Hormonal Methods Of Contraception

Hormonal methods of birth control work by changing the body’s hormone levels either so that conception is prevented or so that the body is made unsuitable for sustaining a pregnancy. The combined pills (commonly called just ‘the pill’) are the best-known hormonal contraceptives. Other oral contraceptives (those taken by the mouth) are the mini-pills, or progestogen-only pills. Hormonal methods also include hormone implants, hormone-releasing Rms, and long-lasting injections, all of which are now quite well-established methods of birth control, and also newer areas of research such as the male pill, vaginal rings, hormonal nasal sprays etc.

There is considerable controversy in Christian circles over the ethics of various hormonal methods of birth control. First and foremost is the Roman Catholic Church’s objection to any ‘artificial’ methods of birth control (i.e. anything other than the rhythm methods). Interestingly, one of the main developers of the contraceptive pill and its use was Dr John Rock, himself a Catholic. The official teaching of the Catholic Church inevitably proscribes the pill, although some Catholic individuals find no objection.

Some Christians of other denominations disapprove of the pill because it interferes with the body’s natural processes. This is undoubtedly true; the combined pill supplants the body’s own rhythm with a similar, but infertile, rhythm that is artificially produced. Since the pill is taken by healthy women who are functioning normally, some people feel that it is wrong to interfere with the body in this way. I have great sympathy with this view on an individual level — I fully understand any woman deciding that she doesn’t want to alter her body in this way. However, I feel that there is no reason for a blanket condemnation of the pill just because it does this. We all alter our body’s natural rhythms by all kinds of everyday activities such as drinking tea and coffee, watching an exciting film, taking exercise. The fact that the pill alters natural body rhythms is not sufficient reason to condemn it.

A charge often levelled at hormonal methods of contraception is that they are not ‘natural’. This is generally quibbling over words. No form of contraception is strictly natural: if things were left to nature, women would get pregnant far more often than they do. John Guillebaud, who is this country’s leading authority on the pill (and who also is a committed Christian) points out that in some ways the pill is more ‘natural’ than non-hormonal methods. The usual course of events in a past or present society that is not contraceptively aware is that married fertile women have a baby roughly every year. Between the birth of one and conception of another they are usually breastfeeding, and so often do not have sustained cycles of ovulation and menstruation for years at a time during their fertile life. Guillebaud points out that the pill actually imitates this ‘natural’ cycle far more accurately than barrier methods, IUDS or rhythm methods, as it too suppresses the cycle of ovulation and menstruation. Contraception to some extent is bound to be an unnatural process, and if all other factors are equal no one method can strictly be described as more or less natural than any other.

Another feeling about the pill is that it introduces lots of artificial chemicals into the body. This is less true than many people realize — the elements of combined pills, oestrogen and progestogen, are very similar to the oestrogen and progesterone produced by the woman’s body. In fact, if they were not virtually identical in structure the body’s chemo-receptors would not accept them into the system. The reasons that synthetic hormones are used are that they are cheaper, and also they are not broken down by the body when taken orally. Early trials had to use injections rather than pills until it was discovered which compounds could be taken successfully by mouth. However, these early trials showed that the contraceptive effect was just as good with the naturally-occurring hormones as with the synthetic substitutes that were developed later. The difference could perhaps be compared with using artificial colours instead of crushed precious stones to make paint; the final result is just as good, but the synthetic version is cheaper and easier to produce.

The pill has rather suffered from being blamed for the permissive society. It is quite true that ready availability of the pill made promiscuity more tempting as it offered widespread protection from pregnancy. However, just because something can be abused it doesn’t necessarily mean that it is wrong in itself— that is rather like looking at the spread of gambling and saying ‘there, I knew money was wrong’. Money can be used for good or for ill; so can contraception, the pill included.

Having looked at some of the ethical questions raised by the idea of hormonal contraception, what about the ethics of the way each method works in controlling the birth rate? Here I feel there is an important distinction between the combined pill, or its derivatives, and the other available hormonal methods — mini-pills, implants and injectables.

The ordinary combined pill, which contains oestrogen and progestogen, acts mainly by preventing ovulation. This means that no egg is released at any stage of the cycle, so of course there is no chance of one being fertilized. Combined pills which are low-dosage (50mg or less of oestrogen) are thought to be only 95-98% effective at inhibiting ovulation. In these cases the rest of the contraceptive effect is supplied by lesser changes resulting from the hormones: the cervical mucus becomes both physically and chemically virtually impassable to sperm, and inhibits sperm capacitation. Therefore using a combined pill, in the very unlikely event of an egg being released, it is extremely unlikely that it would be fertilized. For people who accept hormonal contraception, there are no ethical quarrels against the use of the combined pill.

The case is very much more complicated, however, in hormonal contraceptives which use progestogen only. It is mainly the oestrogen which suppresses ovulation; mini-pills, Depo-Provera (the most common injectable) and NORPLANT (the most common implant) use only progestogen. To some extent progestogen is responsible for preventing fertilization, by making the cervical mucus inhospitable and by inhibiting capacitation to some extent. However, its back-up effect in most progestogen-only contraceptives is to inhibit implantation of the fertilized ovum in the uterus, by changing the nature of the endometrium (uterus lining). This means that if you believe that life begins at conception, progestogen-only methods can cause early abortions in the same way as IUDS. The sperm and the ovum have joined and a new life has started, but it cannot implant successfully in the uterus and so is discharged from the body. The evidence that this method works solely by preventing implantation is much less clear-cut than that for IUDS, which seem from recent studies generally to work in this way; in fact it is unlikely that progestogen-only methods do rely mainly on this factor. However, it still plays a large part in the methods’ successes. This needs to be considered carefully and prayerfully by any couple thinking of using the mini-pill, Depo-Provera or implants.

The other area of ethical concern over hormonal methods is the attached health risks. Only some health risks are associated with progestogen-only methods, which is why some couples choose these methods in preference to the pill as they do not understand the way in which the progestogen acts. Far more attention is paid to the health risks of combined pills as (a) they are better documented, (b) the risks are greater, (c) many more women use them, and (d) they affect far more of the body’s systems than progestogen-only methods.

A contraceptive which makes periods lighter and virtually pain-free, which is extremely reliable, which is dissociated from sex itself and which helps protect the user against several forms of cancer, anaemia, duodenal ulcers, pre-menstrual tension, toxic shock syndrome, vaginitis, ectopic pregnancy, endometriosis, benign breast disease and arthritis would be very good news. The pill is such a contraceptive. However, a method which increases the risks of weight-gain, high blood pressure, heart attacks, strokes, thrombosis, gallstones, malignant melanoma, liver tumours and cystitis would be pretty bad news. This also is a description of the pill.

Many of the undesirable side-effects of the pill would be tolerated virtually unquestioningly if the medication were being taken to save life — for instance if it were a treatment for heart failure or leukaemia. In particular the possible mild side-effects such as weight gain or headache would probably be tolerated quite happily. However, because the pill is (or should be) taken by healthy women, they need to decide whether it is the benefits or the risks which weigh heaviest in their thinking. Obviously there is no substitute for careful medical assessment of the woman’s health and medical history, and the preferences and priorities before God of the couple concerned, for deciding whether or not a particular woman is a good candidate for the combined pill. I don’t want in any way to underestimate the possible risks for some women taking the pill. On the other hand, here are some factors which help us to see the debate in its most accurate light, and may help you in deciding whether or not you want to take the pill.

1 Many of the studies on the pill have been done on women who have exclusively or for part of the time been taking pills containing far higher levels of hormones than are now prescribed.

2 It is the studies themselves which have helped to identify women who are at risk from the pill; these days most such women are never given the pill at all.

3 The pill is an extremely reliable contraceptive.

4 The risks of the pill must be carefully weighed against the risks of becoming pregnant, which is a very real possibility if you use a less reliable contraceptive instead. Presently, the chance of dying as a result of pregnancy or childbirth is 1 in 10,000 in the UK (1 in 500 in a developing country). The chance of dying as a result of taking the pill is 1 in 77,000 for non-smokers under the age of thirty-five, who are the women most likely to be given the pill.

5 The pill is less dangerous than many other risks taken commonly by many of us. For instance, you stand a greater likelihood of dying if you regularly go swimming or drive a car than if you take the pill.

6 Your doctor will tell you if you have any known conditions which are likely to make pill-taking dangerous for you.