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In the early 1900’s, the only reliable method of avoiding pregnancy was abstinence. There were no safe commercial alternatives, and very little access to education on the subject. Then in 1916, a nurse named Margaret Sanger opened a clinic in New York, the purpose of which was to educate women about family planning. Although she was initially arrested for promoting the then-radical idea that women might want to choose whether or not to become pregnant, she continued her mission upon her release. She founded the American Birth Control League, which later became Planned Parenthood.1
Although Ms. Sanger’s encouragement of women to make reproductive choices gained grudging acceptance in some arenas, birth control was not legally accessible in all states until 1965, and was still assumed to be mostly applicable to married women. In 1967, an activist named Bill Baird intentionally courted arrest when he gave a lecture at Boston University, after which he publicly provided an unmarried college student with several types of barrier contraception. As he had hoped, his legal case was ultimately brought before the Supreme Court, and in 1972, the Eistenstadt vs Baird decision provided equal access to contraception independently of the marital status of the patient.2,3
At the time of Bill Baird’s arrest, barrier contraception was still very much the norm. It had only been a few years earlier, in 1960, that the FDA approved Enovid, an exogenous hormone designed to mimic a pregnant state, for use as a contraceptive.4 At that time, this approach to reproductive planning was so unique that it could be known colloquially as simply, “The Pill.” The medical and cultural implications of this innovation were far reaching: its advocates lauded the feminist advance of women’s ability to make unilateral decisions about contraception, and hoped it would reduce abortion rates. Its detractors pointed out the increase of blood clots, the lack of protection from STI’s in the absence of a barrier, and the concern that this would lead to female promiscuity without consequence. Whether for or against, to call the Pill “revolutionary” would not be an overstatement.
Although I do not know of any clinician who longs for the days of restricted reproductive choice, I know of many a clinician who would admit that at least when there were only one or two hormonal contraceptives, it was a lot easier to tell them apart. My friends who have done international work universally describe how jarring it is to return from a developing nation and enter an American supermarket: the sheer volume of options is dizzying. It would seem that the range of options for those who wish to manipulate their reproductive cycle is similarly imposing. Do we want high or low estrogen to progesterone ratio? Which won’t make people gain as much weight? How about if you are breastfeeding? What does the literature REALLY show about oral contraceptive and reproductive cancers? How about stroke? How about acne? And will Obamacare cover it?
Fortunately, in this edition of OFP, we have a few cheat sheets. Author Erin Rainey, PharmD, BCPS, BC-ADM brings us the article that breaks some of this down, in the cover article “Individualizing Selection of Hormonal Contraception”, which helps the physician streamline the thought process and keep the evidence close at hand. The ensuing conversation with the patient is enhanced by Peter Zajac, DO, FACOFP’s educational handout “Birth Control”. We will not be able to answer all our patients’ questions (“Why does my IUD have the same name as the princess in the Sea World Dolphin Show?” “If I practice a spirituality that attends to the phases of the moon, will oral contraceptives compromise my relationship with the universe?”5) but it will give us a good starting place. We will also discuss hormones and alternatives for the patient with symptomatic menopause, palliative care options for patients with progressive illness, and a policy discussion about a new paradigm of patient activation for population health.
As always, we at the Editorial Staff hope you find this issue of the OFP enjoyable as well as educational. Whatever your clinical leaning, be it at the beginning, end, or change of life, we are certain there will be something of interest to you.
Sincerely,
Merideth C. Norris, DO, FACOFP
REFERENCES
1. Kathryn Cullen-Dupont (1 August 2000). Encyclopedia of Women’s History in America. Infobase Publishing. P. 11, ISBN 978-0-8160-4100-8. Retrieved 28 November 2011.
2. “The Short History of Our Right to Contraceptives: Eisenstadt v. Baird 40 Years Later.” Planned Parenthood Advocates of Arizona Blog. Retrieved 9 May 2013.
3. Discussed in Mr. Baird’s lecture to the Unitarian Universalist Church of Ellsworth, Maine, 2004
4. Junod SW, Marks L (2002) “Women’s trials: the approval of the first oral contraceptive pill in the United States and Great Britain.”, J Hist Med Allied Sci 57 (2) 117-60
5. Actual questions that have come up in the Editor’s clinical practice.