Part Three In A Four Part Series About Fertility And How We Experience It
What would you put up with in exchange for reliable contraception? An implant bursting out of your arm? Severe depression? Weight fluctuation? These are all among the side effects women tell me they’ve endured while on hormonal contraception.
When Amy, 28, started taking the combined contraceptive pill as a teenager, she found it was causing weight gain, so moved to another brand. She describes it as “the worst thing I have ever put in my body”, and began to experience severe depression. “I’d never suffered with my mental health before and I didn’t know what was happening” she says.
“I felt completely out of control and it’s really hard to talk about... but this pill made me feel suicidal. I was standing on the train platform one day, considering what to do, and that’s when I knew something was really wrong.”
Amy’s experience is extremely rare, but there are clearly links between hormonal contraception and mental health. A study in Denmark of over a million women by Øjvind Lidegaard, Professor in Obstetrics and Gynaecology at University of Copenhagen, found those taking a combined contraceptive pill were 23% more likely to use antidepressants than those who did not. Women taking a progesterone-only pill were 34% more likely to need them, while for the vaginal ring and contraceptive patch the risk was even higher.
Many more women experience issues such as mood swings, inflamed skin and swollen breasts – but find doctors dismissive of their impact.
When Sadie*, 27, began taking the contraceptive pill at 15 years old, the possibility of side effects wasn’t really discussed. “No one explained to me the whole picture of the pill. It was just like: ‘Here you go, you’re a woman now so you must take this. Don’t worry about it and don’t question it.’” When she questioned the downsides of the pill she was initially prescribed, “all of these side effects were not seen as a big deal by the doctor,” she recalls. Living with them was seen as “just part of the process to find the right pill”.
“No one explained to me the whole picture of the pill. It was: 'Here you go, you're a woman now so you must take this."”
But lately the conversation seems to have shifted. Fed up with managing the side effects of hormonal contraception, some women are deciding to ditch it altogether.
There are many forms of contraception. Some contain hormones: the combined pill, mini pill, contraceptive injection, implant, IUS, patch and vaginal ring; while others don’t: condoms, diaphragms and the IUD (a copper coil fitted inside the uterus). And then there are fertility apps, which help women to understand when they are at their most and least fertile, thereby informing them of when they can and can’t have unprotected sex. Essentially, they’re natural family planning 2.0.
Last September, Sadie decided to come off the pill because she was living with depression and thought it might help boost her mood. “I couldn’t say with any accuracy if it had a big impact on helping me feel better, as there were so many contributing factors, but I found it really empowering that I was taking control of my body and not pumping hormones into it anymore,” she says.
“I found it really empowering that I was taking control of my body and not pumping hormones into it anymore."”
She decided to try Natural Cycles on the basis of a recommendation from a friend, what seemed like convincing science and because “condoms can be a right faff”. The app, which has 800,000 users worldwide, requires a woman to record and input her basal body temperature each morning so it can calculate where she is in her menstrual cycle. It then predicts her ovulation day and offers an insight into when is safe to have unprotected sex with the lowest risk of falling pregnant.
Sadie has now been using the app for a year and says while the algorithm hasn’t quite “nailed” her cycle, she’s learned a lot more about her body and fertility. She still gets a bit anxious around the time her period is due. “I definitely get a bigger sense of relief when my period comes and I’m not pregnant, but I think that’s just because I need to build up more trust in the algorithm.”
Natural Cycles was the first app to be certified as a contraceptive method in Europe. However in the past year it has faced increasing scrutiny. It was told by the Advertising Standards Authority (ASA) it was no longer allowed to claim it is a “highly accurate” and “clinically tested alternative to birth control” in adverts.
The controversy doesn’t stop there. Earlier this year Swedish broadcaster SVT reported that 37 of 668 women who sought an abortion at a Stockholm hospital between September and December 2017 had relied on Natural Cycles, which the hospital reported to Sweden’s Medical Products Agency (MPA).
Novelist Olivia Sudjic was among those who had an abortion after, she says, the app failed. “I was sold on shiny promises, a sleek user interface and the fact that a former Cern physicist, Elina Berglund, was at the company’s helm,” she wrote in an article for the Guardian. “But four months in, it failed. Berglund helped discover the Higgs boson; but it turns out her algorithm couldn’t map my menstrual cycle.”
The MPA reviewed the rate of reported unintended pregnancies among Natural Cycles users between January and June 2018 and found the number to be in line with the published typical use effectiveness rate of 93%, which is based on a study of over 22,000 women.
Natural Cycles CEO Raoul Scherwitzl said of the findings: “There has been a lot of discussion about this investigation, and we hope that it will provide some reassurance to women to see eminent bodies like the Swedish MPA and the US FDA in alignment based on the strength of our clinical evidence.”
Maria*, 27, swears by the app, which she began using after trying three types of contraceptive pill and the implant. “I had finally found a way to use contraception without pumping my body full of hormones,” she says. “And I have never looked back. Since then, several of my friends have made the same transition.”
“I finally found a way to use contraception without pumping my body full of hormones. And I have never looked back.”
Data on contraceptive apps shows their failure rate can be high, according to Dr Christine Ekechi, consultant gynaecologist at The Portland Hospital, part of HCA Healthcare UK. “Up to one in four women using these apps will get pregnant,” she says. “This is higher if cycles are irregular or periods are not tracked religiously.” In addition, during your most fertile days, you’ll need to either abstain from sex completely, or instead use a condom – one of the least reliable forms of contraception.
There are no statistics to show just how many women are switching from hormonal contraception to fertility apps, but Clare Murphy from the British Pregnancy Advisory Service (BPAS) says anecdotally the charity does seem to be talking to more women using apps – and also experiencing unplanned pregnancy because of them.
This “isn’t surprising”, however, Murphy argues. All contraceptive methods fail, so these apps will also have their own failure rates.
On the whole the charity is “very supportive” of people using fertility apps as contraception. “We definitely think natural family planning needs to be part of the contraceptive menu,” she says. “It’s an option many women prefer, especially if they’ve had a hard time with hormonal contraception.”
Prof Øjvind Lidegaard from the University of Copenhagen, argues that fertility apps are suitable for some women, “as long as you can live with one or two unwanted pregnancies”.
“For some people the worst thing they can imagine is unwanted pregnancy and an abortion, for other women it’s no problem,” he adds. “Women are so different in their opinions and therefore it’s necessary to talk with them about that.”
His advice is that women in their twenties, who are more likely to get pregnant, are probably better suited to hormonal contraception, unless they are predisposed to depression or thrombosis.
When women reach 30-35 years old, and as thrombosis and breast cancer risks increase, he says “it’s reasonable that women reconsider their contraceptive habits”. In this instance, apps like Natural Cycles might be preferred as the risk of pregnancy at this age is lower.
For those reluctant to rely on an app, Aly Dilks, clinical director of The Women’s Health Clinic (a private clinic in London) and an advanced nurse practitioner, says she’d only recommend using fertility apps if “you’re a meticulous person that knows your periods inside out”. She advises women to have a conversation with their nurse or doctor, who can then take an in-depth look at their lifestyle and family history to make a decision around the best contraception for them.
“It’s such a minefield and each doctor differs in how helpful they are.””
Of course, that luxury isn’t always afforded to women using stretched NHS services. As Professor Helen Stokes-Lampard, chair of the Royal College of General Practitioners, acknowledges: “What GPs need to do is have a deeper chat with people [about their health history] but it’s hard to do with the modern NHS and people’s busy lives.”
Many women also have trouble making that conversation work for them – often finding their concerns dismissed. As Sarah, 28, from Brighton says: “It’s such a minefield and each doctor differs in how helpful they are.” So what happens next?
If you aren’t having any luck with your current GP, it’s perfectly fine to ask to see someone else who specialises in contraception and sexual health, says Prof. Stokes-Lampard, before adding: “We don’t want people suffering in silence.”
There can be a happy ending, but for some women it might take a while. Sarah spent 12 years trying to find the right contraceptive for her. She endured severe anxiety, panic attacks, paranoia and worsened endometriosis symptoms on that journey, however she says she is finally in a positive place. “Now I have the Mirena coil which is the best thing for keeping my condition [endometriosis] in check,” she says. “I have barely any side effects and haven’t had a period in 18 months.”
*Some names have been changed.
This is the third part of a four-part series about fertility and how we experience it.