Forum: Whose Pill Is It, Anyway?
As we enter the the birth control pill's fifth decade of use in the United States, we appreciate how much the pill has changed. The doses, types and mixes of hormones through the menstrual cycle have all undergone great evolution in an attempt to minimize adverse side effects while maintaining high contraceptive efficacy. Nevertheless, under the control of health care providers, third-party payers and politicians, how the birth control pill is prescribed and used within the medical model remains rigid. It is time to ask ourselves, whose pill is it? We commonly say that the provider "gives" the pill to the patient and that she "takes" it. The only way women have a voice in this system is by deciding not to take the pill—by "noncompliance" and by "discontinuing" the pill—the way it is offered to them.
When viewed from the patient's perspective, today's medical practitioners hold a woman's pills hostage until she undergoes the routine health screening that the experts believe she needs, including a pelvic exam. They do so despite the fact that a pelvic exam can discover virtually nothing that would exclude a woman from using birth control pills. Although a pelvic exam is critical to discovering many important health problems, such as sexually transmitted diseases (STDs), cervical dysplasia, ovarian cancer and uterine fibroids, bundling contraception with general health care decreases and limits a woman's access to contraception. The decision to join or separate those issues should be the woman's. Men are not required to undergo STD screening or prostate exams to obtain a prescription for Viagra. Bundling all sexual health services may be important in gaining access for women who could not otherwise afford those services, but there may be other ways to achieve our goals without building such tall barriers around birth control pills for all women.
How women use the pill is also severely limited by unnecessary controls. Why do we still advise so many women as a matter of course to start their pills on Sunday now that we have packaging that permits first-day starts? Starting on the first day of menstrual bleeding provides immediate onset of action and obviates the need for a backup method. Historically, the Sunday-start pattern was introduced to ensure that women would bleed during the week and be available for tidy coital activity on weekends. But what about the woman who works on Saturday and Sunday and who wants to enjoy her partner on Tuesday or Wednesday? Many providers are so wedded to the "one size fits all" approach that they make no provision for that woman. One doctor told me that he still prescribes the Sunday start so that he can know where his patients are in their cycles just by knowing the day of the week. That is wonderful for the doctor, but where does it leave the woman?
Why are women using the pill forced to have monthly withdrawal periods? We have decades of experience using pills to suppress menses for women with endometriosis1 and to occasionally move menses around to accommodate special events like honeymoons. The grandmothers and mothers of our current patients may have preferred "natural" cycling in 1960, but many of today's women have other priorities. Yet, we routinely continue to cycle women with three weeks of active pills and one week of placebos or subsuppression doses. What does cycling do for women? It allows them to experience menstrual cramping, headaches and bloating, and provides an opportunity for the next crop of eager, easily excited ovarian follicles to be recruited and selected. We accept monthly cycling and work hard to ensure it despite the fact that the single greatest cause of lost days of work and school for young women is dysmenorrhea.2 Women endure a host of discomforts during those active-pill-free days.3 Yes, it would cost third-party payers the price of an additional four packs of pills each year, and yes, manufacturers of sanitary napkins and tampons would suffer an economic loss—but are we more concerned about their economic interests or the health and well-being of our patients?
As we approach the 40th anniversary of the pill, we have to ask ourselves whether these control issues have had a deleterious impact on women's desire to use the pill and on their motivation to use it correctly. For example, have we done everything we can to maximize the benefits an individual woman can derive from the pill, and have we clearly explained them to her? In the most recent survey sponsored by the American College of Obstetricians and Gynecologists, 58% of American women could not name one single noncontraceptive benefit of the pill.4
This lack of information tends to perpetuate the negative image so many Americans have about this wondrous little pill and to reduce its successful use. Could the pill's relatively high failure rate in typical use, compared with its potential effectiveness in perfect use, be related to our failure to effectively inform women about the positive impacts of the pill and to our exclusion of their priorities from our calculus?
Today, we can more clearly see these subtle control issues and observe their negative impacts on our patients' enthusiasm to take the pill. We have an opportunity to adapt our practices to involve our patients more actively. We can commit ourselves to helping patients tailor their pill use in ways that best fit their lives. Diversity and individualization are key. We may be quite surprised at how meaningful involvement in decisions about pill-taking could affect a woman's adherence to her chosen pill regimen. Can we imagine how well women would take their pills if they could use them to control when (and if) they menstruated? I think today would be a good day to find out.
1. Kistner RW, Management of endometriosis in the infertile patient, Fertility and Sterility, 1975, 26(12):1151-1166.
2. Ylikorkala O and Dawood M, New concepts in dysmenorrhea, American Journal of Obstetrics and Gynecology, 1978, 130(7):833-847; and Freedman SB et al., Comprehensive Adolescent Health Care, St. Louis, MO: Mosby Year Book, 1998, p. 1008.
3. Sulak PJ et al., Hormone withdrawal symptoms in oral contraceptive users, Obstetrics & Gynecology, 2000, 95(2):
4. APGO-sponsored Gallup survey findings: health benefits are the best kept secret of the pill, APGO Reporter, 1998, 26(3):14-16.