When hormonal birth control debuted in 1960, it was hailed as a major breakthrough for women. After decades of research and advocacy, women finally had a way to control their fertility and prevent pregnancy; one that was totally under their own control, requiring no participation or cooperation from their sex partners.
But more than 50 years later, public sentiment about the pill seems to have turned. In the fall of 2016, a Danish study reported that hormonal contraception was linked to an elevated risk of depression; a finding which many women saw as proof that the pharmaceutical industry had done women a severe disservice. The reaction only intensified when, a few weeks later, it was announced that a male birth-control study had been suspended due to adverse effects experienced by men taking the medication, including mood disorders. Although many experts cautioned against reading too much into this single study, dissatisfied women around the world saw it as confirmation of what they’d long felt to be true.
There’s no question that the existing modes of birth control don’t work for everyone, and creating new methods for people for whom hormonal methods and copper IUDs just aren’t an option is important. But if we want to make contraception available to everyone who’s interested in regulating their fertility, we’ll need to explore other areas of research as well. Innovations that retool existing methods to make them less time intensive to obtain and use, cheaper, and longer lasting are also incredibly important — especially as American conservatives ramp up their assault on reproductive rights.
Currently, the only reversible non-hormonal birth control methods available are the copper IUD (known in the U.S. as the Paragard) and barrier methods like condoms, diaphragms, and sponges; save for the condom, none of those methods are designed with people with penises at top of mind. Remedying that dearth of options by creating more non-hormonal contraceptive methods for women, ideally long acting, reversible options (known within the public health space as LARCs), and reversible contraceptive methods for men would undoubtedly seem like a priority.
And browsing through Calliope, a database of potential contraceptive methods currently being researched and developed, reveals a number of novel birth control options currently being explored. There’s a non-hormonal weekly pill that’s been in use in India since the early 1990s, and works by blocking estrogen receptors in the uterus. Non-hormonal vaginal rings are also under development: the Cornell vaginal ring would disrupt insemination by releasing ferrous gluconate, ascorbic acid, pharmalytes, boclysinated betulonic acid, and tenofovir into the vagina, while the OvaPrene is a one-size-fits-all silicone barrier that would simultaneously block the cervical opening and release spermicides (making it not unlike an extended wear diaphragm). There updates to the diaphragm that aim to make it simpler to use, as well as a number of variations on the non-hormonal IUD, some of which are already available in other countries, like the IntraUterine Ball (a string of small copper balls that form into a larger ball once inside the uterus). And despite the difficulties faced by that widely cited male hormonal contraception study, there are a plethora of potential male contraceptive methods, including a pill that would impair sperm motility, a male counterpart to the subdermal hormonal implant, and the much hyped Vasalgel, a polymer that can be injected into the vas deferens, where it would block sperm until being dissolved by a second injection at a later date.
But format isn’t the only low-hanging fruit for contraceptives; there is a lot of room to improve in terms of access, too. Last month, a new contraceptive developed by the Population Council, Annovera, received FDA approval to much excitement and applause. It didn’t signal a major shift from business as usual: Annovera is still a hormonal method, and still intended to be used by people with uteruses. It’s less a dramatically different form of birth control than an iteration on an existing product, Nuvaring, a vaginal contraceptive ring that must be removed and replaced monthly, which received FDA approval in 2001.
While it’s similar in form and function to the NuvaRing, a single vaginal Annovera ring lasts a full year. NuvaRings must be refrigerated prior to use — an annoying detail for users who want to stock up on several months worth of rings. In contrast, Annovera is stored at room temperature. And although Annovera’s one year of use is significantly less than the multiple years provided by IUDs and implants, the device’s ability to be inserted and removed at will, without the assistance of a medical provider, is a significant improvement for many users. In theory, a person could acquire and get a full year’s birth control out of Annovera without ever going to a doctor’s office, using a telemedicine service to get approved for the prescription and self-inserting once it arrives through the mail, without any need to worry about ordering refills or figuring out storage for future months’ pill packs or rings. It’s an exciting possibility for someone whose schedule, home life, or physical limitations makes getting to the doctor difficult.
Pills, patches, and the NuvaRing are monthly prescriptions that can require regular visits to the pharmacy — while some insurers allow users to pick up months’ worth of medication at a time, others are more restrictive, requiring users to visit the pharmacy every single month. Depo-Provera, a contraceptive injection, is longer-lasting, but still requires a visit to a clinic or doctor every three months for a follow up injection. LARCs like the IUD and implant offer years of effective contraception, but they have to be inserted and removed by a doctor, placing the regulation of a user’s fertility in the hands of a medical professional — a requirement that can feel pretty intrusive if you don’t have easy access to a high quality reproductive healthcare provider. Annovera holds a lot of promise for people whose birth control use is stymied by concerns that have more to do with the time and effort required to obtain and use these methods rather than the physical effects of the methods themselves.
Annovera is far from the only attempt to innovate on birth control by making it more accessible. Planned Parenthood — which, unlike many of its colleagues in the reproductive health space, has the benefit of being both a research organization and a direct services provider — has explored a number of different strategies that might improve their patients’ contraceptive experience and increase compliance, all while relying on existing hormonal birth control methods.
In recent years, the organization has been exploring telemedicine. Because telemedicine operations are regulated and approved at the state level, roll out has been happening slowly, one state at a time. But at present, residents of Alaska, Arizona, California, Connecticut, Florida, Hawaii, Idaho, Minnesota, Montana, North Dakota, Rhode Island, South Dakota, or Washington are able to receive and fill a prescription using the the Planned Parenthood Direct app, no in-person appointment needed.
Planned Parenthood also examined whether having the option to self-inject Depo-Provera — rather than being required to a clinic for additional injections every three months — would affect patients’ use of the injectable contraceptive. In a study of 401 Planned Parenthood in New Jersey and Texas published in the March 2018 issue of Contraception, researchers found that having the option to inject at home dramatically increased adherence. After a year, 69 percent of the self-injection group had used the shot continuously, with no gaps in coverage. Just 54 percent of the clinic group could say the same. Encouraged by those results, Planned Parenthood is working to update its national medical standards and guidelines to make self-administered Depo-Provera an option for all of their patients. (Because self administered Depo-Provera is considered an off label use of an already approved medication, no regulatory bodies would need to be involved in Planned Parenthood’s decision to make this option available to clients.)
“Birth control is not one size fits all,” says Julia Kohn, the National Director of Research at the Planned Parenthood Federation of America. “I can’t imagine another area of healthcare where we would say, ‘Okay, I think we’re done here,’” she continues, noting that — as much progress as the reproductive health industry has made — there are still many gaps that need to be addressed before we can consider contraceptive technology to be perfected.
“I can’t imagine another area of healthcare where we would say, ‘Okay, I think we’re done here.’”
Making birth control available to everyone who wants it requires a diverse collection of strategies, and there are many people for whom Annovera, or telemedicine, or self-injected Depo-Provera will not be an adequate solution. Accessibility and ease of use remains the most important issue especially as political assaults on reproductive healthcare make high-quality providers harder to get access to. The most effective, long term contraceptive method ever doesn’t mean much if you can’t get ahold of it in the first place.
Even for the first contraceptive pill introduced in 1960, its slow path to mass adoption was due to social and political factors: Doctors who wouldn’t prescribe the medication to unmarried women, women who feared judgment from family and friends should their pill use be discovered, and state laws that banned contraceptive use entirely.
“Regardless of what the technological innovations are, the real issue is women getting access to birth control of any kind,” says Elaine Tyler May, author of America and The Pill, a history of the birth control pill’s development, debut, and adoption in America. Ensuring that access requires a multi-pronged strategy: not merely innovating new methods preventing pregnancy, but also making existing methods more usable, and ensuring access to existing methods for everyone who wants them.