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.”
Months into her physician-prescribed course of hormonal contraception, Ella, a 21 year-old Yale senior who asked not to be identified by her real name, experienced a steep drop in sexual interest. “Can you imagine? You just feel numb.” To complicate things further, the pills performed a complete renovation of her personality. “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 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. 82 percent of American females — young single women, married women, mothers or girls barely out of adolescence — will take contraceptives at some point in their lives. Many women who choose the popular and diverse hormonal methods of birth control (the pill, the patch, the shot, the ring) will use them, off and on, for upwards of 15 years. Yet anecdotal evidence and a small but growing body of research suggests that Ella is not the only one who has a bone to pick with her meds.
The distance between the pituitary gland, at the base of the brain, and the vagina is about two feet. This distance encompasses the female reproductive sequence from start to finish: a chain of events that begins in the brain, where the pituitary, via the hypothalamus, stimulates the ovaries. Once a month, the ovaries release an egg and initiate the basics of the birds and the bees. This is the fertilization mechanism that birth control tries to prevent.
This chain of reproduction is an emotional and physical ride — a ride that everyone, by definition, eventually hitches. Birth control, which in hormonal forms is close to 100 percent effective, works by disrupting the trip and simulating pregnancy; a woman taking birth control’s regular doses of estrogen, progestin or both has the brain chemistry of a woman already carrying a child. First her pituitary stimulus and then her ovaries shut down, refusing to relinquish their eggs until the brain decides to reopen the gates. Birth control is fast, 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. Flooded with prescription hormones, the body may respond with a host of unrelated emotional, physical and sexual side effects. Ross cites the better-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 aware of these responses to birth control. The issues are “probably not so reinforced. I really try not to tell people side effects they may have other than the real really 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.”
Part of the reason for this less-than-full disclosure is that the details are still unclear. While we know, for example, that one in 200,000 women on birth control will die from a blood clot, with higher incidence among smokers, the prevalence of depressive or sexually disruptive effects is nowhere near as fully understood. Not much research has been focused on these supposedly peripheral effects, and the question of how birth control alters psychology and sexual function has been debated since the appearance of the drugs in the American market in the 1960s. When Enovid, the first “pill,” was introduced, a million women jumped on board almost instantly. Women expected increased personal choice and the freedom to have sex unhampered by reproductive concerns — and the pill certainly lived up to the hype. What was less clear was how generations of hormone use would change the way women think, feel, and behave in both sexual and nonsexual spheres.
Visit unit 202 of New Haven’s Oxford Apartments, and it becomes clear that not getting pregnant is only part of the issue of birth control. Empty wine bottles and women’s magazines are standard accessories for the gathering of my friends Mary, Nora, Shayla and Tess, all Yale seniors. Their chatter in the comfortable living room touches on men, midterms, and Thanksgiving break. But I’m here to talk contraception.
The swirl of 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, and Nora and Tess at 17 or so. Nora thought the pill would help clear her skin; hormones in the pill stabilized Tess’ 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.
Shayla 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 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.
The girls are all astonished that no one made the connection earlier. I am more astonished that Shayla reached a point of such despair just from taking a pill. Birth control, meant to prevent an unwanted body within you, can apparently create an unwanted mind — your own. Women who react strongly to hormones may merely be trading miseries. Even now, five years into this new arrangement, Shayla admits she still feels extreme 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 ayeahs, then a thoughtful pause, hits the room as the women contemplate a pill-less reality.
Nora, who quit the pill in the last year, thinks that without distance there is no way to tell what life is like without the pill. “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.”
The girls get noisy when sharing similar light-bulb moments, making the connection between their hormones and their moods. “I remember when I first was on it I would get horrible mood swings all the time,” says Mary, “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 says, “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.”
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 or switching hormonal methods. And as with Shayla, extended use may make a former personality inaccessible. This makes responding to adverse effects by seeking medical or psychological support less a problem of ignorance than of self-awareness. If you don’t know something’s broken, you can’t fix it.
The trouble of not knowing goes 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. She describes when 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 (lack of menstruation), that are totally unrelated to contraception. Cramps, migraines, acne, and in Maya’s case, a reclusive period, are all acceptable causes for medication.
In the five 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, 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 her periods began at 16, they continued like clockwork.
Two months ago, Maya received some shocking news. She had gone off the pill at the beginning of the year for a trial period to see if she could produce estrogen naturally. “I didn’t get my period for three months,” she says. “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 asked aloud what was going on.
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 without extra hormones. “The birth control has suppressed symptoms of that for six years,” she says matter-of-factly, “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 stress of avoiding pregnancy are now totally moot; instead, a more serious problem has arisen. “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. 50 years ago, her situation would have been hopeless, but fertility drugs have improved drastically in the modern era. From the early, high-dose Enovid to today’s plethora of birth control options, diverse means of administering hormones are available.
Yet the burgeoning contraceptive industrial complex failed her. Who did this to Maya? Or the other girls, for that matter? I spoke with young women who experienced sudden and debilitating nausea, drastic weight gain, flu-like symptoms, stress-induced sicknesses, absent libido, strains on personal relationships and oceans of tears. At every turn, these women 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?
Marjorie Green is 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 waitingroom outside Green’s office, the Mount Auburn Female Sexual Health Clinic in Cambridge, Mass., is full of women suffering from various symptoms that make sex difficult. A certain proportion of them, Green says, experience debilitating sexual dysfunction as a result of hormonal birth control.
Ella’s problem of sexual disinterest straddles psychology and internal medicine. In Ella’s case, her body actually felt deadened. But another senior who used to take birth control says 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 types of birth control suck up the body’s free testosterone, which controls the sex drive. For some women, the decrease causes vaginal dryness and accompanying pain. For others, the change means total disinterest in sex.
Most women take birth control in order to have sex more freely and, according to some feminists, fairly. But in some cases, they end up forfeiting good sex just to have sex at all.
Green states 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. Worrying about getting pregnant can affect sex just as much 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.” Even if a patient manages to wade through the sea of evidence— that hormones are friendly, that women are naturally moody, that the pill is the best thing since the high heel, that she is just fine — and expresses concerns 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, the patient will inevitably have to compromise.
Research and discussion of hormonal birth control has lagged behind the rapid expansion of the industry. Professor Jayashri Kulkarni cannot understand this silence from the medical community on issues of sex and female contraception. A psychiatrist at the University of Melbourne who specializes in mental disorders and their effect on women, Kulkarni 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 one of the telltale symptoms of depression.
But more interesting to Kulkarni, beyond small-scale confirmation of a long-suspected problem, was the social conversation triggered by the trial. The issue, she believes, is ripe for explosion into the public domain. Following the study’s publication in November 2005, Kulkarni received a deluge of personal e-mails 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 had previously been splintered or flawed.
Maya, who began taking the pill not long after freshman year in high school, thinks that familiarity without facts can be dangerous. “I think that people sort of just ‘go on the pill’ and don’t know enough about it. 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. And medical professionals who prescribe hormonal contraception without conversation can contribute to the knowledge gap. Physicians can add to awareness about a broader range of side effects. They can also 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 at length, with themselves and a physician. Both Ross and Green stress the importance of taking a good medical history at these junctures, and encouraging an environment of openness that allows women to really evaluate their reproductive health. Though they “talk about what to change, what you’re using, all of that,” Green says, they can’t reach all 82 percent of American women who will try birth control at one point in their lives.
The makers of the drugs, however, can. And the inserts that accompany all prescriptions for birth control emphasize sexual and psychological factors even less than doctors do. 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.” 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 is that the ring, like a pretty bracelet, is an accessory that comes on and off with ease.
The two-foot distance between brain and body has grown longer and harder in the age of hormonal contraception, becoming a marathon distance that encompasses sex and 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 women 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 medicine that will help to bridge the distance.