Vaughn Wallace/Al Jazeera America

For many, hormonal birth control an increasingly bitter pill to swallow

Fed up with side effects of some birth control, growing movement of women looking at fertility awareness-based methods

In front of eight women eager to learn about their reproductive system, and one intrepid boyfriend, Sarah Bly lifted her hand from a bowl of egg whites, her fingers covered in the slippery substance. “That’s what super fertile fluid looks like. See how that hangs off my finger,” she told her students. If you’re brave enough to taste it, she offered, “it is sweet, full of proteins and alkaline,” qualities which, she said, help the sperm reach the fallopian tubes.

Bly teaches a class on fertility awareness, a secular form of natural family planning. Fed up with the side-effects of pharmaceuticals or distrustful of the drugs industry, a growing community of women are turning away from hormonal products in favor of fertility awareness-based methods (FAM) — which use the body’s natural fertility indicators and statistical rules of thumb to help women know when in their cycle they are likely to conceive and when they are not.

Advocates of FAM are quick to point out their differences to the rhythm method, or calendar method — which have traditional associations with Catholic Church teachings.

Whereas the rhythm method relies on a fixed number of days for every period to calculate the moment of ovulation and is generally considered unreliable, women like Bly chart three bodily indicators such as temperature, the consistency and quantity of their cervical fluids and, if desired, the position of the cervix to accurately assess when they can become pregnant — and when they cannot. Most women are potentially fertile for about one third of their cycle, or between eight and 10 days.

Used correctly, this symptothermal method — a type of FAM — has an efficacy rate that rivals that of the pill but hasn’t caught on nearly as much as its hormonal counterparts, despite the considerable list of side effects such as depression, blood clots, weight gain and loss of libido stemming from the latter. About 1 to 3 percent of women use FAM, according to a study from the University of Iowa, but 23 percent said they might consider using one of the methods after learning what they were, surveys show.

One third of all women on hormonal birth control have switched methods

Source: CDC, "National Health Statistics reports," Feb. 14, 2013.

One person who wished she had learned about FAM sooner is Mimi Vu, a 38-year-old mother of a 2-year-old girl. Vu started taking hormonal birth control in her early 20s, prescribed by her doctor "without blinking twice,” two years after she entered a serious relationship with her boyfriend.

Such was their attraction that she bought a one-way ticket from New York to Los Angeles little more than a week after her boyfriend had suggested she move in with him. But their love didn’t last. She blames the pill for the "downright disgust and dread" she suddenly started feeling. “The pill actually made me lose interest in someone,” she said.

A number of studies have provided evidence to back up Vu's experience.

One Swiss study concluded women are naturally drawn to partners with hormonal body odors that indicate their immune response genes are different from their own to ensure a healthy match — a process that a later study showed to be adversely affected by the pill. “It’s such accepted wisdom that the pill is a really safe thing. It was a very passive thing that I did: just pop, just pop a pill every day,” Vu said. “I actually didn’t know how my reproduction system worked, and I think this is true for a lot of women.”

A screenshot of FAM app Selene
Courtesy of Daring Plan LLC

Bly’s class aims to change this. Her three-hour session on cervical fluids and how to interpret their quantity and substance as a crucial indicator of fertility offers much more than a basic recap of the workings of the endocrinal system and female cycle. Bly delves into the intricacies of interpreting mucus — a subject many women still feel uncomfortable discussing, even among close friends.

Using glue sticks, lubricants and lotions to demonstrate different types of cervical fluids over the course of a woman’s cycle, her session included many details not to be found in standard sex-education. “Not everyone has a comfort with their genitals and what’s going on down there,” Bly said.

Ilene Richman, founder of Fertility Awareness Network, the only secular organization promoting FAM methods in the United States, said she connected these feelings of shame to a cultural predilection for the pill. “‘I touch my labia every day,’ you can imagine what the popular response is to that.” Whereas “‘I take my pill every day,’ that’s perfectly acceptable,” she said.

Throughout her class, Bly stresses that FAM is also an opportunity to check other issues, not just to prevent or encourage pregnancy. Some women use the method to detect medical irregularities, such as abnormally low basal body temperatures, which could indicate a thyroid disorder. Other problems women can detect include endometriosis, polycystic ovarian syndrome and vaginal infections.

"The less we know the more we are reliant on external sources (birth control) and the more therefore we are reliant on pharmaceuticals and consumerism and corporations,” Bly said. “In almost every class I teach I have someone who says to me: why didn’t anyone ever tell me this?”

But increasingly, knowledge of an alternative method is spreading. Apps such as Selene and Kindara allow women to keep track of their cycle on their mobile devices as the modern alternative to paper charts. Digital communities or four-course webinars using Google Hangout like Bly’s have also helped spread the word.

A profitable industry

Many women interested in FAM are suspicious of a multi-billion dollar industry that serves about (PDF) four of every five women of reproductive age in the U.S. Nearly a quarter of women use long-acting hormonal injections, more than five times as many as 20 years ago, while the relatively new contraceptive patch and ring make up about 16 percent of users. Further, the use of the intra-uterine device (IUD) increased in the past decade to about 8 percent (although it was unclear how many were hormonal and how many were copper-based).

The desire to avoid unwanted pregnancies are just part of the reason that women are prescribed hormonal contraceptives — a process which some advocates say has come to resemble a modern rite of passage into womenhood. When Vu first asked her doctor for birth control, for example, she was prescribed what he called a "starter pill," which came with the bonus of keeping her skin clear and wasn’t supposed to have any real side effects. "It was marketed or sold like a beauty aid as well as a contraceptive," Vu recalled. "They're sold as a lifestyle drug basically, 'keep your weight down; keep your boobs bigger.’”

Treating acne, regulating menstrual periods or to prepare for having sexual intercourse are among the most common reasons cited by teenagers who plan to begin taking the pill before being sexually active.

But some reproductive health advocates question why periods need to be “regulated” and take issue with what they say is the “problematic” depiction of menstruation in many cultures around the world. They also argue that painful or irregular periods are often symptoms of a hormonal imbalance which the pill camouflages, but definitely doesn't "regulate."

Women are increasingly using condoms and withdrawal as birth control methods

Source: CDC, "National Health Statistics reports," Feb. 14, 2013.

Medical dismissal

Despite FAM's increasing popularity, medical practiotioners are slow to catch up with women's complaints about the pill. When Vu later went to see her OB/GYN to talk about her loss of libido and inquire about FAM, her concerns were dismissed. When she mentioned the symptothermal method, her doctor suggested it was “basically something like the rhythm method," Vu said. She added: “It just gets repeated endlessly, but the rhythm method is not accurate and not effective by any means. And not once from any doctor have I heard of something called fertility awareness. It's still not something a doctor will educate you on."

Kim Chinh, 38, a fertility awareness trainer and body literacy advocate from New York, said medical practitioners' reactions to FAM range from incomprehension to downright scorn. Chinh, who first used hormonal birth control when she was 18 after entering into a steady relationship, instantly experienced side effects. "I was just nauseous and would vomit, but everyone said that was normal." Then she started getting "really bad yeast infections." But doctors dismissed her complaints: "[They said] 'You're just using a new soap or wearing synthetic underwear.' Everyone continued pointing me toward the pill," Chinh said. 

One team of physicians at the Department of Obstetrics and Gynecology at the University of North Carolina even advised clinicians against counseling women about the pill’s side effects.

In 2010, a group of practitioners founded the Fertility Appreciation Collaborative to Teach the Systems (FACTS) in an effort to provide information and awareness about FAM to medical practitioners, who, the organization found, were overwhelmingly unfamiliar with it. In a survey (ppt) of 120 residency programs, the group found that 25 percent of programs did not provide training on FAM at all. The rhythm method appeared most well known among the group.

The American College of Obstetricians and Gynecologists did not respond to Al Jazeera’s request for comment. It did, however, provide a brochure about natural family planning that it said it provides to its members, which explains the rhythm method, "or, more recently, fertility awareness." The brochure noted that one in four women who use this method become pregnant, but it failed to make the distinction between the rhythm method and other FAM. 

Feminist conundrum

But there are other issues with FAM and the pill that go beyond their respective medical efficacy. With the pill being hailed as one of the most important feminist milestones of the past century, questioning hormonal birth control can be a delicate endeavor, especially among women's right advocates.

Planned Parenthood, the nation's largest provider of women's health care, has long based its mission on the provision of affordable birth control to women, reducing the rates of unintended pregnancies and the need for abortions. But, critics say, the organization sometimes allows reproductive health politics to get in the way of what it perceives as women's best interests.

Laura Wershler, a veteran sexual and reproductive health advocate who is a former president of the Planned Parenthood Federation of Canada, wrote in an email to Al Jazeera there is anecdotal evidence that the organization may discourage women from using natural methods. “My contention is that there's no reason why mainstream sex and reproductive health care providers are not providing fertility awareness instruction for women who want to learn the methods," she said.

But Vanessa Cullins, Planned Parenthood’s vice-president of external medical affairs, told Al Jazeera in a statement that the organization offers women information and education on the full range of birth control options, including FAM, “to help them make informed decisions about which contraceptive method is best for them.” However, she added, “Because FAM take time and dedication for partners to learn and use correctly — especially in the ‘heat of the moment’ — they are among the least effective birth control methods."

Learning FAM does take time, and one of Richman’s classes can take up to 10 hours and be “incredibly time-intensive,” she said.

Thus far, mostly white, educated women are contacting her and other instructors, a reflection that the full range of birth control options are often predicated on demographic realities. The ability to take your wakening temperature at a consistent daily interval, as well as the bit of time it requires to assess and chart cervical mucus multiple times a day, can be obstacles for many women to practice the method. Having a supportive partner is also crucial to the method’s success, as well as the willingness to abstain from sexual activity or use barrier contraception during potentially fertile days.

And of course, FAM, like the pill, does not protect against sexually transmitted infections.

But these hurdles should not absolve medical practitioners from educating women on the full scale of options, Richman said, adding that she’s not “anti-pill, but anti-ignorance. My goal is for everyone to have body literacy. My goal is not for everyone to get FAM,” she said. “There’s nothing inherently elitist about the method.” 

Compared to long-term prescriptions on the pill, the price tag of FAM instruction comes relatively cheap. Bly charges $140 for four three-hour sessions and between $60 and $90 for private consults; Anna Churchill, a FAM teacher from Belmont, Mass., said she charges $110 for two three-hour sessions and a follow-up consultation. One type of FAM, the Billings method, relies only on cervical fluids, eliminating the need for a thermometer and pushing the cost even further down, Churchill said.

“It’s important for a woman to talk with her health care provider about which method may work best for her. Only she can decide which method best fits her life,” Planned Parenthood’s Cullins said.

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