In a Spartan examining room at a clinic in San Jose, Calif., Tanya waits patiently with the sleeve of her white shirt rolled up, exposing the upper part of her left arm. A medical assistant comes in, rubs her skin with alcohol and then pricks it with a needle filled with 5 cc of a milky white substance. The 27-year-old winces a little bit, but the shot is over within seconds. "That didn't hurt that much," she says, relieved, looking at the Band-Aid that now neatly covers the mark.
It's the third time Tanya, who asked that her last name not be used, has been injected with Depo-Provera, a contraceptive that will allow her to have sex whenever she feels like it for the next three months, without really worrying about getting pregnant. And getting pregnant is the last thing she wants; she already has two children, both conceived while she was on the birth control pill. "I was in shock, I didn't expect to be pregnant," she says.
After having the second child, who is now 19 months old, she learned about this contraceptive, which she says her doctor never told her about. "With Depo, there's a slight weight gain and sometimes I get headaches, but I'd rather do that than get pregnant again," she insists. Tanya says she sometimes forgot to take the Pill every day at the same time and thinks that's why she got pregnant. Finding the right contraceptive for her has meant not adding another baby to her family.
It's been nearly 40 years since the Pill first came on the U.S. market as the first oral contraceptive, revolutionizing women's lives and the lives of those around them. The invention of the Pill has been called one of the greatest achievements not only of the last century, but of the last 2,000 years.
But opinions differ as to the significance of advances since then. Everyone bemoans the lack of the perfect, truly revolutionary birth-control method for women. At the same time, there have been some advances -- the IUD, injectables, implants and so forth. And as we end this century and begin the next, a slate of potentially liberating new methods are expected to make their way to the U.S. market -- including a patch, an improved injectable and a new form of implant.
To some, this is proof that birth control as we know it in America is about to change. "With an extended availability of products, we're hitting the next revolution," says Dr. Elof Johansson, vice president of the Population Council and professor of obstetrics and gynecology at Rockefeller University in New York. "I think it will further empower women to take contraception into their own hands and that will be very good."
To others, however, the list only shows how little we've progressed after all these years. Carl Djerassi, known as the man who gave birth to the Pill, is sad that what he predicted a decade ago -- that no new revolutionary methods will appear by the turn of the century -- has come true. "Gullible people think something is about to happen, when nothing is," says Djerassi. "They are repackaging old goods in new clothing and it's not doing the public any good." Many of these products are not new, he explains. They have been in other countries for years. What's more, they are not new approaches to contraception. They are mostly just different methods for delivering hormones.
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Out in the waiting room at the clinic in San Jose, a woman leafs through a pamphlet called "What Is Right for You?" that contains descriptions of the birth control pill and other contraceptive options already on the market. On this hot summer morning, women stroll in off the street, some toting toddlers for the clinic's pediatric care, others coming to use the walk-in service to find out if they're pregnant. One woman in her early 20s, who was using condoms and foam, is late. But she says she's happy with what she's been using. Thirty minutes later she finds out she's pregnant.
For three-quarters of a woman's child-bearing years, she is trying to avoid getting pregnant, according to the Alan Guttmacher Institute, a not-for-profit organization that focuses on reproductive health. Those in the field of fertility and contraceptives say this illustrates how important it is to have as many birth control options as possible; women need different types of protection during the many stages of their sexual lives. Insufficient birth control choices, according to the Guttmacher Institute, is one of the reasons why one out of two pregnancies is unintended.
"It's one thing to pick the wrong lover; it's another thing to pick the wrong father," says Pepper Schwartz, a sociology professor at the University of Washington and the author of numerous books on sex. "If you can control your fertility, you can control the other." In terms of importance to a woman's life, Schwartz ranks a woman's ability to control her fertility right after life and death. As a testament to its significance, one doctor says when the wall came down in East Germany, among the first things to sell out were Tampax, Kotex -- and birth control pills.
And most of the contraceptives that enter the market aren't significantly different from the Pill; they are made from hormones. Two weeks ago, the U.S. Food and Drug Administration approved another "morning after pill," which is supposed to be taken within 72 hours of having unprotected sex. Plan B, to be distributed by Women's Capital Corp., is made out of levonorgestrel, a synthetic hormone that prevents fertilization and ovulation. It is supposed to have fewer side effects, such as vomiting and nausea, than Preven, the product already on the market.
The next expected product is a once-a-month injectable type called Lunelle, a version of which is being used in other countries. Pharmacia & Upjohn expects FDA approval sometime this fall. Unlike Depo-Provera, Lunelle will allow a woman to get pregnant shortly after getting off the drug. But since it is made of components similar to those in oral contraceptives -- like progestin and estrogen -- it is also expected to have the same side effects.
"There really is a proliferation of choices and there hasn't been for a while," says Kristin Elliott, spokeswoman for Pharmacia & Upjohn. "Probably everything goes in cycles, but it's pretty nifty that this is happening as we're turning the century."
Another new choice might be the patch. Johnson & Johnson is in the last stages of testing a hormonal contraceptive patch called Evra. It's the size of a half-dollar and can be stuck onto the arm, or in more covert places, like the butt or abdomen. It works like other transdermal patches such as those used for quitting smoking or hormone replacement therapy, and can be worn for seven days before replacement. Johnson & Johnson hasn't completed clinical trials yet, let alone filed for FDA approval.
Other upcoming options may include Orgenon's single implant, which is similar to Norplant's six-capsuled implant; Wyeth-Ayerst's two-rod implant, which releases levonorgestrel; Allendale's contraceptive film; new spermicides; and modified oral contraceptives. In addition, many are awaiting Berlex Laboratories' seven-year IUD, known in Europe as Mirena. And of course, in the fall or thereabouts, the sponge will be back in stores for another go-round.
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Mention to father of the Pill Carl Djerassi that these choices could significantly affect America's contraceptive landscape and he literally spells out his irritation: "P-I-S-S-E-D off," he enunciates slowly in his native Austrian accent. "I think it's an indecent use for the word 'revolution,'" says the 75-year-old Stanford chemistry professor by phone from London, where he is spending the summer.
In 1951 Djerassi gave birth to the first synthesis of what is now the most popular contraceptive in the United States. "When the pill came on the market, it was a revolution," he says. "IUDs were another revolution, and RU-486 I consider a revolution and the last thing developed in the field. But this is not. It's an improvement. And I don't say that's useless; it's a small incremental step."
Every 10 years or so, Djerassi hears the same thing: a mantra claiming that the lull in contraceptive choices is over, that the birth-control world as we know it will be changed because the revolution he waged decades ago is rising again. Just look at all the new options, the media and doctors exclaim. And so it's that time again; he knows the drill.
The problem, as Djerassi sees it, is that there hasn't been enough research going into the development of contraceptive choices that are fundamentally different from the existing types. In the 1970s, about 13 pharmaceutical companies were doing research. Now, he says, there are only four worldwide. (Johansson says two companies are getting back into the business -- Pharmacia & Upjohn and a Hungarian company, Gideon Richter.) Djerassi believes part of the reason for the drop is that pharmaceutical companies are more interested in developing new products and drugs for the affluent, "geriatric" countries. Because of this demographic, he says, firms are developing, among others, hormone-replacement drugs and treatments for conditions such as Alzheimer's disease.
Many agree with Djerassi that the contraceptive field was more advanced years ago than it is today. "The United States used to be the undisputed leader in contraception development; we are now very much in the backwaters," says Dr. David Grimes, vice president of biomedical affairs at Family Health International and clinical professor of OB-GYN at the University of North Carolina. "The contraception revolution stalled for a number of reasons. We can lay this at the doorstep of the federal government, lawyers and special interest groups. The [pro-life groups] would like you to believe that IUDs and the birth control pill are abortifacients."
The current state of contraceptive options is one of the clearest examples of what needs to change in this country, says Dr. Felicia Stewart, a professor of OB-GYN at the University of California at San Francisco and former director of the Henry J. Kaiser Foundation's reproductive health program. And one of the saddest parts, she says, is that women don't even realize what they are missing. "I think women in the United States would be outraged if they realized how many consequences that lag has for their daily lives," she says.
One of the most egregious omissions from women's daily lives, many doctors say, is a contraceptive that does more than prevent pregnancy; women are in need of a birth-control method that also protects against sexually transmitted diseases. Outside of the male condom -- which is hard for women to depend on because it's ultimately up to the man whether he's going to use it -- and the female condom, which is expensive at almost $3 apiece, there aren't really options for women in need of protection. (Although spermicides offer some dual protection.)
"Above all, my major concern is that we have almost nothing for almost the largest generation of young people in this world who are sexually active long before they're monogamous," says Adrienne Germain, president of International Women's Health Coalition. "I just firmly believe that we should no longer say 'contraception' without saying 'STD protection' in the same breath."
Microbicides is one area that Germain believes is promising. Like spermicides, microbicides can be made in different forms, like gels, creams, suppositories or films. There are different types of microbicides, some that prevent pregnancy and infection and others that just prevent infection.
"Right now we can tell a woman, 'If you don't want to get pregnant and you want to protect yourself against a sexually transmitted disease, use a condom,' but what if a woman wants to get pregnant?" asks Pouru Bhiwandi, professor of maternal child health at University of North Carolina and former medical director of Family Health International. "Then she has to risk getting a disease along with it."
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While almost everyone agrees that the United States needs more options, not everyone thinks the situation is so dire. Dr. Louise Tyrer remembers when it was just that; she calls it the dark ages. It was during World War II, and she was an OB-GYN resident at a hospital in Los Angeles. Two wards were filled with dying, hemorrhaging women who were there because of botched abortions. Some patients were going through septic shock. Others had gangrene or irreversible infections. Of course, she says, those performing the illegal abortions weren't using clean or sterile instruments.
As a result of that experience, Tyrer, now 78, has devoted her life to reproductive health and was the vice president of medical affairs for Planned Parenthood from 1975 to 1997. She says that the hormonal methods make sense for women. After all, a woman's body is regulated by them, so giving women different methods just increases their choices.
"I can't understand why a woman can't find something to work for her, or please her and her partner," she says. "I think it's because they have no perspective of understanding how bad things used to be ... They keep saying, 'How come we can't have the perfect contraceptive with no side effects?' Well, there's no such thing in life. Everything has a risk and a benefit."
Many doctors say that after the introduction of these products the United States will have caught up with the rest of the world in terms of options. Whether this truly happens -- and there is a chance that not all of the methods will be approved by the FDA or ever make it to market -- researchers say many women overlook the options already available. One doctor points to the copper IUD, which he says is the more effective method of reversible contraception and is cost-effective. But because people think of the Dalkon Shield IUD, which killed women years ago, they think it's unsafe. Norplant is another good option, he says, but because it is associated with silicone breast implants, people tend to stay away from it.
Tanya, the young mother from the clinic, is a perfect example of someone who did not take advantage of the choices already on the market. Although she loves her two children deeply, she wonders what it would have been like if she had learned about all the contraceptive options. She thinks the solution isn't necessarily to bring new products onto the market, but to educate people like her about what's already out there. "Having the kids changed my life," she explains. "I can't see myself without them. But even now, I think if I had that shot, what would I be doing? No regrets, because I love my kids. But you think, would have, could have, should have."
The real revolution most doctors, and women, are waiting for probably won't come until there's some sort of vaccine -- a shot that would create antibodies in the woman's body to prevent pregnancy. "I think our nation should have a vested interest in contraception, just like immunization," says Grimes. "You get a huge payoff for every dollar invested. And they are both good business and good public health." But most doctors don't see the vaccine coming at least for another 15 years or so, if it comes at all -- long after we welcome the new century and the next generation of sexually active women.