Sunday, June 13, 2021
In 1961, I was a 25-year-old full-time mother in Dunedin taking a two-year break from my medical studies. My husband Peter was a 5th year medical student and as part of his training he was doing some sessions in a general practice.
One day he came home with samples of the Pill, Anovlar, which a drug rep had left at the surgery for the doctors to gain experience with this new method of contraception. I readily agreed to give it a trial.
I had already had a self-abortion in 1956 followed by two children born in 1958 and 1960. For contraception I used a diaphragm; not a fail-safe method for me. If I had not made the decision to take the Pill, the likelihood is that I would have had more children and never finished my medical degree.
I saw no qualified doctor and had none of the recommended medical checks. Anovlar was a high-dose pill and many women experienced side effects but I had none, other than the desired effect of controlling my fertility.
If I had seen a doctor I may well have been prescribed the Pill (or perhaps been given free samples) because I was the ideal candidate – young, healthy, with no pre-existing medical conditions, married, with two normal births, not wanting more children and prepared to take the risk with an experimental new drug. One of the important boxes that I ticked was ‘married’. In the early years it was very difficult for single or unmarried women to obtain the Pill.
Around this time the thalidomide disaster emerged. Babies were stillborn or born with limb and other congenital defects to pregnant women who had taken thalidomide for morning sickness during their pregnancy. There were 21 affected survivors in New Zealand.
This heightened the concerns about the safety of new drugs and the need for adequate research before being made available for public consumption. In the case of the Pill women had to weigh up the risk of taking a new more reliable medication against the risk of continuing with less reliable methods and having an unplanned pregnancy. I chose the Pill.
The New Zealand Branch of the British Medical Association considered it was unethical for doctors to prescribe the Pill for the unmarried. There was also a general recommendation that it should not be used for longer than two years. Part of this was a healthy conservatism and a concern for safety, as the effects of long-term exposure to potent hormones were unknown.
But there was also a patronising element. Some doctors did not prescribe the Pill for reasons of religion, morals or a professed conscientious objection or maybe just lack of knowledge and interest. Some chemists had a conscientious objection to dispensing the Pill.
When use became more widespread the limitations of the initial research became apparent. As early as November 1961 the first case report warning of the risk of blood clotting appeared as a Letter to the Editor in the Lancet. A nurse in the UK who was treated with an oral contraceptive for endometriosis suffered a fatal pulmonary embolism. Other case reports soon followed confirming the need for more research on the risk of deep vein thrombosis (DVT) or thrombo-embolism.
In January 1963 the first case report warning of the risk of myocardial infarction appeared as another Letter to the Editor in the Lancet. A woman in the UK using the contraceptive pill Conovid-E suffered a non-fatal heart attack. That year I completed my medical degree and kept on using free samples.
In the early years, New Zealand Family Planning doctors were cautious in their advocacy of the Pill and it was not until 1963 that they carried an advertisement for Anovlar. It was not until the 1964 Annual Conference that the Association ratified the use of the Pill.
By 1968 investigations by the authorities in the UK, US and Canada, confirmed the association between taking the Pill and thrombosis. Risk factors were identified, including: pills containing 50 mcg or more oestrogen, women over 35 years, smokers and sufferers of severe migraine.
Guidelines changed accordingly but that did not stop a lot of anti-pill publicity. In 1969 medical journalist Barbara Seaman published The Doctor’s Case Against the Pill which elaborated in great detail the dangers of the Pill.
That was the situation in 1969 when I became a GP in the Student Health Service at Victoria University of Wellington. The Director, an experienced doctor, adhered to the ethical guidelines of the Medical Association and did not prescribe for the unmarried.
Thanks to the student grapevine, those needing contraception went to a nearby general practice in Kelburn where Dr Erich Geiringer and Dr Carol Shand prescribed the Pill free to students. I thought that the University should be providing this service but I didn’t know much about prescribing the Pill, other than what I had gained from using a succession of free samples. At Medical School we had one lecture on contraception in 5th year which did not equip me for the needs of students.
That was when I made contact with Family Planning and in 1970 I attended clinics to gain experience in all methods. A pivotal event for me was attending the Annual Conference of Family Planning in September 1970 where for the first time I met a group at the forefront of challenging not just the medical but also the societal issues. The doctors that I met there included Dr Alice Bush, Dr Ruth Black and Dr Betty Glennie.
I came away from that conference with enough confidence to challenge the policy operating at Student Health. With items collected at the conference I made an elaborate educational display for the waiting room which included the simple message to ‘Ask Your Doctor’.
That didn’t go down too well with the Director but I survived two weeks of stony silence, didn’t lose my job, and thenceforth we agreed to differ. I gave a public lecture on contraception on campus organised by the Students Association and word soon spread.
I then became involved in introducing the ‘morning-after pill’. In Time magazine 8 November 1971 I read an article on research using oestrogen as a ‘morning after’ pill and I thought that this would be useful to prevent conception after unprotected sex. That month I attended a course on contraception at National Women’s Hospital and Professor Liggins supported the idea so I began prescribing it.
Over the years I saw many changes. In 1977 we cut up packets of Nordiol contraceptive pills for what was known as the Yuzpe method, after Dr Yuzpe, a Canadian student health doctor. We gave two pills 24 hours apart.
In 1995 the name was changed to ‘emergency contraception’ or ECPs as reflected in these Family Planning pamphlets.
In 1998 the Wellington Family Planning Clinic was involved in an international WHO trial which found that progestogen-only pills were better ECPs than the combined pill. In 2000 Pharmac funded one of these, Postinor-2. In 2002 there was a significant advance when ECPs became available, over the counter from a trained pharmacist. In 2003, as a result of another WHO trial we went from two progestogen-only pills to one: Postinor-1 (prescription brand) or Levonelle (pharmacy brand). In some countries including Australia, another method is now available, using an anti-progestogen, Ulipristal.
The Pill was often in the headlines and even though there are other medical benefits from taking the pill (e.g. reduction in endometrial, ovarian and colo-rectal cancers; and treatment of menstrual conditions) there was more publicity about negative findings.
In 1970 animal experiments found certain progestogens were associated with the development of breast lumps in beagle dogs, and two pills were withdrawn from sale in NZ – the first progestogen-only pill Normenon and the sequential pill Sequens (both containing the progestogen chlormadinone acetate). Later studies confirmed that there was in fact no association between the drug and breast lumps in humans, but the decision to withdraw was not reversed. In December 1975 two other pills, Serial-C and Serial-28, containing a related progestogen (megestrol acetate) were also withdrawn.
In 1976 when I became the Medical Director at the Wellington Family Planning Clinic it was often my responsibility to respond to media requests for information on contraceptive issues such as this article on the front page of the Dominion newspaper.
In August 1978 free contraception was introduced and remained so until December 1986 with the introduction of part charges for some pills.
In the 1980s concerns about breast cancer and cervical cancer regularly made headlines. Studies in the UK and US found a slightly greater risk of breast cancer in young women using combined pills but not progestogen-only pills. These findings were confirmed in 1989. Not helping the public debate was the discrediting of Australian Professor Michael Briggs in 1986 after admitting he fabricated some of his pill research from smaller studies by others.
Other less serious but troublesome side effects such as nausea, headaches, weight gain and mood changes resulted in the promotion of lower-dose or so-called 2nd generation pills containing new progestogens such as levonorgestrel and a lower dose of oestrogen (Microgynon-30, Nordette).
It was not until 1995 that Schering withdrew Microgynon-50 from the New Zealand market. New pills came with persuasive advertising reinforcing the notion of the modern liberated young woman conveniently exploited by pharmaceutical firms.
The 1990s heralded so called 3rd generation pills, promoted as superior pills with different progestogens such as Marvelon and Mercilon (containing desogestrel) and Femodene and Minulet (containing gestodene). Diane-35 (containing an anti-androgen, cyproterone acetate) was promoted for use in young women with acne. However, in 1995 many women stopped taking them when it was reported that they were not superior but were associated with a higher incidence of blood clots than the pills containing 1st and 2nd generation progestogens.
Following a public announcement in UK in 1995 many women stopped the pill and there were an estimated 20,000 extra unintended pregnancies and 10,000 abortions as a result. In October 1995 the New Zealand Ministry of Health issued a press statement and sent a letter to all GPs with the advice that pills containing 3rd generation progestogens carried a higher risk of deep vein thrombosis (DVT) and should not be used as a first choice. Doctors were also advised that the risk was even higher in pills containing cyproterone acetate.
The reaction in New Zealand was not as dramatic as in the UK, perhaps in part due to the fact that the publicity at the time was somewhat overshadowed by a series of spectacular eruptions on Mt Ruapehu. It was always a balancing act between informing patients of genuine risks yet not causing unnecessary alarm and worry.
In June 1996 there was a meta-analysis (major review) of breast cancer published in the Lancet, which found a small increased risk of breast cancer while women were taking the Pill and for 10 years after but no increased risk after that. This article was publicised in the New Zealand media but its effect was somewhat muted as it coincided with the Atlanta Summer Olympics (July 1996) when Danyon Loader won two gold medals and this created more of a splash. There were also further eruptions on Ruapehu June/July 1996.
With the turn of the century questions were raised about the necessity for breakthrough bleeding when taking 21 days of active pills followed by 7 days of inactive pills. Experts agreed that cycles could be manipulated and, indeed, dispensed with altogether if the woman wished.
And then came the 4th generation pills with new progestogens such as drospironone (Yasmin, Yaz).
Not quite the reinvention as claimed in this advertisement but they did reignite concerns about blood clotting. Would they be better than the 3rd generation pills? Latest evidence says ‘No’; they carry a similar increased risk, all other factors being equal (that includes age, ethnicity, family history, personal history, smoking, injury, surgery, immobility, and obesity).
However, pregnancy increases the risk of DVT greatly, especially in the 6 weeks after birth, so preventing an unplanned pregnancy is important, even if the method carries a small risk.
In 2005 I retired from clinical practice. At about this time progestogen-only implants were introduced and for many women of all ages LARCs (Long Acting Reversible Contraception) also known as ‘fit and forget’ methods became their first choice such as the implant Jadelle (effective for up to 5 years). Copper IUDs had improved and in November 2019 after many years of lobbying the progestogen-releasing IUD, Mirena (effective for at least 5 years) was funded by Pharmac. There is also a smaller version, Jaydess (effective for 3 years).
The reduction in abortions is attributed in part to the uptake of LARCs. Not only are they more reliable (no forgotten pills!) but menstrual loss is usually reduced, so less anaemia, especially with Mirena. LARCs are safe with no significant association with deep vein thrombosis or heart attacks. However, they do require a trained provider.
One thing to bear in mind with both pills and LARCs is that there is no protection from sexually transmissible infections so in some situations condoms should also be used.
From May 2015 to February 2016 Te Papa Tongawera held an exhibition Uncovering the collection of Dame Margaret Sparrow, curated by Stephanie Gibson, in which the Pill was given a prominent position as the ‘pill that changed the world’.
Over the years, questions were often raised about what restrictions were necessary, even going so far as to recommend that the Pill be available ‘over the counter’ as is possible with ECP. A diluted version has recently become policy.
In February 2017 the Medicines Classification Committee recommended selected oral contraceptives be reclassified as restricted, rather than as prescription medicines, meaning trained pharmacists can now dispense pills to women who have received a doctor’s prescription any time within the last three years.
After 60 years oral contraceptive pills (combined and progestogen-only) still have a place but they have been superseded by LARCs. Historically the Pill will always be remembered as the catalyst that led to advances in fertility control which in turn brought greater opportunities for women. I hope that there will be many more improvements in the future for both women and men.
Dame Margaret Sparrow, April 2021
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