Why Women Stop Taking the Pill (Episode 477)

Full Transcript: Episode 477

Lisa: As a follow-up to last week’s episode with Holly Grigg-Spall, all about feminism and the pill and that interesting topic of is it anti-feminist to question the pill, today I wanted to share a brand new FAMM Research Series episode. And today we are focusing on the level of dissatisfaction that women often experience on the pill. So without further ado, let’s go ahead and jump right into today’s episode.

So what we’re looking at in this study is they’re looking at the different types of contraception and the women that were taking them and how many of them are essentially still on the contraception after a certain period of time. And I think that these kinds of studies are interesting because it gives us some insight into how many women come off of them in a short period of time. I think it raises a number of important questions if a fairly significant percentage of women are so dissatisfied with their experience on hormonal contraceptives that they come off of them regularly.

Essentially, the study took a fairly significant sample size of women who are of reproductive age, and in their sample they included women who were between the ages of 15 and 40. And they looked at their prescriptions for hormonal contraceptives and determined whether or not they filled that prescription. So after a certain period of time, they would look to determine how many women essentially came back to fill those prescriptions. And then they kind of shared out the data and went through it and talked about it. And so we get a sense of how many women are stopping the use of their contraceptives.

So a little background information that I think is really useful in case you didn’t know: as many as 50% or more women stop using hormonal contraceptives within one year of starting. And within that umbrella, that includes a variety of different contraceptive methods, but a lot of studies look specifically at oral contraceptive pills. And many of these studies have ranges between 30% to 50% to 60% of women who are taking a certain formulation who stop within that year.

And of course, there’s a variety of reasons why women might stop taking their contraceptive pills. Obviously, many women stop taking their pills to get pregnant, but outside of that really practical reason, there are several significant reasons why women stop taking contraceptives, not least of which are the most common side effects, including depression, low libido, anxiety, mood changes, sexual side effects, pain with sex, different things.

And interestingly, when you look at the studies and the language that they’ll use, they’ll often list, “Oh, this many percentages of women stop taking contraceptives for minor”—quote, “minor”—”side effects” and things like that. But again, they’re not looking necessarily at the information qualitatively to determine a woman’s experience.

Also, one of the most common reasons that women discontinue contraceptives is because of irregular bleeding patterns. And so particularly, the IUD is certainly a culprit of a significant percentage of abnormal bleeding, at least for a period of time. For example, the hormonal IUD is well known to contribute to and cause irregular bleeding, abnormal bleeding, particularly in the first three to six months. That tends to reduce a little bit, but again, that’s one of the very common reasons why women will discontinue.

Injectable contraceptives—so the shot—also have a high discontinuation rate, with over 75% of women stopping it within the first year of use as well. And many women will discontinue the brand that they’re taking, but that doesn’t mean they’ve completely stopped taking oral contraceptives, whether it’s oral contraceptives or other types. Often women are switching from pill pack to pill pack, brand to brand, in search of that best brand that gives them the least number of side effects.

And so these studies indirectly highlight the side effect profile of contraceptives because many women are coming off their contraceptives because they are unable or unwilling to tolerate the side effects associated with it.

And it’s interesting, again, when you look at these studies because they’re not necessarily being done to get a better understanding of what’s happening with these women and a better grasp of their complaints and concerns. They’re not doing these studies to try to make the drugs better so that they’re more tolerable for these women. They’re often doing these surveys to figure out what are the reasons that they are discontinuing so that they can improve their message delivery system to increase compliance.

So they’re not really concerned that the women have these problems. They’re more trying to gather this information so that they can just get more women to stay on it longer. And when you understand that about some of these research studies, it kind of helps to explain why they kind of skirt over the fact that so many women are coming off of it, and they see the problem differently. So the problem is that we’re not getting compliance. The problem from their perspective is, you know, how do we get them to stay on it without changing it? So they’re not actually looking at, okay, what are the problems? They’re just saying, how do we get them to stay on it without changing anything?

All right. So what did the study find? Well, I’ll go through the findings. After the first three months on oral contraceptives, about 36% did not refill their prescription at the three-month mark. And that’s interesting in and of itself. Only two-thirds, approximately, of oral contraceptive users continued to take their pill prescription at the three-month mark of using it.

With injectable contraceptives, there was a much higher rate of discontinuation. So the women who were using injectable contraceptives—the shot, Depo—those women were two and a half times more likely to stop. So they were two and a half times more likely not to come back and fill their prescription. And then the women who used the patch and the ring were 1.6 and 1.7 times more likely to stop using it than the women on the pills.

So interestingly, okay, well, you know, the oral contraceptives were the least likely to be discontinued and these other ones were more likely to be discontinued. But again, I think it’s worth mentioning that a third of the women stopped using it. A third of the women were not satisfied with it. And that was only the tip of the iceberg because when we got into the other options like the patch, the ring, and the injectables specifically, there was a much higher rate of discontinuation. So many more of them stopped using it.

And of course, the highest level of dissatisfaction was with the shot. If any of you have listened to the podcast for a while, you’ll know that the shot is my least favorite hormonal contraceptive option, and there’s several reasons for it. One, the side effect profile is the worst as far as I’m concerned. You can read the insert for yourself. And many women report significant side effects with injectable contraceptive options.

And the bigger issue, even bigger than that issue, is how long it takes these women’s cycles to normalize following discontinuation. So I’ll keep using the word discontinuation, but when a woman comes off of injectable contraceptives, it takes a significantly longer time for her cycles to normalize, typically, compared to a woman who took oral contraceptives or combined contraceptive method or whatever the case is. And so generally speaking, you can look at a period of a year to a year and a half or even two years in some cases before those cycles normalize off of injectable contraceptives.

So then to me, it’s no surprise that the women who were using injectable contraceptives were much more likely to stop and much less likely to refill their prescription in this particular study.

There were a couple of interesting stats that the researchers cited toward the beginning of the study. One was that during the first six months of use, at least one in five oral contraceptive users stops taking it. They also mentioned discontinuation rates with adolescents in particular. So young women who use hormonal contraceptives have a significantly higher rate of discontinuation, estimated at 50% in the first three months.

So teenage girls are also much more likely to stop taking contraceptives within the first three months, not even let alone within the first year. And so that is something to think about.

And again, if we take this back to what it means from my perspective—so again, the researchers are looking at it in a different way—but this type of data matches the stories that you’ve heard on the podcast, right? When women are sharing their experiences in the Pill Reality Series (fertilityfriday.com/pillreality if you haven’t heard some of these episodes), when women are sharing their experiences with the pill and things like that, it’s like it’s falling on deaf ears often, and it’s outlets like this that give them the opportunity to share what they’ve really experienced. And many women find the side effects to be intolerable.

Of course, whenever I talk about this issue, I also share that there are plenty of women who don’t have these problems. And even if you think about the statistics with about half of women discontinuing their contraceptives within a year, that means that half are not discontinuing. Half are actually fairly satisfied, and I’ve spoken to many women over the years that didn’t have any issues that they were aware of while they were taking their pill, and they were fine. Well, they felt fine, although there were still side effects.

Often when I speak to women who’ve come off of their pills, even though many women do not have issues with contraceptives and are satisfied with their use, it still doesn’t negate the fact or overshadow the fact that so many women have a negative experience.

And I think, again, there could be other questions that could be asked. One of the questions that could be asked is: why is it that certain women have these problems and other women don’t? Are there certain potential markers or factors? If we could identify what physical characteristics or whatever were associated with an increased likelihood of experiencing bad side effects, maybe that would help us to understand what this pill is doing or what this medication is doing in the body. And maybe that could even lend itself to future research that could alter the formulation so that there’s not as big of an issue.

With that said, though, I don’t know that altering the formulation is necessarily going to be the solution. The formulation—contraceptives are designed to shut down ovulation. That’s the main mode of action for the majority of contraceptive options. So as long as contraception involves shutting down ovulation, I don’t think we’re going to get out of these side effects that are so negatively experienced by so many women.

And so even the mode of action is useful to be aware of because even if we were to change—and this is what they’ve been doing for years—they’ve been tinkering with the formulation, they’ve been adding this synthetic hormone instead of this one and patenting this synthetic hormone over this one, and, you know, “Oh, we’ve got a new synthetic hormone here, we’re gonna slap a catchy ad campaign on it and try to get women to take it.” And it’s essentially the same thing, just a new outfit or something like that—the same drug in a different outfit.

And so as long as we continue on this path by tweaking and tweaking the same thing, essentially, and putting new outfits on the same drugs and putting new ad campaigns on the same medication, essentially, then we’re gonna continue getting the same result.

And I think that this is where fertility awareness charting comes in. This is where other non-hormonal birth control options come in because at the end of the day, you know, these non-hormonal methods don’t have a side effect profile. You don’t have side effects when you use a non-hormonal method that doesn’t change or alter your physiology, hormones, chemistry, pheromones, or anything like that. These side effects are coming about because of the way that these drugs operate.

So what does this study tell us? I think ultimately it gives us a confirmation that many women are dissatisfied with hormonal contraceptives. Many women experience side effects that they don’t want or that they don’t like. And even within the first three months, up to 36% of women on oral contraceptives are not filling the prescriptions. They’re not going back, they’re not getting more.

And in this particular study, oral contraceptives had the best continuation rate, so they had the highest number of women that filled the prescription and continued taking it. Whereas the injectables and the other alternatives—the patch and the ring—women were much more likely to stop and to not fill those prescriptions.

This study simply confirms what many of us have experienced personally or what many of us already know, which is that a high percentage of women are not happy with their contraceptives. And obviously, this does mean that there’s a pretty significant percentage of women who also are satisfied, or at least were not bothered enough to stop taking it.

With that said, I’ve had many conversations with clients over the years, many of whom continued to take these drugs to prevent pregnancy because they felt that they had no other choice, especially after switching from brand to brand to brand over several years looking for something better. And I think that does mean that there’s potentially a silent minority of women who are not satisfied, but not bothered enough to come off, but are essentially just tolerating the medication because they feel that they have to do it in order to get the result they’re looking for, which obviously is preventing pregnancy.

And so in a nutshell, many women are not satisfied with their contraceptives. A significant number of women stop taking them in search of something else, whether that’s switching brands or trying something completely new. And it also normalizes it because it’s extremely common then for women to have these issues.

If you were in the situation, or maybe you tuned into this episode and you personally had—whether it’s switched from brand to brand to brand or had a really difficult time with the hormones and couldn’t really find one that didn’t make you feel not great—so it’s useful to know that you’re not the only one. It’s useful to know that it’s actually quite common.

Also, it’s worth thinking about the broader context of the study. Right there in the conclusions related to the study was a comment that identifying the factors related to—I’m paraphrasing—coming off of contraceptives could help management. It says, “may inform management and improve adherence.”

And again, the focus of the research is—I can’t stress this enough—it is not on the woman in improving her experience. It is on the provider and improving their experience, helping them to be more effective at prescribing and improving a woman’s likelihood of staying on the medication. It’s really not looking at her experience in any way. It’s kind of, okay, we have this many women who are coming off of the pill. Our main objective is to help them to minimize their chance of unplanned pregnancies. So how do we keep more of them on the drug?

And it’s, you know, maybe my brain works interestingly, but if you know all these people in the room, like, okay, so how are we gonna get these—I mean it’s interesting because it would have to be a situation where none of them are actually saying, well, how about we improve the drug to make it better so that fewer women have side effects and then they won’t be as unhappy with it, right? Like that’s not—there’s no one is making that suggestion. It’s more just like, okay, so let’s figure out like what these issues are so we could just get more women to stay on it. Like, let’s try to do as much research as we can on all these different topics other than actually determining why women are dissatisfied and improving the actual medication to make it a better experience for women. Not that. We just need to change our messaging.

Anyways, so I find this whole thing to be really interesting, and that should also be an important takeaway of the study as well.

And so what do we do? I mean, it comes as no surprise that I think that the study also shows us that we do need better contraceptive options for women. We need to be asking better questions. We need to be involving women in these discussions and actually listening to what their experiences are, validating their experiences and thinking how could we make their experiences better. And instead of just looking at this as a problem with these women who are just discontinuing their medications early, why don’t we look at it as a problem with the drug and how could we improve the drug itself?

With that said, as long as hormonal contraceptives rely on those three primary modes of action—suppressing ovulation, drying up cervical mucus, thinning the endometrial lining—as long as these methods are altering the body in such a way to prevent pregnancy, I don’t know how you’re going to create a formulation that doesn’t have any side effects. There would always be side effects. The question would be how severe, how significant.

And so certainly, there’s an argument here to be made for women, especially for the women who are unsatisfied, because again, I just need to stress that all of the women are not unsatisfied. This study highlights that there is a significant percentage of women who don’t do well on contraceptives, who don’t like it, who don’t respond well to it. We know this. I think that’s quite clear at this point.

And so again, like for those women for whom the contraceptives are really not working, they’ve tried, switched from one to the other to the other to the other, had these side effects, found them to be intolerable—for these women, I think we do need to be informing them about all of the non-hormonal options, including fertility awareness, so that they have the ability to make these choices for themselves and potentially experience an effective contraceptive option that does not cause any side effects.

I mean, it’s real. That’s the fertility awareness method, right? Like, up to 99.4% effective, zero side effects. And as I always say, I don’t think fertility awareness is for everybody. I think that there’s plenty of women for whom, for one reason or another, this method isn’t going to be the best option for them. But for many women it is. And for those who have dove into it and really made it part of their lives, started using it as their primary birth control method, who’ve been able to transition off of hormonal contraceptives—for many women, this has been the game changer that they were looking for to free them essentially from this contraceptive bondage.

And again, I stress that my comments are, at least in this context, intended for women who really just didn’t do well on it, who really did fall into that category of having the side effects that were pretty intolerable or undesirable.

So with that said, I hope that you enjoyed today’s episode. If you are wanting to take a peek at the abstract for the research study that we talked about in today’s episode, you can head over to fertilityfriday.com/477. If you’ve been enjoying the FAMM Research Series, you’ll find the full list of episodes over at fertilityfriday.com/research.

And with that said, I hope you have a wonderful week, weekend, whenever you’re tuning into the show. And of course, as always, until next time, be well and happy charting.