You know those bridesmaid-font t-shirts and mugs with sassy slogans like, “Powered by coffee and wine?” If I were a slogan-merch person, I’d add one item to that list: Mirena. As a person with naturally hellish periods, I am so grateful for my hormone-releasing IUD—and the nearly-nonexistent menstruation that comes with it—that I shudder to think what my life would look like without it. Me and hormonal contraception: It’s love.
In the background of my love affair, though, has been an unsettling feeling that maybe it’s all too good to be true. I keep hearing about people quitting hormonal birth control and wondering: Wait, should I be worried?
After a little digging, I realized I’m kind of lucky: Hormonal contraception has been causing unpleasant side effects for some users literally since it was invented. The earliest trials for birth control pills in the 1950s had large numbers of test subjects (mostly poor Puerto Rican women who, by the way, weren’t even told what they were taking) drop out because the side effects were so intolerable—so researchers began testing on women they could force to participate, such as residents of a Massachusetts mental asylum and medical students, also in Puerto Rico (sense a theme?), who were told they’d be expelled if they didn’t. The amount of hormones in oral contraception has been significantly reduced since those early versions, but for a minority of users, unpleasant side effects like unwanted weight gain or loss, pelvic pain, yeast infections, or bloating still abound. It’s not just oral BC: Though it’s less common, some users of hormonal IUDs, implants, and other long-acting hormonal methods also experience side effects they don’t love.
“On average, young, healthy people who take hormones might have some uncomfortable side effects as their body gets used to it for a few weeks, but in general those minor side effects will go away and they will have a good experience with it,” says Raegan McDonald-Mosely, MD, CEO of Power to Decide, a national campaign to reduce unplanned pregnancy which runs Bedsider.org, a comprehensive resource for contraception information. Still, “It’s important to recognize that there are a small subset of people for whom hormones would not be a good idea, whether because of their family history or because they just had a bad experience.”
But side effects and contraindications aren’t the only reasons hormonal BC isn’t universally adored. In recent years, a cultural shift toward “natural” health and wellness practices has led some to question the safety of using hormonal birth control over the long term, fostered in part by the rise of wellness influencers and people sharing negative stories on social media. Users seem to be turning away from the Pill in particular: about 14 percent of women who use contraception reported taking the Pill in the CDC’s 2017–2019 survey versus about 19 percent back in 2002.
This noise has gotten louder with the arrival of Phexxi, a new nonhormonal birth control method. This contraceptive gel was approved by the FDA in 2020, and then came Phexxi’s irreverent ads, starring The Pill Pia (who raises an eyebrow about using birth control “even while exercising”) and Condom Cait (who “doesn’t like relying on her man”). In a promotional video starring Annie Murphy, who’s now the official spokesperson, the Schitt’s Creek actor says that “I went on the Pill when I was 16, and that meant taking hormones every day. I didn’t ask questions, and I didn’t get educated about it. I just took what I was given.” Murphy goes on to describe the other hormonal methods she was prescribed, and her decision to try the pull-out method after she chose to stop taking hormones altogether, before discovering Phexxi. She never says exactly what gave her pause about hormones (and the Phexxi team canceled my interview with her when I wouldn’t give them sufficient details about the angle of this story), so it’s hard to know exactly what led her to quit them.
As the ads made their way into my social feeds and streaming apps over the past year, I appreciated the taboo-busting of it all (and I love Annie Murphy). But I was still a little skeptical of the way the messaging seemed to dunk on other types of birth control (“No way would [Condom Cait] put hormones in her body!”). Why avoid hormones when they can be so miraculous, so life-alteringly helpful? In addition to easier periods, hormonal BC can help clear skin, regulate your mood, and, for longer-acting methods, free you from having to remember to take or use something every day or before sex. Mileage may vary, and again, some people using birth control do experience unpleasant side effects. But Phexxi’s ads seem aimed at those leery of hormones as a concept.
Wherever someone’s hormone hesitancy might stem from, Phexxi, of course, isn’t the first hormone-free option out there. You’ve got the copper IUD (popular for its extremely low failure rate, less so for its tendency to cause heavier periods); barrier methods such as condoms, cervical caps, and diaphragms; spermicides; and fertility-awareness methods (which aren’t generally recommended because of the high failure rate).
Phexxi is designed to be used right when sex is on the table: If users insert the gel and then don’t have sex within an hour but still plan to, they must insert another dose of Phexxi before intercourse. They also need to insert a new dose before each instance of intercourse even if they’re going to have sex more than once in a short time frame. The method may not be as set-it-and-forget-it as something like an IUD, but the ephemeral nature of Phexxi is part of the point, according to Saundra Pelletier, CEO of Evofem: The as-needed use allows for “sex on demand,” as she calls it. “Not all women have sex every day—doesn’t it seem weird that they put a synthetic hormone into their body every day?” Pelletier says.
For Selina Sandoval, MD, an OB/GYN, contraceptive specialist, and spokesperson for the American College of Obstetrics and Gynecology, Phexxi has been a helpful new option for her patients who aren’t candidates for estrogen-based methods and for patients who plan to start trying to conceive within a few months but need an effective method to use in the meantime. Phexxi is 93 percent effective with perfect use, and 86 percent effective for typical use, about the same as for condoms. And while there can be some side effects—the most common are vaginal burning or itching, or yeast infection—less than 2 percent of patients dropped out of a Phexxi trial because of them, Sandoval notes (the trial excluded those with a history of urinary tract infections, for whom Phexxi isn’t recommended).
Listen, I’m not here to diss Phexxi. And I actually loved the way Pelletier talked to me about the importance of advocating for yourself and asking the hard questions. But, while none of the manufacturer’s marketing materials for Phexxi say outright that hormones are bad, or dangerous — it feels implied, and that’s not cool. “I am not sure where this idea of hormonal contraception being unsafe for an extended period came from. In my practice, I’ve heard it from patients themselves, and patients who say their doctors told them to get off a certain hormonal method ‘to give their body a break’—so this misconception is among not just patients but some doctors as well,” says McDonald-Mosely. “The ‘natural wellness’ movement seems to capitalize on people’s concerns about taking certain medications and putting ‘foreign’ things into their body, and unfortunately hormonal birth control has been pretty centered in that movement.”
That’s not to say that there are zero longer-term health risks associated with taking hormonal contraception: For one thing, smokers and people who’ve had blood clots, breast cancer, heart problems, migraines with aura, high blood pressure or diabetes may not be able to use it safely. And there are very rare but serious complications on the record for the Pill (clots, heart attack, and stroke, among others; although it’s unlikely that those without contraindicatory underlying conditions would experience these outcomes). When it comes to breast cancer, “The data can be conflicting and it’s hard to give a 100% answer,” Sandoval says. “Most data points at [hormonal contraception] not increasing breast cancer risk, but some studies have shown a small increase in risk.”
But by the same token, you could say there are rare potential health risks for those who don’t take hormonal contraception: People who take the Pill have a significantly reduced risk for ovarian, colon, and uterine cancer, Sandoval says.
Though the hormones in the Pill are technically “synthetic,” a concept that scares some people away, they are identical to the hormones the body naturally makes on its own, says Sandoval. To be crystal clear: Over decades of research involving millions of users, no convincing evidence has been found that hormonal contraception is unhealthy or dangerous for long-term use for those without contraindications, and even initial adverse side effects tend to quiet down over time.
It’s important not to “disparage people for being informed consumers,” McDonald-Mosely says. “But we have to be careful not to overemphasize the potential side effects and concerns — that could actually have a negative public health impact of causing more unintended pregnancies or more people cautious about using birth control.”
When I asked Evofem about their messaging, they note “a significant faction of the population” is dissatisfied with current birth control options, and say the goal of their marketing materials is to ensure women are aware of all the options available so they can find the right birth control for them. And while it’s heartening to see people advocating for their own reproductive health and freedom, sharing publicly the good and the bad of their reproductive journeys, and making the choices that help them live healthfully and confidently, there’s something about a pharma company potentially fostering more unnecessary anxiety in people that raises my hackles. The thing is, well, we’re also living in a nightmare of a never-ending pandemic fueled in part by people “doing their own research” and intentionally avoiding a safe, effective, life-saving vaccine. So even subtle nods to vague, murky drawbacks of otherwise excellent interventions that could scare off users who could really benefit from them? They give me pause.
Of course, the critical difference is that while there’s no safe alternative to getting a Covid-19 vaccine, there are plenty of good options for those who don’t want to take hormonal birth control. And having more birth control options on the table will always be a good thing: There are so many bodies and conditions and needs and priorities out there that pharma will never run out of totally valid use cases for new contraceptive products. People with penises—who currently get to choose between condoms or vasectomy (that’s it!) if they want to be in charge of birth control—could use some better options, too. So Phexxi, and whatever new method debuts next, may not be for me, but could be a game-changer for other people. Just leave me and my fellow Mirena stans out of it.
“I’m super glad Phexxi’s on the market. But what we don’t want to do is make people question the safety of a contraceptive method that’s working for them or potentially would work for them,” McDonald-Mosely says. “It’s ok to be excited about a new nonhormonal option and still validate the importance of all of these other hormonal methods that many people have tried and loved.”
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