETSTRA: There was one particular funder who was a very influential funder. And so Wendy was presenting at a conference, and she asked the funder, she said, would you like to hear more about this? And the funder said, period pills? Yeah. Good luck with that - and then just walked away.

SHELDON: Yeah. Yeah, that was a little demoralizing, actually.

WENDLE: A common concern in abortion rights circles is that period pills, by avoiding the word abortion, could reinforce the stigma of having an abortion. Others have said that there's something coy or frustrating about the term period pills - that it's all a game of semantics. In the midst of this resistance, though, there was one important group of people who got the idea immediately.

SHELDON: The vast majority got it right away. It really resonated with them. That was absolutely amazing. And, you know, there were just some - it brought tears to my eyes, sometimes, when I read the reasons that they would have interest in missed period pills.

WENDLE: We'll hear more about this group of people after the break.

A few years back, Wendy did a study surveying nearly 700 people who were at health clinics in two states.

SHELDON: One of the state was what we call the blue state, and another was a red state.

WENDLE: They were at the clinic to get a pregnancy test, and the survey asked if, rather than taking the test, they would prefer period pills instead. There weren't actually pills available that day. They were just asking people - whether they said they wanted to be pregnant or not - would you want to skip the test and instead take some pills to get your period back?

SHELDON: Over 40% of the whole sample said that they would want period pills that day if they could have had them.

WENDLE: Is that surprising? Is that a big number?

SHELDON: I mean, that's a pretty big number. I was pretty surprised by that. I mean, almost half of all the people we asked didn't want to take a pregnancy test if they had an option. They would rather just get the pills.

WENDLE: The appetite was even greater for people who said they definitely did not want to be pregnant. Seventy percent of them wanted no test - just the pills.

SHELDON: It was really striking, actually.

WENDLE: Wendy said interest in period pills was similar in both states. And when she asked people why they were interested, lots of them wrote down things like...

SHELDON: How it would help their mental health - it would be a psychological cushion. One woman said, I'm in no position to raise a child, but I also do not know if I would be able to go through with an abortion. Not knowing whether or not I was actually pregnant and getting my missed period would help me take care of myself and my mental health because I believe a degree of guilt comes along with an abortion but not a period.

WENDLE: For many of the people surveyed, period pills didn't feel like they were reinforcing stigma by not saying the word abortion. They felt like a way around abortion stigma.

SHELDON: I think it's a defiant way for people who are impacted by stigma of saying, you know, I'm going to avoid that. You're trying to put that on me, and I am simply not ever going to find out if I was pregnant. So I don't have to know. I won't feel any of those things you're trying to make me feel about getting an abortion. All I know is I'm going to make sure I'm not pregnant.

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WENDLE: Currently, these pills, branded as period pills or missed period pills, are only available through clinical trials and from a handful of providers in six states.

SIETSTRA: California, Colorado, Massachusetts, Oregon, New Mexico and Washington.

WENDLE: Plus Washington, D.C. - Cari says this is just a start.

SIETSTRA: Even if this is only available in progressive states in the near future, it may really open up cultural space around how we think about interventions in very, very early possible pregnancy.

WENDLE: To be sure, the current cultural landscape does not appear to be moving towards openness. Abortion rights opponents have already called missed period pills a deceptive euphemism, and lawyers we spoke with said conservative state legislatures will likely view them the same way. Here's Khiara Bridges, a professor at UC Berkeley School of Law.

KHIARA BRIDGES: Well, I think that as soon as a conservative legislature gets wind of period pills, they will be sure to include it in, you know, whatever law that bans abortion.

WENDLE: In other words, period pills might never be an option in the very places where they could be most useful.

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WENDLE: But Khiara says there's no reason period pills couldn't become more widely available in states where abortion remains legal. This option, menstrual regulation and the use of medication to bring on a late period, exists as a formal health care practice in other places - in Cuba and Bangladesh. In Bangladesh, in fact, the government helps people pay for MR, despite having restrictive abortion laws. And Khiara says she can imagine a future in the U.S. in which some abortion rights opponents become pro-period pills.

BRIDGES: As people bleed out, as 10-year-olds are forced to travel hundreds of miles in order to terminate pregnancies that are the result of rape, as people develop sepsis, I think that there are a whole bunch of moderates on this issue who are clutching their pearls and trying to figure out a way to put some distance between themselves and that sort of position. And so I think period pills, because of the uncertainty, because it's in this space of, well, we don't know if they're pregnant or not, that might allow a compromise that they're willing to accept.

WENDLE: For now, this is all hypothetical. But lawyers told me, if period pills were to become more widely available, they could help people avoid the risk of criminalization. For example, the later someone terminates a pregnancy, the more likely they are to have complications which can land them in the emergency room, and that's where they might get reported to law enforcement. Period pills could prevent that trip to the ER from ever happening by safely restoring a period before there's a need for an abortion. Their impact would be indirect. And when it comes to indirect impacts, Cari, from the period pill working group, mentioned this other thing.

SIETSTRA: Putting pills into people's hands in progressive states is a great way to put pills into people's hands.

WENDLE: Set a period pill free in the world, and it will find its way to a missed period in need.

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WENDLE: When I first learned about all this - period pills and menstrual regulation - I called up a lot of researchers and reproductive rights advocates, and I would ask, the women who do this - do they know they're pregnant and think it's abortion by another name? But the researchers and advocates would just shrug and tell me, Abby, there's no way to know that. And if there's no official pregnancy test, regardless of what they think, the reality is ambiguous. The people could be pregnant. They could not be. There are, after all, other reasons people miss periods, like malnutrition, sickness, exercise, stress. One researcher I spoke to, Suzanne Bell, says missing a period is kind of like that thought experiment in quantum mechanics where a cat is trapped in a sealed box with poison.

SUZANNE BELL: Like Schrodinger's cat and that philosophy of the cat in the box could be dead or alive at the same point, but until you open up the box and confirm, both realities could be true. In the same way, you know, you could be, perhaps, pregnant and not pregnant at the same time. But if you don't test, you don't know.

WENDLE: Suzanne calls this productive ambiguity, and she says this ambiguity is precisely what gives people power, control, room to move in a world that's trying to pin them down.

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WENDLE: Suzanne, apart from studying it, has also personally experienced the power of productive ambiguity. She was actively trying to get pregnant, had the hundred pack of strips she was peeing on every day, testing for ovulation.

BELL: 'Cause that's me. That's the biomedical Western influence. I was trying to control every aspect of the experience (laughter).

WENDLE: If she was even a little bit late, she would take a pregnancy test.

BELL: But interestingly, when I was most certain that I was pregnant, I didn't test for multiple weeks. It was a strange way in which my work had become personal, where I was in that Schrodinger's cat box scenario. I was pregnant and not pregnant at the same time. There was uncertainty there and ambiguity, and I was kind of holding onto these last few moments of being nonpregnant. That was my last moment where it was just me. I was on this precipice, and I wasn't quite emotionally and mentally ready. So I was sitting in that ambiguous state until I eventually confirmed.

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WENDLE: Before we had the pregnancy test, women used to have to sit in this ambiguous state, sometimes for up to six months. Because without the test, there was no way to determine from the outside if a missed period was, in fact, a pregnancy. And so the diagnosis came from the pregnant person themselves, when they felt the baby kick or move. Opting out of the pregnancy test now, in addition to organizing, voting, all of that, could help people access the health care they need and possibly avoid some of the risks of criminalization.

But it could do something else, too. It could help people to once again control their diagnosis and to center that diagnosis on a different question - not are you pregnant, but do you want to be? - to flip the order of things. Instead of testing and then orienting your feelings around the results, checking in first, not with your physical state, but with how you feel. If you don't want to be pregnant, then you've got your diagnosis. Without the want, without the desire, a missed period can be just a missed period.

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NATISSE: That's Abby Wendle.

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WENDLE: This episode was reported by me, Abby Wendle, produced by Clare Marie Schneider and Liza Yeager, Yeager, with editing help from Deborah George, fact-checking by Hilary McClellen and mastering by Maggie Luthar.

NATISSE: INVISIBILIA is also produced by me, Kia Miakka Natisse, Ariana Gharib Lee, Andrew Mambo and Yowei Shaw, with additional support this season from Lauren Beard, David Gudhertz, Lee Hale, Nic M. Neves and Phoebe Wang. Sara Long was our intern for the season. Our supervising editor is Neena Pathak. Liana Simstrom is our supervising producer.

WENDLE: Thank you to the many, many, many researchers, midwives, doctors and health workers, lawyers and reproductive justice advocates we spoke with over the course of reporting this story, including Ushma Upadhyay and the folks over at If/When/How, Plan C Pills and the Miscarriage and Abortion Hotline. A special thank you to those who helped me understand menstrual regulation internationally and historically - Carole Browner, Ruth Dixon-Muller, Fauzia Akhtar-Huda, Rebecca Irons, Jacqueline Pitanguy, Leslie Reagan and M.V., and to Joanna Erdman, who first told me about period pills. Additional thanks to Nicole Beemsterboer, Lorna Bracewell, Pablo Arguelles Cattori, Rhaina Cohen, Anne Eckman, Carrie Feibel, Dan Girma, Gerry Holmes, Addie Lancianese, Pam Malinga, Tesmerelna Atsbeha, Sarah McCammon, David Schulman, Jenny Schmidt, Brianna Scott and Anayansi Diaz-Cortes.

NATISSE: Sign up for our newsletter at npr.org/invisibilianewsletter. And if you want to learn more about the history of abortion in America, check out the episode "Before Roe: The Physicians' Crusade" from our friends over at NPR's Throughline podcast.

WENDLE: Legal and standards support from Micah Ratner and Tony Cavin. Our technical director is Andie Huether. Our deputy managing editor is Shirley Henry. And Anya Grundmann is our senior vice president of programming.

NATISSE: Theme and original music by Infinity Knives and additional music in this episode provided by Blue Dot Sessions and Physical Fitness. See you next week.

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