'Pill' at 50: Hunt goes on for foolproof contraceptive

It was supposed to make every child a wanted child, give women control over their bodies and grant couples worry-free sex.

Such were the aspirations of health professionals worldwide when the medication now known simply as "the pill" arrived on the market 50 years ago. It was the first birth-control method that did not require use in the heat of the moment, the first that could be used by a woman without her partner's knowledge or cooperation.

An estimated 12 million American women take the pill today, and about 80 percent of women will use it at some time during their reproductive years. Its uses have moved far beyond the original intentions of its makers: Today it is given to cut the risk of uterine and ovarian cancer in high-risk women; to alleviate abnormally heavy or painful periods; to fight anemia; to stabilize mood; even to clear up acne.

As a tool for women's career advancement in the latter half of the 20th century, the pill had a monumental impact, said Elaine Tyler May, a historian at the University of Minnesota and author of "America + The Pill: A History of Promise, Peril and Liberation."

But despite the freedom in career and family planning the pill extended to so many women and couples, it has not fulfilled one big hope. Fifty years on, about half of all pregnancies in the United States are unintended and 22 percent of pregnancies end in abortion.

"It's not going to be the answer to unintended pregnancy — we can be sure of that," said James Trussell, director of Princeton University's Office of Population Research and a leading authority on contraception.

Trussell said he believes the pill's time is passing — and that the future lies instead with foolproof contraceptives that require almost no thought or action.

Before the Food and Drug Administration (FDA) voted in May 1960 to approve the first oral contraceptive, the only forms of birth control were sterilization, the diaphragm, condoms and natural family planning (the "rhythm method").

The thought of out-of-wedlock pregnancy struck terror in women in midcentury America, said Claudia Goldin, a Harvard University professor of economics who has studied the pill's effect on professional women. The proper course of courtship was to go steady, become pinned, then engaged.

"They were a set of steps that led almost irrevocably to marriage, and they were set down at an early age," Goldin said. "The pill allowed us to get rid of all of those steps."

That first pill, Enovid, contained a mixture of the hormones estrogen and progestin that worked to prevent ovulation. Women took one active pill a day for 21 days, then a placebo pill for seven days to allow for menstruation, which the pill's inventors believed was necessary and would assure women they weren't pregnant.

In the post-pill era, the average age of first marriage began to creep up as women and couples no longer felt they needed to wait to become sexually active. The rate of women in professional schools rose from 18.4 percent of professionals in 1960 to 36.4 percent by 1998.

The pill also has been credited — or blamed — for overturning sexual mores, but there is less evidence that it caused or evenly greatly contributed to the sexual revolution, May said. The nation, she noted, experienced sharp changes in sexual behavior in the 1920s, during World War II, and during the 1960s and '70s.

Other predictions swirling around at the time of the pill's debut did not come true, May said. The pill did not curb worldwide population growth, create happier sex lives for married couples or reduce rates of divorce.

As a drug, it did not deliver as expected, either. It was not as safe as its creators had hoped. Within a year of Enovid's introduction, reports trickled in that its high hormone content raised the risk of blood clots, heart attacks and strokes, and that women who smoked had an even higher risk of side effects. This led to reformulations to lower hormone dosages and warnings for smokers to avoid the pill.

Today's birth-control pills contain about 25 to 35 micrograms of estrogen compared with the 150 micrograms Enovid contained, said Dr. Daniel Mishell Jr., a professor of obstetrics and gynecology at the University of Southern California. Progestin content went from 10 milligrams in the original to about 1 milligram.

"It has remained effective but with increased safety," Mishell said.

While today's oral contraceptives are far safer than the first iterations, they still have risks. And the new pills continue to invoke controversy. The FDA last year reprimanded Bayer HealthCare, makers of Yaz, for marketing the pill to treat PMS and acne, and for failing to cite the drug's risks. More than 1,000 lawsuits against Bayer charge that the kind of progestin in Yaz and Yasmin, another pill it markets, raises risks of blood clots and strokes.

The nation's rate of unintended pregnancy stands at 49 percent of all pregnancies — a number that has not budged since 1994 and far surpasses that of many industrialized nations. Although the pill is the most popular contraceptive, more than 10 percent of women at risk for pregnancy use nothing.

The pill also remains unaffordable or inaccessible to some women. Some insurers require women to refill the prescription each month, usually with a co-pay of about $20, instead of allowing a three-month supply. Efforts to persuade the FDA to allow the pill to be sold over the counter have gone nowhere.

When the pill is used perfectly, one woman in every 100 will get pregnant on the pill during the course of one year, Mishell said. But with "typical use," the failure rate is as high as 8 percent — because many women forget to take a pill every day.

That is precisely why the pill's time has come and gone, Trussell said.

In a 2008 scientific paper, he argued that many women would be far better served by newer long-acting contraceptive methods that don't require remembering to take a pill each day. These include the ParaGard copper intrauterine device that remains in place in the uterus up to 12 years; Mirena, an IUD that blocks ovulation and can remain in place for five years; and Implanon, a hormone-releasing rod implanted in the upper arm for as long as three years.

Increased education and public funding should be directed toward these reversible, long-acting methods, Trussell said. Moreover, he said, progress must be made in finding a product that would prevent pregnancy with high effectiveness and also protect against sexually transmitted diseases (STDs). The condom — a centuries-old method — remains one of the most popular contraceptive choices because it offers a degree of STD protection, too.

But the pill is unlikely to be dethroned soon.

"Oral contraceptives are, by far, the most popular method in the United States," Mishell said. "I don't see a big turnaround of pill use in this country. I think we'll have improved types of pills."

And perhaps even a contraceptive pill for men — a product that, despite years of research, remains nowhere in sight.