Contraception: are Women Paying the Price for Family Planning?

Is contraception a woman’s responsibility? If so, do the methods presented to women work effectively, without having negative consequences?

121 million pregnancies each year - almost half of all pregnancies - are unplanned. Unplanned pregnancies not only represent a failure in the use of contraceptive methods, but also are at risk of leading to health issues for both mother and child, including malnutrition, neglect and abuse. As of 2019, only 27.4% of contraceptive practice worldwide consisted of methods which require direct male participation (such as male sterilisation, withdrawal, and the male condom). Although vasectomies are more cost efficient than female sterilisation, and have fewer side effects, in 2014, in the US, 15.5% women depended on their own sterilisation surgery, in comparison to 5.1% depending on male sterilisation surgery. On the other hand, 100% pregnancies involve a sperm. Evidently, there is a gap which must be bridged. 

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Male condoms have the highest rate of failure of all the contraceptive technologies. There has been very little advancement in the last century, to create new male contraceptive methods, whilst there have been around a dozen new methods for women. Is it simply because it is harder to create contraception technologies for men? Unlikely. The pharmaceutical market responds very much to the demands of the consumer. In a study conducted in 1994, it was found that American college men chose against using contraception due to ‘bothersomeness’, or it being ‘against nature’.  A study conducted by Martin et al. in 2000 showed that up to 34% men were against male contraception on the grounds that it would threaten their masculinity. Thus, the issue here is the association of contraception with femininity, and the fear men feel, regarding their social image. The study carried out by Peterson and colleagues in 2019 showed that within their sample of college men, 35% were reported to show moderate to high willingness in using male contraception, with 77.5% showing any level of willingness. This figure has definitely increased, with it previously being 20% in 1994. On the other hand, whilst there has been a general increase in the use of contraception worldwide, the use of IUD and male sterilisation have declined, suggesting that whilst attitudes towards male sterilisation may be improving, they are not doing so at a sufficient rate to keep up with the increase in the use of contraception. However, with the current technologies, there are barriers to simple, effective male contraception, with vasectomies being permanent, and condoms and withdrawal being ineffective if not done correctly. 

On the female side, the most frequently prescribed form of contraception is the combined pill. So, what is it costing women to use this as a method of autonomy over their own pregnancy, given the fact that men do not currently play a large role in contraception? The combined pill consists of a mixture of two hormones: oestrogen and progestogen, which prevent luteinising hormone (LH) and follicle-stimulating hormone (FSH), from being released from the pituitary gland. As a result, they are prevented from stimulating the thickening of the uterus lining, and enabling the maturation of the egg follicles in the ovary. Oestrogen and progestogen also control the thickness of the uterus lining, with oestrogen stimulating endometrial growth (the endometrium is the layer of tissue lining the uterus), and progestogen countering this effect to prevent hyperplasia (excessive growth). The typical regimen is 3 weeks of taking the pill daily, and one week without (either through not using the pill, or using a placebo without the hormones). On the week without, ‘breakthrough bleeding’ takes place, as there are lower levels of progesterone and oestrogen, so the endometrium is shed. In this way, taking the combined pill makes the body imitate a cycle of 3 weeks of pregnancy, and 1 week of bleeding. The Pill has been marketed as a period suppressing drug, with Lybrel coming out in 2007, promising no periods whatsoever, by not giving a placebo pill. This can cause issues when a woman becomes pregnant, and does not realise, because she never bleeds. The menstrual suppression which can be achieved with the pill is also used to treat endometriosis and other cases of severe period pains, but what are the consequences of this seemingly perfect method of contraception for women? 

General adverse effects of oral contraceptive pills include an increase in hypertension - causing this condition in 4-5% of healthy women, and exacerbating it in 9-16% of those who already have hypertension. It can have negative effects on glucose metabolism, to the extent that those suffering from diabetes may need to increase the amount of insulin they take. Nausea, headaches, breast tenderness and abdominal cramping are all common consequences of taking the pill, but the effect I would like to focus on is that on inflammatory bowel disease (IBD). IBD consist of Crohn’s disease (CD) an ulcerative colitis (UC), with UC being characterised by inflammation and ulcers along the lining of the colon and rectum, and CD by inflammation most commonly in the small intestine, but also potentially in the large intestine and upper gastrointestinal tract. Oral contraceptive use has been consistently associated with an increased risk of Crohn's disease (CD): in 2008, Cornish and colleagues showed that the use of oral contraceptives related to an almost 50% higher risk of developing CD, with discontinuation of oral contraceptives apparently diminishing the risk. One reason for this may be the fact that oral contraceptives are linked to a 60% increase in endogenous oestrogen, and a 50% decrease in testosterone. Testosterone is involved in the immune system, such as in cytokine production (cytokines modulate elements of the immune response, such as inflammation), and in a 2015 study by Khalili and colleagues, increased levels of endogenous circulating testosterone were associated with a lower risk of CD. Thus, by impacting levels of testosterone, oral contraceptives may increase the likelihood of a woman developing CD. The symptoms of IBD include diarrhoea, fatigue, weight loss, abdominal pain and rectal bleeding. 

Evidently, the contraceptive pill, although extremely useful, is not perfect. Whilst the search for improvements to the pill should certainly continue to minimise these effects, there should also be an emphasis placed on the development of male contraceptives, and on changing the social stigma regarding male contraception. In this way, we can move from a world with 121 million unplanned pregnancies annually, to men and women both taking an equal responsibility for ensuring that all pregnancies are purposeful, and carefully considered. After all, creating life is a miraculous concept, and should not be an act mistakenly carried out by young adults trying to maintain a masculine image. 

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