On the 50th Birthday of the Birth Control Pill, Looking Ahead to What’s Next

By Mark Hathaway, MD, MPH

Happy 50th, Pills!  You have really arrived in the world.  Not only are you 50 years old, but many, many versions of you have come about in the last half century, and you’ve gotten better with age. Your accomplishments are impressive, and your unexpected benefits are equally notable. We salute and celebrate you, Birth Control Pills, but also hope you’ll share the limelight in future years with some up-and-coming stars in the family planning world.  These other players have great potential for women’s health — if we can get them out into the public more broadly.

The ability to control fertility was a tremendous breakthrough. The impact for reproductive health in general, and for women’s health and lives in particular, has been felt worldwide.  The history of the birth control pill (or oral contraceptive pills [OCPs]) reaches back to the early part of the 20th century when Margaret Sanger, Planned Parenthood’s founder, dreamed of a pill that would prevent pregnancy and be as easy to take as aspirin. Birth control pills were developed in the 1950s by scientist Gregory Pincus and physician John Rock, aided by advocacy and donations from Sanger and Katharine McCormick, one of the first women graduates of M.I.T. and heiress to a large fortune.  The Food and Drug Administration (FDA) approved OCPs in 1960. 

Today there are over 60 formulations of the Pill, containing varying amounts of estrogen and progesterone, and taken on varying cycles. In the last 50 years OCPs have become the number-one contraceptive for women in the U.S.  The numbers vary slightly from year to year, but the top three birth control methods used in the U.S. today are OCPs (17.9%), female sterilization (16.7%), and condoms (13.9%).¹  

To be sure, oral contraceptives have many benefits even beyond contraception.  The American College of Obstetricians and Gynecologists lists several in their evidence-based guidelines:

• Menstrual cycle regularity
• Decreased amount of menstrual bleeding
• Decrease in pain and mood swings with menses
• Decrease risk of several cancers (uterine, ovarian, colorectal)
• Improved acne symptoms.² 

Make no mistake about it, the Pill works well for many women.  If patients can get to a clinician, get a prescription, have the insurance or means to pay for OCPs, take them every day, get prescription refills, and keep paying for them, OCPs will be about 92 percent effective in preventing pregnancy. But for many women, that’s a few too many ifs, hitches, barriers, and obstacles to overcome, and discontinuation rates and gaps in consistent daily use of OCPs are common, putting women at great risk for unintended pregnancy.

In the urban clinic system and hospital where I work, my colleagues and I see far too many unintended pregnancies.  That’s not unusual for this country.  The percentage of U.S. pregnancies each year that are unintended, mistimed, or unwanted is a staggering 50 percent. That’s three million unplanned pregnancies annually, an astonishingly high number in a country that has the knowledge and the means to prevent unintended pregnancies.  One result is approximately 1.3 million abortions — almost half of the unplanned pregnancies end in abortion — and too many unwanted births.  Some of our most vulnerable women — adolescents, young women in their 20s, and underinsured and/or uninsured women — have the highest rates of unintended pregnancy. Oral contraceptives (and condoms) are the most commonly used methods in this huge sector of our society; I think we’re failing them by not providing them with a birth control method that is simpler, more effective, and doesn’t require daily pill popping, and visits to clinics or pharmacies.  In other words, we can and should do better.

This past week, a typical week in my practice, I saw three patients who asked for help with an unwanted pregnancy.  One woman’s story is particularly illustrative of the challenges women face around OCPs.  At her appointment, “Molly” described to me that she had recently given birth.  At her postpartum appointment, she was given a free package of brand-name birth control pills (we’ll call them YAZ), and a prescription for six more months of pills.  But, her insurance was deactivated because she had stopped working in order to stay at home with her newborn; she quickly discovered that YAZ cost $65 per cycle.  She couldn’t get through by phone to her doctor to find something cheaper, couldn’t get into another clinic for a visit, and couldn’t afford the $65 cost to refill her prescription.  Five weeks later she was pregnant and in our clinic in tears.

What’s distressing about this story is that Molly was clear, at least with me, that she had wanted to avoid pregnancy for at least three to four years.  That’s a lot of pills to take and a lot of hurdles to jump through for 3-4 years to prevent an unintended pregnancy! She wasn’t aware of other methods and her provider failed to discuss them with her. As Molly found, birth control pills can be prohibitively expensive. They are also not the right answer for everyone. Some women want to avoid exposure to hormones in the Pill, while others worry about its side effects, such as blood clots in certain populations. (It should be noted, pregnancy has many more risks than almost any birth control method.)

For the past 30-50 years relying on OCPs as a birth control method for women like Molly who do not want to get pregnant in the near-future may have been acceptable because we didn’t have other options for highly effective and reversible methods. But not now. Today, there are many simpler and more effective methods that can better meet Molly’s needs and reproductive life plans than OCPs do.  Specifically, long-acting reversible contraception (LARC), a category of birth control that includes two types of intrauterine devices (IUDs), and the single rod hormonal implant (SRHI). 

The advantages of LARC methods are that they:

•  Do not interrupt the sexual encounter and there's nothing to remember every day.
•  Are highly effective (99.2% efficacy or greater) ³
•  Offer the highest rates of both continuation and user satisfaction
•  Do not require “resupply” prescriptions or frequent office visits
•  Are reversible, with a rapid return to fertility after their removal
•  Are suitable for long-term usage (up to7-12 years for the IUD and up to 3 years for the implant)
•  Are safe for almost all women, even those who cannot take the Pill because of other medical conditions

Although IUDs and the implant have high up-front costs and necessitate the need for office visits for insertion and removal, their cost effectiveness surpasses all other reversible methods, even over relatively short-term use of 12-24 months. ⁴ Despite these benefits, IUDs get little attention in the U.S., although they are popular in most other parts of the world.  And the implant, first introduced in the U.S. in 2006, is still relatively unknown and underutilized. 

So, although LARC methods are safe, more effective, longer lasting, simpler, and more cost-effective when compared to OCPs, they represent only 2-4% of contraceptive methods used in the U.S.⁴   Underuse can be attributed to multiple factors, including negative myths about these methods, limited advertising, a dearth of trained clinicians, and poor reimbursement from government funding sources and insurers. 

In addition, medical providers are much at fault for the slow uptake of LARC methods, partly due to overly restrictive criteria they place on IUD use. A recent patient told us that she had called three ob-gyn offices seeking a gynecologist who would provide her with an IUD.  “Maggie” is 28 years old and has never been pregnant. She was told that she could not use an IUD because she had never been pregnant. The myth here is that IUDs might cause infertility, but current evidence indicates there is no increased risk of pelvic inflammatory disease or infertility among IUD users. This myth lingers, but the fact is that modern IUDs may be safely used by almost all women of reproductive age. We saw Maggie and, in one visit, inserted her IUD through a procedure that is only a touch more uncomfortable than a Pap smear and takes just 30-60 seconds longer.  Maggie now has one of the most effective, reversible contraceptive methods in place.

Little by little, we’re improving the use of LARC methods; I imagine much the same process occurred 50 years ago when birth control pills were so novel. But, the potential health benefits of LARC methods for women are far too important to wait on. They could make a large dent in the astoundingly high rates of unintended pregnancy in our country, if only they were better promoted and utilized.  Let’s not wait another 50 years to celebrate such effective birth control methods.

Mark Hathaway, MD, MPH, is the Director of Community Programs for Washington Hospital Center’s Obstetrics and Gynecology Department. This work involves directing Obstetrics and Gynecology services at Unity Health Care, Inc., a system of 14 community health centers throughout Washington, DC. The Washington Hospital Center was recently awarded a Family Planning Fellowship, which Dr. Hathaway will co-direct. He has recently been elected to the Board of Directors of the Association of Reproductive Health professionals (ARHP).

References:

1. Mosher WD, Jones J, “Use of contraception in the United States: 1982–2008,” Vital Health Stat 2010; 23(29). Online at http://www.cdc.gov/nchs/nsfg/abc_list_c.htm#contraception
2. ACOG Practice Bulletin #110 “Non Contraceptive Uses of Hormonal Contraceptives,” Obstetrics and Gynecology 2010; 115(1): 206-18 (PMID 20027071).
3. Trussel, J. “Contraception Failure in the United States.” Contraception. 2004; 70(2): (89-96).
4. Sonnenberg FA, Burkman RT, Hagerty CG, et al., “Cost and net health effects on contraceptive methods,” Contraception 2004; 69:447-459.
5. Mosher WD, Jones J, “Use of contraception in the United States: 1982–2008,” Vital Health Stat 2010; 23(29). Online at http://www.cdc.gov/nchs/nsfg/abc_list_c.htm#contraception