Ali Lytle started on birth control when she was fifteen years old. As far as her gynecologist was concerned, teenagers had to avoid pregnancy at all costs.
The first contraceptive Lytle tried, an injection called Depo-Provera, gave her splitting headaches nearly every day. Then there was the weight gain. In just a year, she put on seventy pounds. She switched to a pill that was supposed to help manage the unwanted side effects, but her headaches became unbearable, often making her skull feel like it was about to crack open. Another pill with a smaller dose of estrogen seemed to be the best option: it made her feel low, sure, but at least the inside of her head felt less like a construction site. She was on it for ten years.
Over the course of that decade, Lytle was in and out of doctors’ offices for a medley of health problems. She developed a condition called supraventricular tachycardia, or SVT, which caused her heart to beat abnormally fast. Some days, she would be sitting on the couch, doing nothing, when all of a sudden, she’d feel like she’d run a marathon in the sweltering July heat. By 2020, the frequency and intensity of her flare-ups were getting worse, and her migraines had returned with a vengeance. Her family was worried and insisted she get a second opinion. Eventually, she went to see a naturopath, who ordered a series of tests.
The blood work showed high inflammation markers and cortisol levels—the main hormone responsible for stress. Certain medications, including some contraceptives, can cause the body to produce more cortisol than it needs, and since she wasn’t taking any other prescription drugs at the time, the pill was the primary suspect. She stopped taking it soon after, opting for condoms and a fertility awareness method instead.
Within the next five months, Lytle noticed several changes: her heart condition mysteriously vanished, and she lost forty pounds without even trying. Food tasted different—especially chocolate, which was suddenly too sweet. Her body hair, once fine and blond, grew back thicker, and her sweat smelled more pungent. But most importantly, her head was clearer. She was starting to feel more like herself again—though it was short-lived.
In the fall of 2021, Lytle married her long-time boyfriend. On their honeymoon, in 2022, she started to feel like she was floating—not in a good way. She was dizzy; her body felt heavy. Soon after they returned to Kansas City, where they live, things escalated. She couldn’t get out of bed and was admitted to hospital for an abnormally high heart rate. Though rare, she was experiencing complications as her hormones adjusted. It took her months to recover.
“My husband would leave for work and I would text him twenty times a day to tell him I loved him, because no one could have convinced me that I wasn’t going to pass away,” says Lytle. “The whole experience changed my life.”
Lytle’s story is extreme; some people love the pill. It can reduce period cramps, lighten monthly bleeding, make hormonal acne vanish, and even lower the risk of uterine cancer. That’s all in addition to the most obvious benefit: a roughly 91 percent pregnancy prevention rate. There’s also no denying that the pill’s invention transformed women’s lives, giving them more autonomy than they’d ever had.
But the contraceptive can come with serious side effects. Those who take birth control pills, especially those which contain estrogen, are at a small but increased risk of blood clots, heart attack, and stroke. And one Danish study from 2018 found that women on hormonal contraception were twice as likely to attempt suicide for the first time in the initial year of use as those who had never taken contraceptives. Less severe issues include headaches, weight gain, loss of libido, and bloating. Despite all this, the pill has become the default prescribed form of birth control since it came on the market more than half a century ago, and there has been relatively little innovation. Today, the most effective contraceptives are still largely limited to hormones that alter our bodies. All of this, combined with a growing mistrust of medicine, which has often dismissed women’s pain, has many searching for something better.
People who menstruate have historically shouldered the burden of avoiding pregnancy; by default, they handle the bulk of the consequences around bearing a child. There are records of people in China drinking liquid mercury to make their uteruses uninhabitable, ancient Egyptians blocking sperm with elephant dung, and women from the Middle Ages donning weasel testicles around their legs as amulets in an attempt to prevent pregnancy.
By the early twentieth century, researchers began looking for ways to control ovulation. In the late 1940s, Carl Djerassi—an Austrian-born American chemist who would later get the nickname “father of the pill”—used wild yam root to synthesize progestin, the hormone now used in every oral contraceptive on the market today. Progestin, which mimics the body’s naturally occurring progesterone and is often combined with estrogen, can effectively suppress signals in the brain that tell the body to ovulate. It can also make the cervix unfriendly to sperm.
By giving women the power to avoid unwanted pregnancy, the discovery set off a revolution. In the 1950s, about 6 percent of women attended university, according to US census data. By 1970, they were earning 43 percent of bachelor’s degrees, and the proportion studying subjects like medicine and law was beginning to rise. Birth control went on to transform the economy. Over the next half of the century, as women graduated and entered the workforce, the female employment rate about doubled in comparison to pre-pill figures in the US and Canada. At the same time, birth control drove a wedge between sex and procreation: once restricted to the marital bed, sex was now available to women whenever they wanted. “The ability to decide when and whether to have children is the single biggest determinant, worldwide, of whether a woman is healthy or not, educated or not, active outside the home or not, and how long she will live,” Gloria Steinem told Al Jazeera in 2019.
Despite their effectiveness, the earliest pills on the market—a brand called Enovid, which also contained estrogen—were far from perfect. During the first large-scale clinical trial in the mid-1950s, researchers turned to women in Puerto Rico, where there was less regulation and a history of mass sterilization, in part due to US officials’ support of eugenics theories that poor and racialized people should not procreate. The 200-plus people involved (some estimates are as high as 1,500 over several years) had no idea they were participating in a first-of-its-kind human trial, nor were they given proper information about the risks.
“Women who stepped forward to describe side effects of nausea, dizziness, headaches, and blood clots were discounted as ‘unreliable historians,’” wrote researchers Pamela Verma Liao and Janet Dollin in a Canadian Family Physician journal article. Enovid got Food and Drug Administration approval in 1960, but the dosages of hormones were “drastically different” from what we have today—98.5 and 3.28 times the lowest and highest modern doses of progestin, respectively, and 7.5 times the lowest dose of estrogen in today’s pills. This is, in part, because today’s hormones are “much more pharmacologically specific and more focused in their drug effect,” but the high doses increased the risk of things like heart attacks and strokes as well as the intensity of side effects (something it took scientists more than a decade after approval to figure out). “Despite the substantial positive effect of the pill,” write Liao and Dollin, “its history is marked by a lack of consent, a lack of full disclosure, a lack of true informed choice, and a lack of clinically relevant research regarding risk.”
The history of contraceptives is also marked by a lack of options for men, who are limited to condoms (which are typically only 85 percent effective) and vasectomies (which are meant to be permanent). Research into pills and injectable gels that could serve as an “in between” form of male birth control shows promising results, but interest and funding for these studies are low. In a YouGov survey, only 33 percent of the approximately 440 sexually active male respondents in the UK said they would consider taking something like the pill (16 percent said they didn’t know), which suggests that, for the foreseeable future, birth control is still likely to be seen as a “women’s issue.”
Most forms of birth control on the market now rely on a similar combination of progestin and estrogen to stop ovulation from happening. Today’s contraceptives no longer contain the same dosages, and the vessels that deliver the hormones have expanded beyond the pill: they include implants, some intra-uterine devices (IUDs), patches, vaginal rings, and injections. But that doesn’t mean they aren’t disruptive to the body.
Hormones are chemical messengers: they travel through the bloodstream, delivering instructions that help keep all of our systems in sync in the same way a conductor unifies the distinct sounds of different instruments in an orchestra. Since hormone receptors are present in cells throughout the entire body and brain, they contribute to an exhaustive list of functions, including digestion, metabolism, sleep, stress, sex drive, and mood, just to name a few.
“Although many of us think of hormones as something that ‘happen’ to us, that isn’t quite right. You are your hormones,” writes Sarah E. Hill in This Is Your Brain on Birth Control. When it comes to birth control, while the most sought-after effect may happen in the reproductive system, the hormones that contraceptives contain are picked up by receptors throughout the entire body—which is why the medications have the ability to change not just your weight or your skin but also your very sense of who you are, Hill continues.
For decades, researchers have focused their attention on the side effects of hormonal birth control that pose the highest health risk: things like stroke and blood clots, which are about two and six times more common among individuals on the pill. In 2010, the pill also became the subject of a class action lawsuit against Bayer, the maker of Yaz and Yasmin. Health Canada documents obtained by the CBC in 2013 linked the deaths of twenty-three Canadian women with complications from the contraceptives. But researchers have paid little to no attention to what it can do to the brain.
One of the most commonly cited complaints from those on hormonal birth control is changes in mood. Hill proposes two reasons. First, naturally occurring progesterone creates a powerful anti-anxiety effect, but artificial progestins in birth control don’t seem to offer the same benefits. Meanwhile, higher estrogen levels mean higher levels of dopamine and serotonin—the feel-good neurotransmitters responsible for so many of life’s pleasures. Since contraceptives keep our own natural estrogen levels low, it’s possible that they also have the ability to increase the risk of depression. One of the most comprehensive studies to explore the connection between the two happened in Denmark in 2016. Using records from the national health registers, researchers tracked rates of first-time depression diagnosis and antidepressant usage alongside the use of hormonal contraception among all physically and mentally healthy women in Denmark between the ages of fifteen and thirty-four (totalling more than 1 million people). The fourteen-year analysis concluded that women who took hormonal contraceptives were more likely to be diagnosed with depression and use antidepressants than those not on the pill.
Lytle told me that this was something she struggled with throughout the years she was on birth control. One day, she would feel perfectly normal, and the next, she would wake up under the weight of a heavy, unexplainable sadness. “My thoughts and emotions never really felt like my own,” she says.
Hormones can also alter parts of the brain responsible for functions that seem less important from a medical standpoint but still have big effects on a person’s life—like attraction. From an evolutionary perspective, humans are pre-programmed to reproduce, and the menstruation cycle comes equipped with built-in features to try and ensure that happens. In her book, Hill presents the idea that our hormones at high fertility make us “look, sound, and smell sexier.” Though the science is still emerging, Hill references studies in which men have been shown photographs of women’s faces and played recordings of their voices at various times throughout their cycles. Interestingly, the men found the women more attractive when they were most fertile. And it’s not just in the lab: there have been documented, though anecdotal, instances of people who met their partners while on the pill and were less attracted to them after going off it. In an interview with Stuff, a woman who had been with her husband for a decade spoke about going off birth control to try and have a baby but instead filed for divorce. “I couldn’t find him attractive,” she said.
For those looking for contraceptives without the hormones, choices are limited. The copper IUD is an appealing option, with a 99 percent pregnancy prevention rate. But for some people, especially teenagers and those who haven’t had kids, insertion can be extremely painful. Women have shared stories of throwing up or passing out during the procedure. Despite this, most doctors typically don’t use anaesthetics or offer pain-relieving drugs beyond Tylenol or Advil. The copper IUD can also make periods heavier and more painful.
In Canada, nearly 50 percent of sexually active fifteen-to-twenty-four-year-olds rely on oral contraceptives, compared to 3.6 percent who use a copper IUD. That number tends to decrease with age and, according to a separate 2016 study published in the Canadian Medical Association Journal, has been declining on the whole over the years, with many women over thirty now opting for less effective forms of birth control—mainly, condoms or the pull-out method. That’s in part due to adverse effects. It may also be because of a lack of trust in health care professionals. “Women have not felt heard,” Laura Wershler, a Calgary-based women’s health advocate and member of the Society for Menstrual Cycle Research, told researchers in 2017. Doctors tend to default to prescribing oral contraceptives or other hormonal contraception, “but they do a poor job of acknowledging and hearing young women who say they don’t want to do that,” she said.
According to data from the Centers for Disease Control and Prevention in the US, of all the women surveyed who had ever used the pill, 35 percent stopped using it, with the leading cause being side effects. Why are there so few non-hormonal alternatives available? The answer may lie in how we approach women’s health as a whole.
Before 1993, women and minorities did not need to be included in clinical research. In fact, a 1977 FDA guideline banned women of child-bearing potential from being included in trials, largely due to protective ethical concerns around birth defects. That means drug companies had little understanding of how most medications affected men and women differently. Those years of neglect have left a knowledge gap, and doctors still know comparatively less about people who menstruate. And despite recent changes, research indicates that a disproportionate amount of funding is allocated to studying conditions that affect men. In her book, Hill also estimates that it can cost double or even triple the amount to conduct health research on women because that research needs to account for hormone changes throughout the menstrual cycle. These things take more time, and time is, of course, money. But the larger issue is the trivialization of women’s health complaints. Countless studies have found that women are more likely to have their concerns minimized or dismissed altogether by medical professionals. The result is a health care system that doesn’t care about or account for their needs.
When it comes to birth control, the lack of innovation boils down to continued demand: regardless of whether a person is happy with their birth control options, most still have to choose one. Sometimes, any option is better than no option, regardless of whether it’s what you actually want. That’s especially true in the US, where the overturning of Roe v. Wade, in 2022, has put even more pressure on pregnancy prevention. Nearly a year after the ruling, the FDA approved the first ever over-the-counter pill. While many people are seeking alternatives, there hasn’t been a drastic enough reduction in sales, creating little incentive for new ideas: the oral contraceptive market was valued at $17.9 billion (US) in 2022 and is expected to grow an additional 7.25 percent by 2031, according to estimates from Growth Plus Reports.
According to a journal article published in Nature, over the past two decades, many major biopharma companies sold off, reduced, or closed divisions that were developing non-hormonal birth control and products to help manage menopause. They instead decided to focus on areas of medicine that are growing more quickly. Between 2017 and 2020, there were less than twenty-five industry-funded clinical trials for contraceptives, and the few that did take place focused on making tweaks to existing options. By comparison, in 2019, there were over 3,000 trials for cancer drugs and 600 for cardiovascular drugs.
Some women are taking things into their own hands: Elina Berglund Scherwitzl—a Sweden-born physicist now based in New York—couldn’t find non-hormonal birth control that made sense for her, so she decided to make one herself. She had been on the pill briefly, but it made her feel low, so she switched to an implant. Years later, when she and her husband began planning for children, she wanted to take a break from hormones and started reading up on ways to track ovulation. A person can get pregnant really only six days every cycle, so if there were a more reliable way to tell when fertility would be high, she thought, the right amount of planning could mean a person may not need hormones at all.
Fertility awareness methods, which involve tracking the menstrual cycle to predict when pregnancy is most likely, have been around for decades, if not longer. But Berglund Scherwitzl’s method goes some steps further: she created an algorithm that uses body temperature (which increases slightly during ovulation), menstruation data, and the results from an optional at-home urine test that detects the luteinizing hormone (which peaks just before ovulation) to accurately determine the user’s fertility status on a given day. In 2013, she launched Natural Cycles—the first “digital birth control” app to be cleared by the FDA in the US and to receive the equivalent approval in Europe. (The company recently applied for approval as a medical device from Health Canada but has yet to receive it as of November 2023.) For the most accurate reading, users must take their temperature first thing in the morning—“before sitting up, drinking water, snoozing, or getting out of bed,” according to their website—and the company’s corresponding Bluetooth thermometer syncs the data to Natural Cycles’ app. The more data the algorithm has, the more green days will appear, indicating which days a user can have unprotected sex without getting pregnant.
There are downsides, of course. Fertility awareness methods can be hard to use correctly. Nicole Todd, a clinical associate professor in the University of British Columbia’s department of obstetrics and gynecology, says that when it comes to these methods, there’s a big difference between “typical use” and “perfect use.” Todd advises those who are trying to find the contraceptive option that works best for them to make a decision based on the former.
According to Planned Parenthood, fertility awareness methods are about 77 to 98 percent effective, meaning that two to twenty-three out of 100 couples who use it will get pregnant each year. Natural Cycles, however, argues that its algorithm elevates it above these traditional approaches. According to studies conducted by the company, Natural Cycles is 93 percent effective with typical use and 98 percent with perfect use.
Last summer, the company launched a partnership with Oura Ring, a $260 to $300 (US) wearable, similar to a smartwatch, that’s equipped with sensors that track everything from sleep and blood oxygen levels to heart rate and body temperature. That data can automatically be synced to the app, eliminating the need to remember to take your temperature every morning.
“When it comes to birth control, there will never be one-size-fits-all, so different women will need different solutions,” Berglund Scherwitzl says. “I think the fact that women now are starting to realize that they can actually get to know their body instead of changing it is probably thanks to more innovation on the tech front.” She believes they will have more options in the future.
That idea has been slow to catch on: for so long, birth control was treated as one-size-fits-all, and the pill’s legacy as the most accessible and convenient form of contraceptive is likely to linger until more options become available. But in recent years, we’ve started to see progress. There is one new non-hormonal contraceptive gel on the market, Phexxi, that was approved by the FDA in 2020. Unlike spermicides, which block the entrance to the cervix and slow down sperm, Phexxi uses ingredients that control the pH balance of the vagina. A lower pH makes it more difficult for sperm to swim, lowering their chances of reaching the egg. However, the product’s effectiveness, at 86 percent, is lower than that of hormonal methods, and cost is a barrier: a pack of twelve is more than $300 (US), or $25 per applicator.
Deborah Anderson, a reproductive health researcher and microbiologist at Boston University, has also been experimenting with a new type of intravaginal birth control. It’s administered as a topical film—almost like a Listerine strip—that goes inside the vagina, dissolves, and quickly releases monoclonal antibodies, according to Boston University’s The Brink. These antibodies, which are localized in the vagina, can not only immobilize sperm but also have the potential to prevent the transmission of herpes and HIV. The results of the clinical trial were promising: during the month that women used the film, there were almost no moving sperm in their cervical mucus, as opposed to fifty per microscope sample when they weren’t using the product.
In Denmark, femtech company Cirqle has seen similar success with what is best described as “mucus engineering.” Their researchers discovered a molecule that interacts with the body’s natural cervical mucus to thicken it and make it temporarily impenetrable—essentially, a fly trap for sperm that prevents them from swimming into the cervix. In 2021, the company’s then head of research told Forbes that the molecule is derived from mushrooms (and has already been used in other FDA-approved medical products), so it’s completely non-hormonal.
In animal trials, the gel appeared to stop an average of 98 percent of sperm from making it to the uterus, but more research is needed before the gel can make its way to the market.
Since clinical trials alone can take half a decade to complete, it will likely be years before any of these new technologies hit the market. But it’s a step toward a new era for contraceptives. In many ways, this next revolution isn’t so different from the original one in the ’50s: women wanted birth control to reclaim their bodies, and now they want better birth control for the same reason.
When I spoke to Lytle on her one-year anniversary of being off the pill, she told me she was doing better but still healing. For many years, her body didn’t feel like her own; it was like living in a cheap rental apartment with mismatched furniture and creaky floors. Piece by piece, she’s started to make it feel like home again. “I’m just now getting to a point where I can look in the mirror and be okay with what I’m supposed to look and feel like,” she says.
She often wonders how different the past decade could have been without birth control. Some days, she’s angry that she wasn’t given another choice.
When I asked her if she would ever consider going back on the pill, she doesn’t hesitate.
“Never,” she says.
Correction, December 8, 2023: An earlier version of this article stated that Laura Wershler is a member of the Society for Menstrual Health Research. In fact, she is a member of the Society for Menstrual Cycle Research. The Walrus regrets the error.