Updated: Sep 15, 2020
This article originally appeared in Contraceptive Zine on the 7th April 2019
How the process of contraceptive development has failed women; the case of the injectable contraceptive
It has long been argued that developments in reproductive technology reflect the interests, needs and wishes of the powers that be as opposed to those that use them (Corea et al., 1985). Historically, hormonal contraception has been no exception, leading to the development of methods that are far from ideal for the women that use them. Anita Hardon, a medical anthropologist and technical advisor for the WHO, has written extensively on the process of contraceptive development from a feminist perspective. She describes how the process has been inherently skewed to reflect the interests of the ‘population establishment’ by creating high-dose high-efficacy contraceptives and has systematically failed to listen to, document or take seriously women’s experiences of side-effects (A. Hardon, 1994, 1997). This article summarises the problems with these processes, the consequences they have had for the types of technology we available to us now, as exemplified by the case of the injectable contraceptive, and calls for a re-evaluation of what is prioritised during contraceptive development.
How contraceptive design prioritises high efficacy in all bodies over acceptability for most
Historically, contraceptive development has mainly been carried out for and by those with an interest in limiting population growth (Connelly, 2008). And so, contraceptive methods were developed with a focus on maximum efficacy to prevent pregnancies at all costs. This focus led to dosage selection that allowed a contraceptive to be effective in all women at all times; no matter their physiology. This shows a disregard for the fact that women are likely respond differently to different doses of hormones and thus one dose that is effective in all women is likely to be too high for the majority. The process of choosing this dosage and testing its side-effects is normally conducted by pharmaceutical companies in clinical trial settings, with the assumption that contraceptive doses assessed in clinical trial populations can be exported and used by all women with the same effectiveness and acceptability. This belief relies on the problematic assumption that all bodies respond similarly to biomedical intervention, based on the idea of a standardised body with ‘normal’ reproductive physiology and hormone levels. The archetype of the standardised human body in biomedicine is perhaps unsurprisingly Euro-American, meaning that much of medicine does not account for non-pathological biological variation in parameters, such as natural hormone levels, which are likely to influence reactions to hormonal contraception.
This process of development can lead to the creation of a contraceptive dosage that is far removed from the ideal for many women’s bodies. This is exemplified well in the case of the injectable contraceptive, Depo Provera. This is a progestin-only contraceptive which works mainly through suppressing the luteinising hormone (LH) surge that leads to ovulation, but also affects the cervical mucous and endometrial lining. Depo Provera is currently the most popular method of contraception in sub-Saharan Africa and is associated with a history of human rights abuses in population control programmes as well as with a large burden of side-effects among users. Studies from the 1980s (Bassol et al., 1984; Fotherby, Koetsawang, & Mathrubutham, 1980) show its 150mg dose of synthetic progestin (depomedroxyprogesterone acetate (DMPA)) remains effective for far longer than the 90 day period of intended efficacy and that much lower doses, of perhaps as low as 25mg, would continue to suppress ovulation for 3 months. Even though a new lower dose injectable, Sayana Press, has been created in recent years, it is still relatively high at 104mg and a review of its efficacy stated that approaches to its development “have adopted an ultra-conservative approach, aiming for doses high enough to avoid even a hint of ovulation” (Shelton & Halpern, 2014). This is in stark contrast to oral contraceptive formulations which have been reduced substantially since their inception to increase acceptability, but the same attention and research has not gone into increasing acceptability in injectables despite their widespread use.
How contraceptive design and clinical trials fail to listen to women’s voices
The process of developing contraceptives through clinical trials is also poorly equipped to identify and evaluate the extent of side-effects that women in trials do experience (A. P. Hardon, 1992). Clinical trials measure and report adverse effects in categories determined by value judgements made by the researchers, who at least historically have mainly been men (Corea et al., 1985). Menstrual disturbances, mood changes, weight gain, headaches, or dizziness are often dismissed as minor or not clinically relevant (A. Hardon, 1994). There is also systematic discrimination in which groups are listened to and whose concerns are taken seriously in clinical research. Women reporting pain are regularly taken less seriously than men in health research, despite numerous studies that show women may actually have a greater sensitivity to pain and yet are less often given relief when reporting it (Chen et al., 2008; Hoffmann & Tarzian, 2001). This has a historical basis in early male European physicians’ theories from the late 19th century about female functions being inherently pathological and about women’s normal state as being to be sick, as characterised by conditions such as ‘hysteria’ or ‘nervous prostration’ (Ehrenreich & English, 1979). This dismissal of reports of pain among women intersects with other attitudes towards race and class, leaving reports of pain or adverse effects among poor, marginalised women of colour rarely listened to (Whittle & Inhorn, 2001); communities in which the injectable contraceptive, in particular, is often promoted.
Yet reports from outside of contraceptive trial settings show we have known about side-effetcs from the injectable for a long time now… An article in feminist magazine “Women’s Voice”, published in London in 1979, ran a feature on Depo Provera, describing its side-effects as ‘menstrual chaos, weight gain, severe depression, migraine, loss of orgasm and sex drive’ (Knight & Weare, 1979). Not much has changed and women all over the world using Depo Provera continue to report experiences of pain, nausea, weakness, weight gain, loss of libido, severe irregular bleeding and anxiety, yet it continues to be provided in many family planning programmes. This drug can have very positive effects due to its ease of administration only once every three months, potential for covert use by women and the lack of need to remember to take anything regularly. However, the dose as it stands appears to be causing unacceptable levels of side-effects. Promising avenues would be to reduce the focus on preventing ovulation at all costs and instead looking at the drug’s impact on cervical mucous, as one study has noted that the injectable greatly thickened the cervical mucous to a point where sperm could not penetrate it within a maximum of 3 days of injection in all participants (Petta et al., 1998). Focusing on the contraceptive effect of thickening cervical mucous, instead of totally preventing ovulation, could allow significant reduction of the dose and some natural fluctuation of hormones, which would likely reduce side-effects (Shelton & Halpern, 2014).
Where do we go from here?
It’s time for a reformulation of the way we design and test hormonal contraception. Women’s experiences and reports of side-effects need to be placed firmly at the centre of the process. “Minor” side-effects such as nausea, mood swings, weakness, fatigue, loss of libido and weight gain can have huge impacts on women’s quality of life and weaken efforts to dismantle patriarchal stereotypes of the emotional and fragile woman. We need better tools of recording and measuring women’s voices and experiences of side-effects before, during and after a method is trialled. When deciding on dosage, we need to rebalance priorities to give acceptability, giving them at least the same weight as efficacy. We have seen that lower side-effect methods are in demand, even if it means compromising on effectiveness, with the recent rise in use of the Natural Cycles app, which states it is 93% effective with typical use, compared to some of the more effective hormonal methods that are associated with more side-effects. However, we must be careful not to moralise against hormones as ‘unnatural’ or as a lesser choice compared to natural contraception. Hormonal contraceptives have been revolutionary in allowing women control over their bodies, their sexuality, and freedom from fear of unintended pregnancy and we shouldn’t forget that. Women must be allowed to choose without fear of stigma whatever method is best for them depending on their priorities; be it reducing side-effects or being sure to avoid pregnancy. Yet that does not mean we should be complacent about the choice of methods we have now. There is lots of potential for innovation and change in the way we conceptualise and carry out contraceptive development. If we can implement some of these changes for a more feminist process of contraceptive development, that listens to women and takes variation of experience into account, it is likely possible to provide women with a range of highly effective contraceptives that will be both effective and minimise side-effects.
Bassol, S., Garza-Flores, J., Cravioto, M. C., Diaz-Sanchez, V., Fotherby, K., Lichtenberg, R., & Perez-Palacios, G. (1984). Ovarian function following a single administration of depomedroxyprogesterone acetate (DMPA) at different doses**. Fertility and Sterility, 42(2), 216–222. https://doi.org/10.1016/S0015-0282(16)48016-7
Chen, E. H., Shofer, F. S., Dean, A. J., Hollander, J. E., Baxt, W. G., Robey, J. L., … Mills, A. M. (2008). Gender Disparity in Analgesic Treatment of Emergency Department Patients with Acute Abdominal Pain. Academic Emergency Medicine, 15(5), 414–418. https://doi.org/10.1111/j.1553-2712.2008.00100.x
Connelly, M. (2008). Fatal misconception : the struggle to control world population. Cambridge, Mass.: Belknap Press.
Corea, G., Klein, R. D., Hanmer, J., Holmes, H. B., Hoskins, B., Kishwar, M., … Steinbacher, R. (1985). Man-Made Women: How New Reproductive Technologies Affect Women. London: Hutchinson and co. Ltd.
Ehrenreich, B., & English, D. (1979). For her own good : 150 years of the experts’ advice to women. London: Pluto Press.
Fotherby, K., Koetsawang, S., & Mathrubutham, M. (1980). Pharmacokinetic study of different doses of Depo Provera. Contraception, 22(5), 527–536. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/6451351
Hardon, A. (1994). The Development of Contraceptive Technologies: A Feminist Critique. Focus on Gender, 2(2), 40–44. Retrieved from http://www.jstor.org/stable/4030225
Hardon, A. (1997). Women’s Views and Experiences of Hormonal Contraceptives: What We Know and What We Need to Find Out. In Reproductive health matters (Ed.), Beyond acceptability: users’ perspectives on contraception. (pp. 68–77). Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.467.3196&rep=rep1&type=pdf
Hardon, A. P. (1992). The needs of women versus the interests of family planning personnel, policy-makers and researchers: Conflicting views on safety and acceptability of contraceptives. Special Issue Gender, Health and Development, 35(6), 753–766. https://doi.org/http://ezproxy-prd.bodleian.ox.ac.uk:2066/10.1016/0277-9536(92)90075-2
Hoffmann, D. E., & Tarzian, A. J. (2001). The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. Journal of Law, Medicine & Ethics, 29, 13–27. https://doi.org/10.2139/ssrn.383803
Knight, S., & Weare, T. (1979). Depo-Provera - No Thanks. Women’s Voice No35 Series 2, 18–19.
Petta, C. A., Faundes, A., Dunson, T. R., Ramos, M., Delucio, M., Faundes, D., & Bahamondes, L. (1998). Timing of onset of contraceptive effectiveness in Depo-Provera users: Part I. Changes in cervical mucus. Fertility and Sterility, 69(2), 252–257. https://doi.org/10.1016/S0015-0282(97)00477-9
Shelton, J. D., & Halpern, V. (2014). Subcutaneous DMPA: A better lower dose approach. Contraception, 89(5), 341–343. https://doi.org/10.1016/j.contraception.2013.10.010
Whittle, K. L., & Inhorn, M. C. (2001). Rethinking Difference: A Feminist Reframing of Gender/Race/Class for the Improvement of Women’s Health Research. International Journal of Health Services, 31(1), 147–165. https://doi.org/10.2190/FKJA-CXD7-V4G6-U4W9