Fall 2008 Issue

    What's the real story behind period-suppressing contraceptives?

    When Lybrel, a brand of birth control pill that stops monthly menstruation, became available in July, many women expressed skepticism that suppressing a regular bodily function could come without serious side effects. The media quickly latched onto this attitude, with headlines such as "Many Young Women Wary of a Life Without Periods." One woman told The New York Times she was worried by "the idea that you can turn your body on and off like a tap."

    A debate over period suppression also erupted among feminists. Some worried that this new type of pill would pathologize menstruation - sending the message that a normal female bodily function is something that needs treatment, and not just if you have "problem" periods. They argued that, like everything from bikini waxes to plastic surgery, period suppression reinforces the message that women need to tame their bodies.

    Yet, despite the blogging and the headlines, two-thirds of U.S. women surveyed said they are interested in such pills. More importantly, a whopping 97 percent of physicians surveyed said period suppression is medically safe and acceptable.

    In fact, criticism over manipulating a woman's period can apply to all hormonal birth control methods, because everything from the Pill to the patch to the ring to Lybrel regulates the menstrual cycle. And calling it unnatural to manipulate a woman's cycle can be a slippery slope: What is natural, anyway? In premodern societies, women were pregnant or breastfeeding for a much larger portion of their lives - which were shorter, anyway, and often ended in death during childbirth. Today, we have between 350 and 400 times as many periods as our premodern sisters did. Furthermore, as feminist blogger Amanda Marcotte (Pandagon) pointed out, adopting the natural/unnatural framework sounds awfully similar to right-wing claims that everything from women CEOs to same-sex relationships is unnatural.

    This isn't a new conversation: The idea of "natural" birth control has been a theme of the contraceptive movement for decades, although the word has taken on different meanings. With the advent of Lybrel and other period-suppressing oral contraceptives such as Seasonale and Seasonique, it's not surprising that we are once again considering the nature of natural.

    It's almost common knowledge that the reason the original birth control pills, approved by the FDA in 1960, attempted to mimic a woman's 28-day menstrual cycle is that one of the men who developed the Pill, a researcher named John Rock, wanted to convince the Catholic Church that hormonal contraception could be "natural." And indeed, that's part of the story. But it wasn't just to please the pope.

    Rock created a 28-day regimen to convince himself. As Malcolm Gladwell wrote in a 2000 issue of The New Yorker, Rock, a devout Catholic, believed (as the church did) that the only natural method of contraception was for a woman to abstain from sex when she was fertile. During the rest of her cycle, and when pregnant or breastfeeding, a woman produces the hormone progesterone to keep her ovaries from releasing an egg (although a woman can get pregnant while breastfeeding). Rock thought that if he could simply extend this infertile period by giving women progesterone - the combination oral contraceptive also contains estrogen - he would have a contraceptive method that complied with church teachings.

    There were other key reasons for keeping the 28-day cycle, says Carl Djerassi, a chemist whose research led to the development of the Pill: "At that time, giving a woman the assurance that she was not pregnant - remember there were no home pregnancy kits - was indispensable, and the only way a woman was certain was to experience the usual monthly period."

    Even though the chemical composition of the Pill has been tweaked over time - becoming safer and using fewer hormones - that original cycle of 21 days of progesterone and estrogen followed by a week of placebos or no pills (thus allowing the bloody inner lining of the uterus to slough off) has persisted. So, too, has the perception that this somehow creates natural birth control - or as natural as possible for a contraceptive method using synthetic hormones.

    That view persisted until November 2003 when Seasonale, the first oral contraceptive to promise women only four periods a year, hit the market. The drug works exactly the same as the 28-day regimen; in fact, since the 1960s some doctors had been prescribing continuous use of the Pill (telling women to skip the week of placebo pills) to help with medical conditions such as menstrual migraines, endometriosis, anemia and mood fluctuations due to hormonal changes, and even to help women avoid having their periods at inconvenient times (such as during a special event). Because the uterine lining does not build up as quickly for women on the Pill, there's actually no medical need to slough it off every three weeks. When the woman has her period, it's because her body has responded to the withdrawal of progesterone, not because her uterine lining needs to be shed.

    When it came time to market these period-suppressing pills, Big Pharma rolled out multimillion-dollar ad campaigns selling the idea that monthly periods hold us back from being truly happy and fulfilled. "When you think about what women have accomplished with 13 periods a year, think about what we can accomplish with only four," said "Sex and the City" author Candace Bushnell in a 2003 ad for Seasonale.

    It was this "periods cramp your style" message that prompted the Society for Menstrual Cycle Research to release this statement in 2007: "While we recognize that cycle-stopping contraception may be useful for some medical conditions (such as severe endometriosis), we caution against its use as ‘a lifestyle choice' until safety is firmly established. Historically, nasty surprises with hormonal therapies for women ... have taken many years to surface."

    But the pills also have several discernible medical benefits. Having fewer ovulatory cycles means less regeneration of ovarian and uterine cells, and thereby lowers risk for ovarian and uterine cancers. Avoiding ovulation can also hinder the progress of endometriosis, and resting a woman's ovaries can lower her chance of developing ovarian cysts. In fact, the main complaint about the period-suppressing pill - other than the similar side effects experienced by women on the 28-day oral contraceptives - has been breakthrough bleeding. Long gone are the days of the earliest formulation of Rock's birth control pills, which had 50 percent more estrogen and a much higher risk of heart disease and stroke.

    Of course, some of the most conservative anti-choicers would say the real problem here is that women no longer spend enough time in the "natural" state of pregnancy. Leslee Unruh, the South Dakota anti-choice activist who is responsible for pushing everything from abortion bans to abstinence-only education, warned on Fox News that Lybrel was a "war on women and children" and a "pesticide." She described those in favor of FDA approval as "wanting us women who are feminine and have fertility ... to be like men." (Obviously, this is not a view shared by many American women, 98 percent of whom will use some form of contraception during their lifetime.)

    This gets to the heart of why "it's not natural" is an ineffective argument against period suppression. To some feminists, natural may mean a menstrual cycle unchanged by pharmaceuticals (but we're not giving up our cramps-reducing Advil!); to anti-choicers like Unruh, it means women maintaining roles as fulltime child-bearers and caregivers. So if you're a feminist who opposes period-suppressing pills, critique Big Pharma. Or, if there are dangers found by researchers, pass the information along. But please, don't attempt to once again define "natural."

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    Ann Friedman is deputy editor of The American Prospect and one of the editors of Feministing.com.