One milestone missed amid the chaos of those first pandemic months of 2020 was the sixtieth anniversary of the FDA’s approval of the world’s first contraceptive pill, Enovid. Lauded from the beginning as a “liberator” of women that would free them from unwanted pregnancies, “the Pill” is considered one of the major factors contributing to women’s surge into the workforce and institutions of higher education in the 1960s, ’70s, and ’80s. With the arrival of “the Pill,” it seemed that women, too, had arrived.
And not just because they now felt in control of conception. The Pill has also long been prescribed as a panacea for nearly every health issue related to the female menstrual cycle. In fact, although Enovid was developed specifically as a contraceptive, it was originally approved by the FDA in 1957 for “gynecological and menstrual disorders”; in clinical trials it had proved effective at suppressing the symptoms of certain gynecological disorders, such as heavy menstrual bleeding, pain, and cycle irregularity, and it could not yet legally be advertised as a contraceptive. However, the “contraceptive activity” of Enovid was already so well-known that, by the time the Pill was approved for explicitly contraceptive purposes in 1960 (well before the 1965 ruling in Griswold v. Connecticut effectively legalized contraception nationwide), half-a-million American women were already taking it.
Now, the perspective of sixty-plus years allows us to see how hormonal contraception has shaped both the healthcare system’s approach to women’s health and society’s treatment of women in the workforce. From the vantage point of 2022, it is clear that freedom from one’s fertility and suppression of one’s menstrual symptoms have come with two clear costs: an expectation that women accommodate themselves to the male-normative workforce, and a dearth of effective options to treat the root causes of gynecological and menstrual issues that plague millions of women around the world. In short, the pill has overpromised and underdelivered concerning the dual goals of improving women’s health and meaningfully expanding women’s economic opportunities.
Birth Control’s Effects on Healthcare and Women’s Health Research
Although the Pill’s original 1957 FDA approval for the market was a disingenuous “soft launch” of sorts, intended to gauge women’s interest in taking a daily medication for something other than a therapeutic purpose, it did seem to free many women from the painful, heavy, debilitating periods that since time immemorial were for some part and parcel of “being a woman.” Today, the Pill and other forms of hormonal contraception are still used, often off-label, to manage the symptoms of gynecological issues such as endometriosis, polycystic ovary syndrome (PCOS), and uterine fibroids, and more generally, to “regulate” a woman’s cycle.
In truth, Enovid and every iteration of hormonal birth control developed since has worked both to prevent pregnancy and suppress the symptoms of gynecological disorders, precisely because they override a woman’s natural cycle of fertility with synthetic hormones—namely, synthetic estrogen and synthetic progesterone, known as progestin.
A woman on hormonal contraception, whether it is a combined oral contraceptive, a progestin-only oral contraceptive, an implant, an injection, or a hormonal IUD, does not experience the natural monthly ebb and flow of endogenous estrogen and progesterone that is responsible for ovulation; the synthetic hormones found in birth control suppress it. Because these women do not ovulate, they do not menstruate, and therefore they do not experience symptoms like pain or heavy periods associated with certain disorders of the menstrual cycle.
In fact, some have argued that the Pill has worked a little too well in that regard, drawing attention and funding away from the research needed to find better ways to treat the root causes of the menstrual and gynecological disorders that plague millions of women all over the world. Despite being fairly common and causing a markedly decreased quality of life, including lost time at school and work because of symptoms like severe pain and heavy bleeding, menstrual disorders like endometriosis, PCOS, and uterine fibroids are virtual orphans in the health science and drug research industries. It can take the better part of a decade or more to accurately diagnose these conditions, in part because it is so easy to put a teenager or young woman on the Pill at the first sign of menstrual irregularity, and send her on her way without further investigation into the root cause of her symptoms.
As effective as hormonal contraceptives can be at masking the symptoms of menstrual issues, because they do not treat the root causes of those issues, these symptoms may return with a vengeance if a woman comes off birth control for some reason, whether to have a baby or because side effects have become intolerable. Discontinuation of birth control use is, in fact, quite common, since some of the side effects can be as disruptive as the issues these drugs purport to treat, and some are serious enough to cause death. Among the evidence-based risks and side effects of birth control are increased risk of blood clots (and through these, increased risk of heart attack and stroke); increased risk of certain cancers (chiefly breast and cervical cancers); increased risk of depression, anxiety, and suicide; loss of libido; osteoporosis and bone fractures; weight gain; irritable bowel syndrome; and increased risk of developing certain autoimmune disorders.
The mechanisms behind some of these effects are well-known, but the risks are often downplayed in statistical analyses and in public health policy decision-making. Still, sixty years after the Pill’s FDA approval, researchers have barely begun to scratch the surface of the myriad ways the synthetic hormones used in contraception affect women’s bodies. Likewise, we are just beginning to understand the significant role that endogenous sex hormones play in the proper functioning of the female body’s major systems and how hormonal contraception interrupts their functioning. It’s therefore unsurprising that hormonal contraception has been found to prevent the following: proper development of bone density during the years of adolescence and early adulthood, proper maturation of cervical tissue, development of certain parts of the brain, and maturation of breast tissue, to name just a few of the bodily processes suppressed or interrupted by these synthetic hormones.
As more becomes known about how the Pill works within the female body (and, simultaneously, the importance of natural, healthy cycles for female health and development), many women have begun to question whether hormonal contraception is the “miracle pill” it was promised to be. Likewise, more women are beginning to question the irony of a drug that supposedly “liberates” them by suppressing such a defining, vital aspect of their womanhood.
Birth Control and Women’s Role in Education and the Workforce
It is clear that the existence of a reliable option for pregnancy prevention, particularly among married women in the 1960s and ’70s, played a role in prompting women to pursue higher education and to enter the workforce at higher rates than ever before—and for businesses to eagerly accept them into these spaces. What deserves questioning is the nature of the role the Pill played, because it had serious ramifications for how women were treated in higher education and in the workplace that continue to this day.
To put it simply, hormonal contraception made women’s bodies more like men’s. In doing so, it burdened women with the expectation that they would function like men in the workplace and in higher education.
No longer cycling and mostly protected against an unplanned pregnancy, a woman on birth control could enter a program of higher education or embark on a career path reasonably confident that her fertility wouldn’t cause an unforeseen deviation from her plans. And because birth control typically rendered women’s bodies incapable of becoming pregnant (thereby increasing their similarity to the normative, male body of the workforce and education sectors), its use also made women more acceptable to leaders of previously male-centered spaces.
As I have written at Verily Magazine in discussing the lack of clinical research on pregnant, breastfeeding, and menstruating women, “Bodies that do not have a monthly cycle and cannot become impregnated are easier for science to study, easier to rely upon in the workplace, and so on, with the result being that bodies that menstruate, ovulate, and carry life are often left . . . to fend for themselves.” With the advent of hormonal contraception and legalized abortion, everything that was “problematic” or “unreliable” about a woman’s body—namely, that it menstruated and could become pregnant, and (because of hormonal cycling) could also experience greater fluctuations in professional productivity—could finally be rectified and controlled.
This came with a cost. With widespread use of hormonal contraception and legalized abortion, pregnancy and motherhood became a lifestyle choice, rather than something that, especially in the case of married women, could be expected to naturally occur. Is it any wonder, then, that women are still fighting for fair maternity leave policies in the workplace, let alone paid maternity leave?
And while the pandemic accelerated the acceptance of flex work and working from home (advancements that at first seemed to make it easier for mothers to continue working), it also caused mothers to exit the workforce en masse, as the boundaries between work and home life evaporated, making it impossible for mothers to be as productive in their work while caring for and schooling children, who suddenly found themselves home full-time. In fact, the pandemic has laid bare how little support there is for working parents— and especially for working mothers. While working mothers with college degrees and greater resources could sometimes choose to step away from work during the pandemic (although this may not have felt like much of a “choice”), many poorer, less educated women were fired for being “unreliable” because they lacked childcare. One such woman related in the Washington Post that she was denied jobs throughout the pandemic because, as her would-be employers told her, “‘you are a mom and you’re going to miss work.’”
Has widespread use of birth control—especially birth control directed at and controlled by women, ostensibly identifying them as the only party responsible for family planning decisions—made our society less understanding, less compassionate toward working mothers? It would seem so. After all, with the ample selection of drugs, devices, and procedures available to women to prevent conception and birth, becoming a mother is largely seen as an intentional choice.
Sadly, this lack of compassion extends to women even before they enter the workforce. Several years ago, ESPN uncovered instances of college athletes threatened with the loss of scholarships when they became unexpectedly pregnant and therefore unable to compete athletically. Many of these athletes felt pressured into choosing abortion to prevent the loss of the scholarships they needed to finance their college education. The ESPN investigation does not mention whether they discovered similar pressures exerted on male college athletes who fathered children while on scholarship.
On that note, hormonal contraception has also handed women the same “life script” that men are given in order to achieve success. By this, I mean the belief that upon graduating high school, a woman must enter higher education and then immediately enter the workforce or graduate education, spending the next several years building up a career before considering starting a family.
This is antithetical to how female fertility works; a woman is in the prime of her childbearing potential during her earlyand mid-twenties. This is also the time of life when pregnancy health outcomes for both mother and child are best. But a woman who takes time off from the workforce during the early years following college graduation, when she is expected to be “growing her career,” is often professionally penalized for doing so. This hiatus from educational or professional work to have a family during the most biologically opportune time does not fit neatly on a resume. It is a particularly cruel catch-22 for women: If they do take time off as young women to raise families, they often face many obstacles to returning to the workforce later on; however, if they wait to start their families in their late thirties and early forties after first establishing a career, they may find themselves unable to conceive, or unable to have as many children as they would like.
We know that becoming pregnant and giving birth does not have to derail an education or a career—we currently have a Supreme Court justice who is a mother to seven, and Olympic athletes who have gone on to win gold after becoming mothers. Yet, on the whole, women are still fighting for the things that make working motherhood possible for the average woman: flexible work, reasonable childcare costs, paid maternity (and paternity) leave, the acceptance of resume gaps, and safe, high-quality schools that remain open, instead of throwing families with working parents into chaos by shutting down or sending children home to self-isolate whenever a positive Covid case appears in the classroom or childcare center.
What has become painfully clear over the course of the pandemic is that birth control (and its backup, abortion) did not change the workplace to better fit women, but rather changed women to fit the workplace. In other words, accommodating mothers was never part of the script for equal-opportunity workplaces. Women would be allowed to enter higher education en masse and compete for all levels of workplace achievement as long as they played by the rules: Be like a man, don’t get pregnant—and if you do, make sure you “take care of it.”
And women are the worse for it. In what has been called the “paradox of declining female happiness,” women’s happiness and sense of well-being have eroded over the last handful of decades, even as objective measures of quality of life have improved. Looked at another way, the economic and educational opportunity gains made in lockstep with the advent of widespread birth control use seem to have done little to contribute to women’s happiness. Emblematic of this phenomenon is the fact that, on the whole, Western women are bearing fewer children, while simultaneously reporting that they would like to have more children. There is also the possibility that birth control itself may be robbing women of their ability to enjoy life: In her book, This Is Your Brain on Birth Control, Dr. Sarah E Hill details the data behind the effects of birth control on women’s brains, including anecdotal stories of how hormonal birth control puts some women in a “fog,” causing them to lose their “drive,” and their ability to “see life in color” (an effect that she herself experienced on birth control, only realizing it after she stopped using the Pill and noticed the difference in her own mental and emotional health).
Ironically, side effects like these can actually keep women out of school and the workforce. Consider, for example, the school and work hours lost to depression and anxiety associated with the use of hormonal contraception (the risks of which are well-documented)—not to mention other side effects and risks like pain and prolonged, heavy bleeding (common on the copper IUD), or even more seriously, breast cancer and strokes. While many credit birth control with keeping girls in school and bringing women into the workforce, these adverse effects (including the changes hormonal birth control causes in the structure and function of certain parts of women’s brains, which makes them operate more like men’s brains) compel us to consider what uniquely feminine perspectives we may be missing in these spaces because of hormonal birth control.
Women Deserve Better than Birth Control
Imagine a world where workplaces and institutions of higher education had to adjust to the reality of women getting pregnant, rather than the other way around. A world where women not only had meaningful opportunities to enter the workforce and higher education, but could enter them on their own terms. Perhaps women wouldn’t delay childbearing for so long, and would have more children, relieving the United States and other Western countries from our clear demographic decline.
Perhaps, in such a world, young women would receive real help for their menstrual-cycle problems sooner, from restorative reproductive medical professionals seeking to treat the root causes of those issues, instead of entangling their patients in the vicious cycle of birth control symptoms and the antidepressants so often prescribed to mitigate them. Perhaps women who found themselves unexpectedly pregnant would keep their babies instead of aborting them out of the fear of losing their ability to earn a living. Perhaps women in college who became pregnant wouldn’t believe the lie that they can’t achieve greatness, whether in a sport or in a career, with a child. Maybe employers would offer insurance policies that would cover restorative reproductive medicine, instead of just birth control, egg freezing, and in vitro fertilization, as an enticement to female workers.
A world that makes space for women to be women is one in which women are empowered, families are valued, and children are better protected and provided for. To paraphrase both Pope Francis and the late Supreme Court Justice Ruth Bader Ginsburg, such a world would make it possible for women and their authentic, unadulterated feminine genius to be present wherever important decisions were being made. That is the world I want for my daughters. That is a world worth striving for.
Grace Emily Stark is the editor of Natural Womanhood (www.naturalwomanhood.org) and a Ramsey fellow at the Center for Bioethics and Culture. In 2019, she completed a Robert Novak Journalism Fellowship on the side effects of birth control.