Modern contraception: When will we leave the idea of a “normal” woman behind?

Originally published by Rose Stevens, Research Assistant at the School of Anthropology and Museum Ethnography, University of Oxford, in Pills and Policies

In school, whether it is in sex education or in biology, we are taught about the normal woman’s reproductive system. We are taught that the normal menstrual cycle is around 28 days. We are taught everyone has regular predictable periods. We are taught that in a normal woman these periods are five days in length and start at age 12 or 13. We grow up ascribing to this idea of the “normal woman.” However what we are never taught is that this normal woman does not exist.

Calling the reproductive biology of any woman “normal” is misleading when actually existent natural variation is huge. Ignoring this variation could well be leading to women being prescribed contraception that does not fit with their individual physiology and certainly leading to many women thinking their bodies’ reactions to some contraceptives may be abnormal or dysfunctional. However, by appreciating and recording this diversity, we can help women understand their own bodies to be able to make the best decisions for themselves and can inform healthcare providers of how it may be possible to improve their client’s reproductive health.

Woman to woman variation

The evidence for variation in women’s reproductive biology is out there. A study called ‘How regular is regular?’ found that women’s shortest and longest menstrual cycles varied by an average of 10.2 days (1). Another study in the UK found that 4.8% of girls start their period before age 11 and 10.1% start it after age 15 (4). Variation does not just exist in the menstrual cycle itself but in the underlying reproductive hormones that guide it. Ovarian steroid hormones such as oestrogen and progesterone vary massively between women and between populations across the world. In fact, the average progesterone level of healthy women in some agricultural populations around the world would mean they would be classified as infecund, or unable to bear children, had they been observed in a clinical setting in the United States (6). It is these reproductive hormones that are employed and influenced by hormonal contraception.

The problems of ignoring variation

Contraception is currently administered based on the assumption that all women will respond in a similar manner. Global policy documents on how to improve family planning services rarely contain any mention of needing to take into consideration physiological variation. Most seem to either be unaware of the huge variation out there or ignore it and instead implicitly subscribe to the “normal vs. abnormal” paradigm that steers much medical practice. The default is to view variation as dysfunction (3) instead of trying to account for it.

The reason variation makes giving everyone the same contraception problematic is because the aim of hormonal contraceptive design is to provide an effective and safe dose with minimal side effects that still gives a very low chance of pregnancy. Finding this balance will depend on a woman’s individual level of endogenous hormones — the natural concentrations of hormones in her blood. The further off the contraceptive dose is from this balance, the more potential there is for side effects.

Is this just perhaps the small price some of us have to pay for convenient easy fertility control? According to both providers and producers of hormonal contraceptives, the side effects that do occur are generally considered to be tolerable and not too bad. In a review of the clinical evidence for side effects of the pill, several side effects such as headaches, mood changes and libido changes were dubbed as either clinically insignificant or so rare as to be of minimal importance (2). However listening to the experiences of women can testify to the fact that for some women, these side effects are neither rare nor insignificant but can actually have a noticeable impact upon a woman’s life.

These testimonies are creating a growing recognition that not all women will respond to contraception in the same or positive way. And when combined with the publication of a Danish study that followed over a million women using hormonal contraception and found an association with subsequent first diagnosis of depression (5), the wider world is now paying attention.

Hormonal contraception can bring huge benefits

But the picture is by no means all bad — there are some real upsides to hormonal contraception and it has made a huge difference to many women’s lives. In fact, The Economist went as far to dub the contraceptive pill the invention that ‘defined the 20th century.’ It has given women control over their own bodies; their fertility and their sexuality. It has given them the ability to remain in education or employment for as long as they like without fear of becoming pregnant. In this way, not only has it been one of the most transformative and liberating inventions in the past century, possibly ever, it also has provided a whole host of positive side effects. It has helped women with painful or irregular periods regain comfort and control. In some cases, it has helped ease mood swings, reduce acne and radically lower the risk of ovarian cancer. Globally, it is helping improve individual health, gender equity and family well-being. However, due to a lack of education on what is available and lack of acknowledgement of each woman’s different reproductive profile, many women are not using the contraception that is best for them.

There is a lack of knowledge as to what to do when your contraception is not right for you

Globally, sex education needs to incorporate much more information on the variation that exists in women’s bodies. With better education women who do experience any negative side effects or react differently to their peers, would not consider themselves reacting “wrongly” or feel like they were not normal. On top of that further education as to what contraception is available and that there are different doses that can be prescribed is needed, so women know they are able to seek something better fitted to them rather than persevering on with their current method. This lack of knowledge about their options is exacerbated by the tendency in many countries to start all young girls on one of a few default pills as soon as they seek contraception, giving them the standard dose and sending them on their way. They may not be given the full choice of what is on offer and there is no current way of predicting which dose it is best to start a woman off on so that it has the best chance of matching her physiology.

Ideally we need a measure that can be used quickly and easily and from the off to predict which dose to give women to minimize side effects whilst still preventing pregnancy. This basic individual dosage choice is used across medicine by all health care workers for so many drugs. It is used right from the choice between taking one or two paracetamol to the precise calculations carried out by anaesthetists. However it is still not done for one of our most common drugs: the hormonal contraceptive. Unlike other commonly prescribed drugs, hormonal contraceptives are taken by healthy women for long periods of time so it is really worth finding a way to get the dose right. It is now becoming obvious that our variation-ignorant one-size-fits-all model of initial prescription of contraception is not working and we need a new one.

Knowing your body is the key to finding the right contraception

In the meantime, what can you do if your current method is not working for you? There are now many hormonal and non-hormonal, short-acting and long-acting methods of contraception available across the world. If you are using the contraceptive pill, there are also many formulations available with different dosages and types of hormone. If you would like to switch to try and find a method or dosage that works better for you, speak to your healthcare provider and see what options are feasible. Your doctor may be able to take your hormonal profile to inform their advice as to what switch to make.

However the more information you can give them and the better you understand your own body, the more likely they are to be able to find you a better fitted alternative or identify which method may suit you more. Many of the side effects of hormonal contraceptives are subtle and play out over a long time, such as mood and energy changes. Using a cycle tracker such as Clue, which allows you to input your contraceptive use and changes in mood, energy and bleeding patterns can help you follow the changes that each contraceptive method or dose may cause. Then you can compare over time which method worked best for you and have documented information to tell your doctor so they can use it to help suggest improvements. Clue works from the assumption that variation does exist and aims to help each woman better know her own body and understand what is “normal,” happy and healthy for her.

For more information to help you compare the pros and cons of various contraceptives, see: https://bedsider.org/methods.

Further Reading

  1. Creinin, M.D., Keverline, S. & Meyn, L.A., 2004. How regular is regular ? An analysis of menstrual cycle regularity. Contraception, 70(4), pp.289–292.
  2. Goldzieher, J.W. & Zamah, N.M., 1995. Oral contraceptive side effects: Where’s the beef? Contraception, 52(6), pp.327–335.
  3. Lipson, S.F., 2001. Metabolism, Maturation, and Ovarian Function. In P. T. Ellison, ed. Reproductive Ecology and Human Evolution. New York: Aldine Transaction, pp. 235–248.
  4. Morris, D. H., Jones, M. E., Schoemaker, M. J., Ashworth, A., & Swerdlow, A. J. (2010). Determinants of age at menarche in the UK: analyses from the Breakthrough Generations Study. British Journal of Cancer, 103(11), 1760–1764. http://doi.org/10.1038/sj.bjc.6605978
  5. Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of Hormonal Contraception With Depression. JAMA Psychiatry. 2016;73(11):1154–1162. doi:10.1001/jamapsychiatry.2016.2387
  6. Vitzthum, V.J. & Ringheim, K., 2005. Hormonal contraception and physiology: a research-based theory of discontinuation due to side effects. Studies in family planning, 36(1), pp.13–32.
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