The Pill and the IUD

Because of their more than 98 percent reliability and their requirement of a physician’s services to be obtained and used, oral contraceptives and IUDs (intrauterine devices) are known as "medically effective" methods.39 Next to abortion and surgical sterilization, the method of fertil­ity control used most frequently among American women since the mid — 1960s has been the oral contraceptive pill. It is not my intention here to offer a detailed analysis of the health risks of the pill, since that is available elsewhere, but to examine how publicized evidence of those risks, as well as daily disturbances and side effects, have influenced wom­en’s pill use and increased their reliance on abortion.40

Before reviewing the risks, however, it is important to note that the health picture for women as a result of the pill is a mixed rather than an unredeemably negative one. Between 1955 and 1975, the propor­tion of reproductive deaths related to pregnancy and childbearing declined from 99 percent to 48 percent (not counting abortion-related deaths, which fell even more sharply), whereas by 1975 "complications of contraception" (mostly from the pill) had become the cause of 47 percent of reproductive deaths. Thus federal researchers have stated that "pregnancy prevention [in the U. S.] now causes about as many deaths as pregnancy itself."41 But this 47 percent represented many fewer deaths than had occurred among previous generations of women from all pregnancy-related causes. That is, the pill accounts for relatively more deaths in a context of declining maternal mortality. Moreover, insofar as that decline is due to decreased childbearing, the pill is partly responsible for saving women’s lives by curtailing pregnancies.

Evidence about the pill’s sometimes fatal hazards to health, particu­larly in regard to cardiovascular and circulatory disease, was reported in 1969 in British medical journals and was rapidly transmitted to the American public through the press, Senate hearings (1970), and Barbara Seaman’s widely read expose, The Doctors’ Case Against the Pill.42 Since then, evidence of serious or fatal risks associated with oral contraceptives and estrogens generally, especially for women over thirty-five and those who smoke, has grown substantially and has come to include a long list of conditions extending beyond the original concern with thromboembo — lisms. Extended pill use has now been associated with myocardial infarc­tion, metabolic disorders, liver tumors, gall bladder complications, and possibly breast and cervical cancers, particularly in women whose family histories make them more susceptible to these conditions.43 These studies and the tireless efforts of feminist health advocates led the Food and Drug Administration (FDA) in 1977 to require the insertion by manufac­turers of warning information in pill packages.

Attempting to salvage the pill’s reputation in the wake of adverse publicity and a decline in pill use, researchers and family planners go to lengths to emphasize the importance of "synergistic effects" and "pre­disposing factors," especially age and smoking behavior, in determining levels of risk. Among such spokesmen, it is now the commonly accepted view that the pill may be contraindicated for women who smoke, women over thirty-five, and women who have personal or family histories of diabetes or hypertension. It has become standard clinical practice in many places not to prescribe the pill for such women.44 Epidemiologists at the Centers for Disease Control in Atlanta, studying age-specific reproductive mortality for American women since 1955, found that the reproductive mortality rate had declined by 73 percent for women generally but only by 41 percent for women aged 35-44. This difference was "because of the relatively high mortality rate associated with oral contraceptive (OC) use in this age group" since I960.45 While recommending that reproductive deaths related to contraception be included in national surveillances of maternal mortality, these researchers nonetheless conclude that "for the vast majority of younger women who do not smoke the pill is very safe." Similarly, based on her survey of world literature on health risks to adoles­cents from contraceptive use, Dr. Adele Hoffman, testifying before the Senate Subcommittee on Aging, Family and Health Services, concluded that risks are "minimal." "Fifteen — to nineteen-year-olds, whether or not they smoke, are at the lowest risk" of any group of women using oral contraceptives, particularly with regard to strokes or clotting disorders (not a single case has been reported). While the incidence of cervical cancer has risen among sexually active adolescents and young adults, Dr. Hoffman does not believe there is sufficient evidence to associate this rise with pill use, as opposed to sexual frequency and multiple partners.46

There seems little doubt that the health hazards of pill use rise enor­mously for women in relation to age and smoking and that the risks for younger, nonsmoking women may for many be worth taking. It is also true that longitudinal studies of the pill’s relation to cancer, especially among younger women using lower-dosage pills, remain unsatisfactory and inconclusive. But the ways in which researchers interpret existing mortality and morbidity data, if not the studies themselves, are open to serious question.47 For one thing, the emphasis on compounded risks for smokers diverts attention from the disturbing fact that the risk of cardiovascular mortality for women who use the pill but do not smoke are three to five times greater than for women who do not use the pill.48 Second, the wider range of diseases now associated with the pill suggests that "the cumulative absolute risk" of all of them may pose a greater overall danger to a woman’s general health over time than any one factor taken singly.49 Third, the argument that family planning analysts continu­ally make on behalf of the pill—that, except for women smokers over forty, there are fewer risks associated with the pill than with pregnancy— is specious. It assumes that the alternative to pill or IUD use for most women is multiple pregnancies and births, ignoring the reality that most women in developed countries who go off (or never start) the pill end up using some combination of more traditional—and safer—methods and early abortion.50 In fact, the most definitive conclusion that Christopher Tietze drew from his available data on birth-control-related mortality (shown in Figure 5-1) was not the "relative" safety of the pill, but "the very low mortality combined with 100 percent effectiveness that can be obtained by use of the condom and diaphragm when these methods are backed up by early induced abortion. "51

Finally, the lack of conclusive evidence about a relationship between oral contraceptives and cancer, or other long-range risks to health for younger women, cuts two ways. At this point, we do not know as much as we need to know to make an informed judgment about such risks, particularly the "synergistic effects" that might be caused not only by smoking but by many other environmental agents, when combined with synthetic hormones. Yet, if the risks for pill users who are today in their teens and early twenties turn out to be small, that very fact owes a lot to the active struggle waged by feminists, who publicized the cancer link to estrogen during the 1970s and forced the companies to produce a lower-dosage and safer pill. Not until the mid-1970s did drug companies begin to manufacture pills with substantially lower doses and did repro­ductive researchers come up with the "knowledge" that lower-dosage

source: Howard W. Ory, "Mortality Associated with Fertility and Fertil­ity Control: 1983/’ Family Planning Perspectives 15 (March/April 1983).

pills were as "efficacious" as those high in estrogen. Like the important pill package inserts describing risks and side effects, this was obviously a response to the public outcry about pill hazards and shifted the ground of reproductive rights conflicts.52 As with any technology, the science and the health impact of fertility control methods develop within and in reaction to politics.

How the data on mortality and health risks are used and transformed is thus an important part of the political arena in which doctors and family planners, feminist health advocates and women patients contend in their struggle to negotiate fertility control practices. In a political context dominated by right-wing attacks on abortion, the medical and family planning establishment would seem to be engaged in a campaign to allay women’s doubts about the pill, partly to make an end run around the abortion issue. It is significant that in all the discussions of contraceptive hazards and benefits, abortion is rarely mentioned except to say how it may be avoided. A blatant example is an article by Charles Westoff and others that estimates the number of "preventable" abortions based on the hypothetical assumption that all contraceptive users rely on the pill, the IUD, or surgical sterilization.53 The article is a piece of wishful thinking that totally ignores the practical reasons why many women do not see these methods as reasonable alternatives to abortion; the problems of the methods themselves make continued reliance on abortion a necessity.

My argument here is not that abortion is "safer" than the pill or IUD, although since suction methods have replaced sharp curretage for first — (and early second-) trimester abortions, the health dangers of abor­tion are mainly social and political (the causes of delay or poor sanitary conditions) rather than method related.54 If we look at mortality alone, as presented in Figure 5-1, early abortion and the pill for women under thirty who do not smoke appear to involve similar levels of risk. But women stop taking the pill not only because of fears about severe or fatal health risks but also because of less dangerous but bothersome side effects that doctors and family planners tend to dismiss or trivialize. That pill use has declined among certain groups of American women since the early 1970s seems clear. Almost as soon as the pill became "number one" among contraceptives, a significant rise in the pill "drop-out" phe­nomenon occurred. As the House Select Committee on Population re­ported in 1978, "potential health hazards associated with the most highly effective contraceptives—the pills and IUDs—have discouraged increasing numbers of adult women and adolescents from using them."55 A substan­tial part of the decline among older married women is accounted for by the rise in surgical sterilization; for women over thirty who do not wish to have more children, the serious hazards and side effects of the pill may make sterilization seem a "medically necessary" or "medically advis­able" alternative.56 But younger women too have participated in the pill "drop-out" in substantial numbers. Among American adolescents "use of the pill and IUD declined by 41 percent [between 1976 and 1979], while use of withdrawal and rhythm rose by 86 percent. In 1976, the three most popular methods [among teenagers] were condom, pill and withdrawal, in that order; in 1979 they were withdrawal, condom and the pill."57 This "flight from the pill" occurred among both white and black teenagers, but was much sharper among whites (a 46 percent decline as compared with 21 percent among blacks). This difference may reflect the greater susceptibility of white teenagers to popular media, the trend toward "naturalness" ("it’s no good to put drugs into your body"58), and generalized fears of cancer. It is also likely that some of the decline, among all teenagers, is due to misinformation and rumors about the pill, which may feed into an already present ambivalence about using contra­ception regularly. At the same time, attributing the pill "drop-out" to a media-concocted scare is a way of discrediting the judgment of women and of distorting facts.

In fact, the pill "drop-out" represents not so much an absolute decline in users as a pattern in which a persistently large number of users goes on the pill for a few years and then discontinues its use. What is rarely noticed is that this pattern has existed almost from the beginning of the "pill era" and belies the notion that pill discontinuation is mainly the result of feminist or Black Power propaganda, or scare tactics by the media. Feminists who see women pill users as simply the victims of the male-dominated medical profession and drug companies have their counterpart in family planners and population-oriented physicians who see pill "drop-outs" as simply the dupes of the press. Since clinicians emphasize "efficacy" above all other measures in their evaluation of fertil­ity control methods, they are likely to see deliberate cessation of an "effi­cacious" method by a woman who is not seeking to become pregnant as irrational or manipulated—a psychological rather than a social problem. A recent article in Family Planning Perspectives, for example, attempts to assess "the influence of the media" on pill and IUD discontinuation be­tween 1970 and 1975, through a series of graphs that rather mechanically correlate "peaks" in discontinuation with prime media events (e. g., Nelson committee hearings, FDA warnings).59 In the same article, however, these authors present findings from the 1975 National Fertility Survey indicating that the overwhelming reason women give for their termination of the pill is not "worry about reports of danger to health," but "experienced physical problems."60 The tacit implication is that these physical problems must be imagined, the product of women’s suggestibility to media influ­ence.

But there is ample evidence that they are not imagined, that while many women (and men) are justifiably worried about the long-range health risks of oral contraceptives (by 1977 only 29 percent of men and 25 percent of women still believed the pill to be safe), the reason why they stop taking the pill has to do with the day-to-day, immediate discom­forts the pill causes them. These include weight gain, depression, dimin­ished sexual response, headaches, nausea, and recurrent vaginal infections. One basis for this conclusion is the fact that the pill "drop-out" as a major trend (an over 40 percent discontinuation rate) began in 1967, three years before the "media barrage" publicizing the pill’s hazards, and contin­ued to rise steadily thereafter.61 No matter what year women began using the pill throughout the 1960s, the probability of dropping the pill rose sharply after one year and still more sharply after the second and third year of use. The reason given for discontinuation by between two-thirds and three-fourths of every age and racial group in 1970 was, again, "per­sonally experienced physical problems."62 More recent studies confirm these findings.63 The flurry of recent articles in family planning journals that try to reassure women about the pill, however, focuses exclusively on mortality issues; the side effects and less-than-fatal health risks that constitute the basis for most women’s discontinuation are regarded as psychosomatic or negligible.

In the case of the IUD, it has been much harder to ignore the experi­ence of unpleasant side effects because they are so pervasive and pro­nounced. Women who have IUDs inserted continue to be plagued by problems such as vaginal bleeding, cramps, heavy periods, and expulsion of the device, which account for high rates of discontinuation 64 Although "these local symptoms have been generally considered innocuous and a common accompaniment of IUD usage"65 by clinicians and researchers, for most women there is nothing "innocuous" about such symptoms, and one avoids them if possible. It is thus not surprising that only 6 percent of all American women and 2 percent of teenagers use the IUD as their method of contraception.66 Much more serious is the association of IUD use with ectopic pregnancies or pregnancies resulting in septic trimester abortions that have led to women’s deaths. Above all, there is now conclusive evidence that women who use IUDs, particularly if they are young and have multiple sexual partners, run a three to four times greater risk of developing pelvic inflammatory disease (PID)—an infec­tious, sexually transmittable disease that often leads to tubal inflamma­tions, damage to organs in the pelvic area, and infertility.67 This is the most dangerous health complication for teenagers from any form of contraception 68