Roee Regev

Less and Less Women Are Taking the Pill, and for a Good Reason

In the Western world, the birth control pill is suffering from a serious image crisis. What made us suddenly doubt something we’ve been using all our lives?



Like many of my friends, I took oral contraceptives every day from the time I was in my teens to around the age of 30, when I decided that I wanted to have a baby. After giving birth last November (to a daughter), I started thinking again about pregnancy prevention. But then I discovered, to my surprise, that my approach had changed in the meantime. My gynecologist had given me a prescription for a new type of pill, but I didn’t rush out to buy it. Suddenly, the thought of introducing artificial hormones daily into a healthy body seemed illogical to me. Why should I do that to myself? I’d already done it for half my life, but I’d never considered that question.

While I was contemplating the issue, I resorted to an older method of avoiding pregnancy: counting days. More or less. It didn’t exactly work, and my daughter is expecting a baby brother in advance of her first birthday.

My friends and I may find this story amusing (aside from the economic anxieties it induces), but the doubts I felt about the pill are not mine alone. The birth control pill is without question the most widely used contraceptive in the Western world – at least 100 million women take it regularly. But data from Western countries indicate a new trend.

Canada saw an 11 percent decline in the purchase of oral contraceptives over five years. In France, whereas 45 percent of women used the pill in 2010, six years later, that was down to 36 percent. The BBC reported last year on a significant drop in the use of the pill in the United Kingdom, and also that the number of women using intrauterine devices had doubled between 2007 and 2017. Even in the United States, the “land of the pill,” where four out of every five sexually active women take or took the oral contraceptive, voices of doubt are being heard. Data from the U.S. Centers for Disease Control and Prevention show a huge drop in those using the pill. If in 2002, 31 percent of women were using it, in 2017 that rate had dropped to 22 percent. In contrast, the use of IUDs increased considerably (from 2 percent to 14 percent).

The jump in the use of IUDs is not surprising, given the revolution that has occurred in physicians’ recommendations. In 2014, the American Academy of Pediatrics began recommending IUDs for teens as having first preference over all other contraceptives.

In Israel, too, there are initial signs of a similar shift. The health maintenance organizations refused to provide statistics, and the Health Ministry claimed it has no information on the subject, but according to information provided by the Super-Pharm chain, sales of birth control pills have been falling by 2 percent a year since 2017.

So, 60 years after coming into use, the birth control pill, the great feminist innovation, is suffering from a serious image crisis. Why are women suddenly having doubts about something they accepted almost automatically for many years?

Physicians explain that the pill is safe, that its advantages by far outweigh its drawbacks and that irresponsible media reports are creating a false impression of the risks entailed in its use. Indeed, in regard to risks of life-threatening diseases, the research is on their side.

But those risks, such as blood clots or cancer – the ones that generate dramatic headlines – didn’t even come up in conversations I had with women who have decided to stop taking the pill. They talked about other issues entirely – depression, migraine, diminished sexual desire, weight gain – which don’t endanger life but certainly affect its quality. The interviewees did not talk about the pill in terms of being a toxin and did not preach against its use. But they definitely wondered aloud how it was that they started taking it from a young age, were never warned about its possible (and quite widespread) side effects or asked by their physicians if they had any adverse symptoms – and thus suffered for years from phenomena that harmed the quality of their lives, unnecessarily.

The physicians do not deny those phenomena. In fact, they are mentioned clearly in the package insert that comes with most pills. For example, the information relating to Yasmin, one of the most widely used oral contraceptives in Israel, states, under the heading “common side effects,” that there is a 10 percent chance of users suffering from depression, headaches, migraines, nausea or vaginal discharge.

How is it possible that one of every 10 women might suffer from symptoms that will significantly affect her quality of life, but no one warns her about them? Why is there no clear directive to physicians to conduct follow-ups of women for whom they have prescribed an oral contraceptive, so as to determine how it is influencing their lives?

“It may be a generational matter,” says Dr. Belinda Pletzer, a cognitive neuroscientist at the University of Salzburg in Austria, “but from what I have experienced, men seem to be much more skeptical about the effects of the pill on the brain and tend to take the side effects that women report less seriously and relate them to what they hear on the media. “

Physicians generally hold patients responsible for identifying side effects and reporting on them. But is it possible to be aware of such symptoms without knowing that they are related to the use of the pill? Moreover, how can a woman single out phenomena she has been living with since adolescence and which have simply become part of her life? On this point, few doctors have good answers.

Liking the world

Nina, 50, started talking the pill when she was 15, because of severe menstrual pain. (Hers and some of the other names in this article have been changed for reasons of privacy.) “When you’re 15, you wake up a different person every day. When things happen to you, you have a hard time identifying them. So it was that I always took the pill and felt all kinds of things that I only associated with it later on.” Nina suffered from weight gain when she was young, and worse: from the fact that both she and people around her perceived her to be depressive: “I was like that then, and everyone thought I was like that.” At 28 she stopped taking the pill temporarily, and “suddenly I discovered that I liked the world,” she recalls.

Like Nina, the overwhelming majority of the women I spoke to started taking the pill in their teens, with the result that they did not recognize its effects on their personality and body years later. “You have no idea who you are at 15,” says Tamar, who’s now 33. “So if you have no sexual desire or you’re suffering from depression, you simply assume that this is you, because everyone else says that the pill is no big deal and no problem.”

A similar account is offered by Mayan Rodeh, a 34-year-old journalist from Tel Aviv, who often speaks out on the subject. Rodeh started using the pill when she was 18 and stopped when she was 31, because of a suspicion that the progesterone and estrogen were having an adverse effect on the cholesterol and lipid levels in her blood. After she stopped she suddenly realized that the fact that she had also felt depressed was due to use of the pill.

“Suddenly the color returned to the world for me,” she says. “Before that I had never thought of myself as depressive.” Years of being under the influence of the contraceptive had passed in a sensual stupor.

Rodeh: “I just didn’t feel anything. Those were years when I got married and advanced at work and did things in different fields, and through it all felt like I was outside the experience. I’d accepted that at the age of 27 nothing moved me. I had no sexual desire and I thought it was because I’d been in a lengthy relationship. I thought: That’s how it is, this is me.” After she stopped taking birth control pills, however, she felt a radical change: “Suddenly I’m someone for whom sex is terribly important, along with pleasure in many other spheres. Suddenly I woke up. I was filled with anger, I felt that I had lost much of my life, all of my 20s.”

Meged Gozani

For Zohar, 29, from Haifa, feelings of depression appeared out of the blue. She suffered from them for a few weeks after starting to take the pill, when she was 16. “I was a happy girl and had no reason to feel like that, but it happened. It evolved slowly, until one morning I woke up and felt that I just wanted to die. I remember sitting in bed and crying my heart out.”

Zohar’s mother, who saw what was going on, immediately took her off the pill – and the depression vanished instantly, she relates. But a few years later, when she took a pill of another type, a different problem appeared. “In the army I took a different pill because I was suffering from pimples, and they prescribed something that also supposed to help dry up acne. No one told me that it would dry up everything in the body. I was going with a guy at the time, and I remember that the pain was excruciating. I got home limping. I felt that my body was betraying me. No one had prepared me for that.”

Yael, 35, from Tel Aviv, began taking the pill during her army service, and since then migraines have been part of her life. “I started to suffer from crippling headaches every month. At first I didn’t know it was a migraine. I thought it had something to do with the pressure of being in the military, or maybe with inferior army food. It took me a good few years to discover the connection.” She felt better after she switched to a different type of pill, but the migraines didn’t go away altogether. “In fact, the first time since the age of 20 that I went for a long time without headaches was when I was 32 and became pregnant,” she notes.

In addition to testimony about disturbing side effects, the women Haaretz spoke with also reported the belated discovery of other health problems that were previously unknown to them, because of their regular intake of hormones. “When you take pills you annul your ability to know whether everything is all right or not,” says Tamar.

While she was under their influence, Tamar developed an eating disorder and was underweight – a situation that prevented her afterward from becoming pregnant naturally. But neither she nor her doctors noticed what was happening: “Outwardly the impression was that all was fine. Even when I told my doctor that my period had disappeared when I took breaks between packets [during which time there is supposed to be menstruation], he told me there was nothing to worry about, that it was due to the pills.”

In the case of Or, from Haifa, who works for an events production company, no one diagnosed her polycystic ovary syndrome (a common hormonal disorder that causes irregular ovulation and makes it difficult to become pregnant). “I’d never had an ultrasound scan when I wasn’t on pills, so they couldn’t know.” When she went off the pill, she gained weight “disproportionately,” even though she ate healthful food and exercised regularly with a private trainer. All the tests she underwent to try to understand why she was putting on weight so fast produced normal results, and it was a long time before the right diagnosis was made.

All the women interviewed for this article expressed amazement at the nonchalance that accompanied their being put on the pill. They all relate that they received the prescription quickly, without background tests and in some cases even without being asked whether they smoked – a factor that increases significantly the risk of developing blood clots, the rare but most lethal danger associated with contraceptive pills. Not one was given detailed explanations by her gynecologist about side effects, other than a few who were told about the risk of weight gain and of blood clots.

“I got my first prescription from a doctor who worked with the army,” Yael relates. “There was a long line of women in the clinic, and I was with her for maybe five minutes. There was no time for explanations, certainly not for questions. Only afterward, when I went to a different gynecologist, did I discover that I hadn’t actually been protected against becoming pregnant for a few months, because she didn’t explain to me how to use the pills.”

Most of the women interviewed also reported that they continued to take the pill for years, usually more than a decade, without any follow-up from their doctor or special tests. “It’s inconceivable that you engage in a daily activity whose implications you’re not aware of. It’s treated like people drinking juice, but it’s far from that,” says Netta, 34.

A contraceptive pill for men, which is meant one day to free the feminine gender from the burden of preventing pregnancy, has long been in development. It had already reached an advanced stage, but in 2016 the World Health Organization terminated a clinical trial with men who were receiving a hormonal cocktail to affect their fertility. The reason: The side effects reported by the participants raised suspicions about the safety of the pill. National Public Radio in the United States reported at the time that the most common side effect was acne. Next on the list were mood changes and feelings of despondency, and in two cases participants were diagnosed with severe depression. This is where many women roll their eyes.

They will go on rolling their eyes when they discover that the health establishment makes them responsible for reporting side effects. The directive of the Israel Society of Obstetrics and Gynecology concerning the pill stipulates that at the first appointment the patient is to be asked about her personal and family medical history, “with special attention to be paid to the family story and risk factors such as smoking.” But nothing is mentioned about providing information about possible side effects. After three months, “a follow-up meeting is recommended for giving advice about side effects” – but that’s only a recommendation. According to the testimony I collected, such a meeting rarely takes place.

From the viewpoint of the health system, the need for renewal of the prescription for birth control pills every three months is a sufficient form of follow-up. Yet that renewal usually involves a meeting only with a secretary, conveying a request to the family doctor or submitting the request via an application or phone call.

“If you’re feeling fine, I have no problem with that,” says Prof. Eitan Lunenfeld, who heads the obstetrics and gynecology unit at Be’er Sheva’s Soroka Medical Center. “I’m not saying that someone who doesn’t feel well should go on taking [the pill]. You can say that you don’t associate that with the pills. But talk – talk with your family doctor. A lot depends on communication.”

Physicians, too, are aware that the situation that has developed is not ideal. “Let’s be realistic,” says Dr. Arie Yeshaya, chairman of the Israeli Society for Contraception and Reproductive Health. “A doctor often has between five and 10 minutes for each patient. There’s no doubt that if I had half an hour I could sit with each and every woman and explain all the side effects. Within the framework of our health services, we try to do our best and give the maximum – to sum up and to address the most important things.”

In an attempt to overcome the obstacle of lost time, Dana Weinberg, founder and director of the nonprofit Women and their Bodies, suggests that contraceptives be provided initially at school, and only afterward by the health establishment. “If gynecologists don’t have the time, it can be done by nurses specially trained for this.”

Political sex hormones

Just as the side effects of the pill don’t get enough attention during visits to the doctor, researching them is also apparently not very alluring to scientists. It’s hard to find serious, comprehensive studies dealing with the effects of the pill on women’s sexual desire, frequency of migraines and general mood. Only one study, conducted in Denmark using the medical records of more than a million women, and published in 2016, found a connection between the use of the pill or other hormonal contraceptives, and depression. The researchers concluded that women who use the pill are 23 percent to 34 percent more likely to develop symptoms that lead to taking antidepressants. The findings were even more striking (showing up to an 80 percent greater risk) in the case of hormonal treatment administered to girls under the age of 19.

“In a great many of these matters we are still waiting for the forthcoming studies,” says Prof. Talia Eldar-Geva, head of the Israel Fertility Association. “Sixty years of the pill isn’t enough time, especially because the pills we are taking today bear no resemblance to the pills we took 60 and 40 years ago. Today we have reached the minimal dosages. I cannot tell a woman sitting across from me whether taking the pill today will constitute a risk for her 20 or 40 years down the line. Is there greater incidence of dementia among 70-year-old women who took the pill for 20 years than among those who didn’t? I don’t know, but to say it doesn’t bother me would be a lie.”

Neuroscientist Belinda Pletzer maintains that one of the reasons for the dearth of research in the field is fear of accusations of chauvinism. “When you talk about sex hormones,” she explains in a phone conversation, “the discussion becomes political very quickly. The fact that women’s brains may be affected by the hormones they take can become a political tool. People have already told me that my research undermines all the progress made in feminism over the last few decades, that I am actually proving that women are inferior to men. This is of course complete nonsense since male brains are also affected by sex hormones. But if you do this research, you may sometimes to be accused of sexism.”

Gift from heaven

What, then, can the medical world assert with certainty about the use of the birth control pill? Since FDA approval was first given, on May 9, 1960, almost 60 years of experience and more than 100 million users at any given moment around the world have made physicians absolutely confident about the safety and reliability of the pill, certainly in the modern versions in which the dosage of hormones (progesterone and estrogen) has been reduced to a necessary minimum. The serious phenomena that were detected in the studies are related to a rise in the risk of developing blood clots and certain types of cancer. These are both rare complications that affect a very low proportion of women.

Early in the 2000s, there was a spate of reports and studies that drew a connection between the use of the third- and fourth-generation pills (the difference between the generations lies in the amount of progesterone they contain) and a rise in the risk of blood clots, which are liable to reach the lungs or the brain and even prove lethal. It’s likely that these findings, which prompted the FDA and a similar organization called the European Medicines Agency to issue warnings and clarifications on the subject, affected the attitudes of Western women toward the pill.

The patient information accompanying the latest versions of pills has also been updated to include appropriate warnings. Current inserts (for Yasmin, for example) contain detailed – and chilling – explanations about blood-clot risks and list symptoms that require immediate consultation with a physician.

Apart from the danger of clots, clear-cut effects of taking the pill were found in the development – or prevention – of different types of cancer. According to the National Cancer Institute in the United States, use of the pill heightens the risk of contracting breast cancer for those taking it, and over time also raises the risk of cervical cancer. The risk of both cancers declines over time, after use of the pill is discontinued. On the other hand, taking the pill reduces the risk of endometrial or ovarian cancers. In both cases, the positive effect increases with the duration of the pill’s use and continues for years after it’s no longer taken.

“Whenever there is a disaster from the pill – and you can die from pills, from blood clots – it gets big headlines,” notes Yeshaya. “In contrast, when so many women take pills and nothing happens to them, it’s of no interest to anyone. It’s not a case of hostile media, but if you want an article that will get a high rating, you report on an exceptional case and everyone gets scared and stops the treatment.”

Yeshaya, a signatory to the position paper of the Society of Obstetrics and Gynecology in regard to contraceptives, is very disturbed by the recoil from pills that is spreading among his patients. “I’m like Bibi,” he laughs, going on to accuse the media of promoting an irresponsible dialogue on the subject. “It’s like the panic over vaccinations that supposedly cause autism.” The pills also have many advantages, Yeshaya says, citing endometriosis, an illness that affects about 15 percent of women and causes unbearable pains every month. For its sufferers, the pill is a gift from heaven.

No answers

Women, it turns out, are not the only ones who lack knowledge in this realm: State agencies are also uninformed. How many Israeli women use the pill? How many use other types of contraceptives? What is the favorite birth control method among local women? Has there been a decline in the use of the pill over the past decade here, as in other Western countries? There are no official answers to any of these questions. The Ministry of Health doesn’t aggregate the data and doesn’t commission studies on the subject. The HMOs and pharmaceutical companies I approached did not provide answers or numbers. Only Super-Pharm, as we saw, offered a partial picture of the contraceptives market, one that suggests that women in this country have also begun to have doubts about the daily regimen.

“I think it’s no less than scandalous,” Weinberg says. “The data exist. It’s easy to collect and understand them if only someone would say that it’s sufficiently interesting and important, but the State of Israel doesn’t deal with it at all. We live in a society that encourages childbearing and is very occupied with fertility. But as soon as we get to contraceptives, no one is interested. We – women and girls – pay the price for that.”

The gynecologists’ society, which draws up ongoing position papers, is operating in the dark in regard to how its recommendations influence the reality among the public. Currently, one of those recommendations is to prefer the IUD overall for contraceptive purposes. In fact, a 2017 position paper maintains that “the IUD is also a safe and effective means also for adolescents and women who have not yet given birth.”

The organization is now making efforts to get the message across to gynecologists, and through them to women of every age, that the IUD in its various forms (either with hormones or those made of copper, without hormones) is at present the most highly recommended contraceptive, alongside the pill. This approach is consistent with the recommendation of the American Academy of Pediatrics, which in 2014 revised its position and stated that adolescent girls should be told that an IUD has priority over every other contraceptive.

Daily Herald Archive / SSPL

The principal reason for the change of approach is that the IUD is the most effective means of birth control that exists. According to the Centers for Disease Control and Prevention, the pregnancy rate with the use of the IUD is less than 1 percent, compared to 7 percent with the pill, 7 percent with the vaginal ring and 13 percent with condoms. In addition, IUD manufacturers have worked hard to modify and improve the product, adjusting its size to accommodate young women as well, making it a solution whose side effects pose less of a risk.

“It’s a genuine revolution,” says Arie Yeshaya, recalling the 1970s, when the IUD caused infections, infertility and even death among hundreds of thousands of women in the United States.

In the Israeli market, use is also being made of additional hormonal contraceptives: the vaginal ring (aka NuvaRing), and a trimonthly injection. Anyone who wishes to avoid hormones altogether can opt for a copper IUD or less popular methods: the diaphragm or the contraceptive sponge with spermicide. Last in the contraceptive toolbox is the condom, the only means that targets men. Its great advantage over all other means is the protection it offers against sexually transmitted diseases.

There is also the method that gynecologists usually snub. In recent years, computer applications have emerged that claim to provide protection equal to that of the pill. They rely on an ancient method: taking one’s temperature each day and keeping track of the “safe days,” combined with algorithms that take into account the information that each woman enters into the data base.

The leading app worldwide, with more than a million registered users, is Natural Cycles, which is also the only one that has so far been authorized by the European Union and FDA to market itself as a contraceptive. It was developed by a Swedish physicist, Elina Berglund, who formerly worked at the Geneva-based CERN on the team that worked on the Higgs boson particle.

In Israel the best known name in the field is the Swiss-based “fertility tracker” Daysy, whose website claims a success rate of 99.3 percent. “Let them show the research,” Prof. Lunenfeld says in this connection. He, like all the gynecologists asked about the subject, expressed concern at the use of apps as a birth control method.

Moran Koschitzky, CEO of Daysy Israel, told Haaretz that in its four years of operation the company has amassed tens of thousands of local users. “It’s impossible to call it a contraceptive, because there is nothing here that serves as a barrier, like the condom, or that’s like the pill, which prevents ovulation. But there is a tool that says to a woman, ‘Come on, there’s a 99.3 percent likelihood that you’re covered today.’”

To those in the medical profession who would voice skepticism, Koschitzky replies that “our goal is for every woman to know that she doesn’t have to use hormones.”

Rosy future

Perhaps this whole discussion is one of privilege, not to say anti-feminist? Sixty years after its development, the pill is a usually safe means of birth control, providing an effective, accessible and inexpensive solution for more than 100 million women who want to control their destiny and their body. It’s likely that most of them don’t have the option of taking their body temperature every morning, visit a gynecologist who will insert an IUD safely, or get an injection in a clinic every three months. In Israel, too, the pill is a discreet, simple answer for many women living in a conservative environment who do not wish to become pregnant at all, or want to reduce the frequency of their pregnancies. It’s hard to overestimate the importance of this option in their toolbox.

In its first six decades, the pill changed the life of millions of women – especially in the West. According to a 2015 United Nations report, 19 percent of the world’s married women opt for sterilization (tubal ligation) as a means to avert over-expansion of their family. Only 9 percent stated that the pill was their choice (putting it in third place on the list, after the IUD, with 14 percent). In India, where the state has been paying the cost of sterilization for women since the 1970s, 39 percent of married women had that procedure done for purposes of contraception – even though it is sometimes carried out under appalling conditions, leading to infection and even death.

But the world is changing. Whereas there are signs that women in the developed world are starting to abandon the pill, on the other side of the world there is an opposite picture. Thanks to the increasing awareness of family planning in developing countries and the encouragement of governments such as China’s, the future of the pill looks rosier than ever. In 2018, birth control pills accounted for revenues of $6 billion worldwide for pharmaceutical firms; in 2024, that figure is expected rise to $8.8 billion. In most non-Western countries, no prescription is needed to buy the pill; in India, it’s distributed free to women in 145 districts.

It’s impossible to turn rewrite history, Dr. Yeshaya says: “The pill has changed the life of women, taking them from slavery to freedom. Part of the feminist revolution involved liberating women from constantly becoming pregnant and having unnecessary abortions.” To which Zohar, from Haifa, responds: “For the generation of our mothers, it was a feminist revolution, and the pill is still accessible, convenient and safe. But it’s the most feminist thing in the world when women get up, ask questions, and say, ‘No way.’”

Ask any woman about her pills and she’ll tell you her life story. It makes no difference whether she had side effects. It starts whatever led her in adolescence to the first appointment with a gynecologist – a boyfriend, painful periods, acne – things you don’t forget. That little pill becomes an integral part of the daily routine, accompanying her in the second and third decades of her life until the moment arrives to stop, usually when she decides the time has come to establish a family. Without thinking about it, the pill has accompanied her from girlhood to motherhood.

Maybe that’s one of the reasons that the two sides in the dialogue have a hard time understanding each other. For gynecologists the pill is a convenient tool, a good solution to a problem. For the woman sitting across from them, it affects the most intimate parts of her identity. So, if that’s the situation, then maybe, after all, it’s worth devoting another few minutes of thought to her.

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