What once was liberation is now often seen as a burden: Australia's complicated relationship with the pill

The pill, so ubiquitous it goes by one name, has long been synonymous with women's liberation and sexual freedom.

But there's also a rising disquiet, especially online, about its effect on women's bodies.

On TikTok, young women divulge their hormone horror stories to tens of thousands of viewers. In private Facebook groups, they swap the names of their prescriptions like old friends — Brenda, Yaz, Diane, it goes on — and compare notes on the severity of their side effects. Over on YouTube, a study analysed videos about contraception posted between 2019 and 2021 and found they were "primarily about the discontinuation of hormonal birth control".

Prescriptions and consumption of the pill have steadily decreased in several western European countries over the past decade — a phenomenon labelled pillenmüdigkeit or "pill fatigue" in German — according to a study published this year. Many of these women have moved on to other contraceptives, including long-acting reversible options, known as LARCs, like intrauterine devices (IUDs), implants and injections.

Back home, however, the research suggests a different reality.

While use of the pill has declined marginally over time as longer-lasting and more reliable options have come onto the market, it remains Australia's most popular contraceptive.

"The pill is a very popular option still," says Dr Clare Boerma, the medical director at Family Planning, who attributes much of its enduring appeal to its longevity and widespread use.

Often, she says, "It's the first thing that comes to people's minds when they're thinking about starting a contraceptive."

More than 60 years after the pill first hit shelves, what do history and science tell us about its future in the lives of Australian women?

Australia's embrace of the pill

In 1961, Australia became only the second country in the world to have access to the oral contraceptive pill. The pill in question was called Anovlar and its arrival on Australian shores was a bombshell.

"Prior to the pill, there weren't really very many options for contraception and the options that were available were pretty unreliable," says Dr Bryony Mcneill, a senior lecturer in medical science at Deakin University.

Such options included condoms, diaphragms, spermicides, sponges and natural (and often crude) methods like withdrawal and fertility tracking. Crucially, most required the cooperation of a male partner.

"To have the pill available made a huge difference for women in particular and families to be able to plan when they wanted to get pregnant and separate sex from [having] children, which beforehand you couldn't really do," Mcneill says.

But the revolution didn't happen immediately. To get the pill, much like today, you needed a prescription — and conservative doctors were hesitant to give out scripts at all, let alone to unmarried women. It was also expensive, incurring a 27.5 per cent luxury tax.

It wasn't until 1972, during Gough Whitlam's first 10 days in office, that the luxury tax was scrapped and the pill was added to the Pharmaceutical Benefits Scheme, bringing costs down to about $1 a month.

Five years later, the first-ever national health survey found 20 per cent of women of reproductive age (18 to 49 years old) had taken the pill in the two days before being interviewed. This was likely an underestimation given women at the time were only expected to take the pill three weeks out of every month. It was most popular with women aged 20-24 (35.4 per cent) and 25-29 (29.1 per cent).

These early pills had much higher doses of hormones than we're used to today, and consequently more side effects. They were removed from sale in 1988 and replaced with lower-dose versions.

By 1995, two-thirds of Australian women of reproductive age were using some form of birth control, with 40 per cent opting for the pill, according to the Australian Bureau of Statistics. 

Because it was so revolutionary to have access to contraception at all, Mcneill says early on many women were happy to overlook the physical downsides. "People are now becoming more aware of those … and having the agency to look for better options that suit them," she says.

How the pill works

Contraceptive pills, and other hormonal birth controls, release artificial hormones that mimic those produced when an egg is growing, tricking the brain into no longer sending egg-production signals to the ovary.

At the same time, they thicken the mucus in the cervix, which stops the sperm from getting through, and alter how the uterus lining develops, making it harder for an embryo to implant. 

"In a normal menstrual cycle, you've got two phases: in the first half of the cycle you're preparing for that embryo or fertilisation, and the second half is sort of nourishing it for a pregnancy," Dr Mcneill says. "So by taking the pill you kind of obliterate this natural cycle and sort of switch everything off."

The most common form of the pill contains oestrogen and progestogen (known as the combined oral contraceptive pill). Also available is the progestogen-only pill — commonly called the "mini-pill" — which can be prescribed when people are unable to take the combined oestrogen. It works by thickening the cervical mucus and most women's periods will continue while using it. 

Many people also use the pill for reasons other than birth control: to manage acne, heavy periods, premenstrual syndrome (PMS) and conditions like endometriosis or polycystic ovary syndrome (PCOS).

Some side effects have been well documented, including breast tenderness, bloating, headaches and nausea. While rare, there are also more serious health risks, including strokes, myocardial infarction, and blood clots. Because the pill is taken orally, the hormones have to travel around the entire body, which increases the risk of clots. This is less of a risk with localised contraceptives, like IUDs.

"The thing about the pill is we have incredible safety data over decades and decades, so in fact, we know exactly what the minor risks and potential side effects are," says Dr Catriona Melville, director of clinical excellence at MSI Australia, the reproductive health service formerly known as Marie Stopes International.

"I certainly wouldn't want to paint something like the pill as the enemy."

The pill is still popular

National data on contraceptive use in Australia is patchy, but a report by Family Planning collating Medicare data and national surveys found the pill and condoms remained the most popular form of birth control in 2018, while the use of LARCs had seen "small but consistent" increases over the decade to 2015.

While Pharmaceutical Benefits Schedule data shows a decrease in prescriptions for the pill, many of the newer oral contraceptives are not listed and therefore not captured.

Even among the younger generation, the pill remains popular. In a 2021 study of thousands of Australian high-school students, 40 per cent of female respondents reported using the pill in their last sexual encounter, trailing condoms (47 per cent) but well in front of implants (11 per cent) and IUDs (3.7 per cent).

A small 2019 study tried to understand why women aged between 18 and 24 chose certain contraceptives. From 20 interviews, the researchers found some women felt they were persuaded away from LARCs by their doctor, while others were afraid of having something inserted into their body. "Misinformation about certain methods of contraception, particularly IUDs, was quite common among participants," the study read.

Is social media to blame?

When the pill was first introduced to Australia, information was hard to come by. Not only was advertising of it banned, but any public discussion of pre-marital sex, contraception or abortion was considered taboo.

Writing in the Sydney Morning Herald in 2010, feminist scholar Anne Summers recalled visiting the doctor with her boyfriend in 1966 and being asked: "Are you married?"

"In those days before family planning clinics or women's health services, before telephone helplines or listings in the front of the phone book, before there were books about sex, before there was any information really, we relied on rumour," she wrote.

"The word would go round, and we'd flock to the medico who we'd heard would not give us a hard time for daring to ask for a script."

Today, most doctors offer reliable information and will freely prescribe the pill, but the sharing of information between women that's existed since the pill's beginnings has reached a new scale in the social media age.

"If you go right back to the beginning, this was absolute freedom … it was mind-blowing when the pill was introduced," Dr Melville says. "But there's this strange sort of theory now that people are being forced to be on the pill."

In one oft-repeated TikTok format, women hold up comically large sheets of paper with lines and lines of tiny text. The on-screen caption provides explanations: be kind to your girl, they say, because this is the list of side-effects packaged into boxes of the pill.

While not entirely accurate — the leaflets also include details about what the pill should be used for and how to take it, alongside a list of rare, but terrifying, potential side effects — the meaning behind the video trend is clear: for a long time, women's bodies have borne the brunt of avoiding unwanted pregnancies and, judging by the comments, many aren't happy about it. 

In other cases, the discourse is more concerning. In one TikTok video, a self-described "menstrual health educator" tells her audience that "birth control is a Group 1 carcinogen and has been shown to cause cancer in humans". The video has been liked more than 41,000 times. 

While the pill has been associated with a slightly increased risk for breast cancer and a transient risk for cervical cancer while it's being used, it's also been shown to reduce the risk of endometrial and ovarian cancer. According to the Cancer Council: "On balance, the strong evidence of reduced lifetime risk of endometrial and ovarian cancer outweighs the transient risks associated with breast and cervical cancer."

While Dr Melville believes social media has played a role in "villianising" hormonal methods — after all, it's where many people go for information — she is hesitant to put too much stock in trends.

"People who don't like the pill, or have had issues with it, it's the same as anything in life, they will be more vocal," she says. "Whereas the people that do love the pill and have been on it for 20 years tend not to complain."

Giving up hormones

A particularly pervasive piece of misinformation is the belief that your body needs a break from hormonal birth control. According to doctors, there's no evidence to support this and stopping and starting may actually prolong adverse side effects, which usually subside within three months of taking a birth control method.

Dr Melville says this anti-hormone sentiment is particularly common among younger women, some of whom have ditched hormonal birth control completely in favour of fertility awareness apps. "And the unfortunate problem with that is I'm mostly seeing those people because they've had an unplanned pregnancy," she says.

Apps like Natural Cycles — which is the first to be cleared by the US Food and Drug Administration to market itself as contraception — Clue, Kindara and Flo use menstrual cycle information, daily body temperature checks and an algorithm to predict fertile periods. The idea is that by avoiding sex during these times, it's possible to avoid pregnancy. 

"There is quite a lot of belief that using a calendar method, for example, by itself is very efficacious — and it's not," Dr Melville says. "Natural family planning can be if you put in lots of other data, like your basal body temperature and your cervical mucus, but that's quite time-consuming and arduous."

In her clinic, Dr Boerma has also seen people coming in to reduce their hormone dose or give them up completely. "Hormones are bad and 'no hormones' is good is a bit too simplistic, but certainly some people do seem to be more sensitive than others to hormones," she says.

The copper IUD — a small device placed inside the uterus that is toxic to the sperm and egg, preventing fertilisation — is the only available non-hormonal, long-acting option on the market. It lasts for five or 10 years, depending on the device, but can cause heavier and longer periods in some women.

By comparison, the Mirena hormonal IUD can help manage heavy or painful periods. "For some people, hormonal contraceptives are really beneficial," Dr Boerma says.

"Sometimes people look at it in a bit of a black and white way; we've heard bad things and we want to avoid something that's bad, But often it's much more nuanced and complex."

What strikes Dr Boerma is the shift in attitudes over time. "It's seen as a burden, taking a hormonal contraception, rather than the liberation it once was," she says. "People are doing their own research, and trying to be more informed themselves, which is understandable and a good thing — but it does set a different landscape."

Does the pill have a future?

When advising women on birth control, Dr Melville follows this calculation to find the perfect option: the lowest doses of hormones, with the fewest side effects and the highest efficacy. Long-acting contraceptives are more likely to fulfil the final criteria, because they're not reliant on users remembering to take them or doing so correctly.

"With perfect use, short-acting methods like the pill are really good," Dr Melville says. "But we know that there's perfect use, and then there's real-life use."

Despite this, Australians have been slow to embrace LARCs. In a submission to last year's Senate inquiry into reproductive health, Family Planning NSW wrote that Australia's uptake rate is "well below comparable developed countries across the world", with only about 12-15 per cent of Australian women choosing IUDs, implants or injections. 

This is a problem, according to Dr Nicole Higgins, president of the Royal Australian College of General Practitioners (RACGP). "LARCs are much more user-friendly, they've got lower risks, they've got lower side effects," she says. "From a public health perspective, from a personal perspective, they're much better options for women."

Does this make the oral contraceptive pill obsolete? Dr Melville doesn't think so. There are currently plans to increase access to it by allowing pill refills to be provided over the counter in some states. "The pill has a lot to be commended for and I don't think it will ever disappear," she says.