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The Pill: still swinging at 50

Steve Ainsworth
Medical Journalist

What made the '60s swing? Was it the music of the Beatles? Or maybe the "race for space", which saw the end of the decade being marked by the first landing on the Moon? In fact, it was none of these things. What really made the '60s swing was the arrival, exactly 50 years ago, of the contraceptive pill ...

Known officially as the birth control pill or the oral contraceptive pill, this miracle of pharmaceutical science was quickly given a unique accolade. It was dubbed THE Pill - an honour given to no other prescription item.

In a year that will see the contraceptive pill being handed out directly by pharmacists for the first time, never mind under the more watchful eyes of GPs and practice nurses, it's hard to recall the way the world looked before the arrival of the most effective contraceptive ever.

Fifty years on, only a minority of today's practice nurses will be able to remember what Britain was like all those years ago. The Second World War had ended only 15 years earlier, and the memory of Adolf Hitler still cast a dark shadow over the lives of everyone above the age of 20. Many cities still had unexpected architectural gaps where German bombs had destroyed buildings. Steam trains were a common sight. There were only two television channels - BBC and ITV - and they broadcast only in black and white. Most homes were still heated by coal fires. Few had central heating. Money was still counted in sixpences, shillings and half-crowns.

Homosexual acts were punishable by imprisonment; and murder by death. The NHS was only 12 years old. In the post-war baby boom, children teemed in streets largely empty of cars. Abortion was illegal, and contraception often a hit-and-miss affair.

And into this now-unfamiliar Britain, a place that seems like a foreign country, there exploded something that would change the nature of society more than anything that musicians, politicians or fashion designers might do.

Where did the Pill come from?
The surprising answer is the Mexican yam. Hundreds, possibly thousands, of wild plants have some natural contraceptive effect; the reason being that they contain chemical compounds which are closely analogous to human hormones.

A little-known researcher named Russell Marker first extracted diosgenin from Mexican yams in the 1940s. This, in turn, could be made into synthetic progesterone. In the next decade, both cortisone and testosterone were also synthesised from the same source.

Some of the synthetic progesterone was sent to the Worcester Foundation for Experimental Biology in Massachusetts. It was there in 1951 that biologist Gregory Pincus began developing synthetic hormones as potential contraceptives. Behind Pincus and his team, however, was a woman named Margaret Sanger, a pioneer of birth control in the USA. She is credited with coining the very expression "birth control". In 1916 she had been jailed for 30 days for opening a family planning clinic in New York - convicted on a charge of "maintaining a
public nuisance".

Three decades later, however, Margaret Sanger had become a highly respected figure in the USA, one capable of influencing the allocation of research grants. It was she who arranged for Gregory Pincus and his colleague, Min-Chueh Chang, to receive sufficient funding to enable them to develop a hormonal
oral contraceptive.

Clinical trials began in 1955. Bizarre as it now seems, prescribing any form of contraception was then a criminal offence in Massachusetts. The clinical trials were, therefore, conducted offshore, among poor women in Puerto Rico. Two years later, norethynodrel was approved by the US Food and Drug Administration. Avoiding controversy, the new drug was approved only as a "menstrual regulator".

In 1959, however, norethynodrel was officially recognised as a contraceptive. In 1960, it was marketed by the Searle company under the name Enovid. The "Swinging Sixties" had arrived.

Public outcry
The women of Britain had to wait a further 12 months to get their hands on the latest scientific miracle. Inevitably, the arrival of the Pill caused controversy in a country still ruled not only by men, but also by men who had been born in the reign of Queen Victoria.

The Pill was made available at family planning clinics - institutions intended to help only married women plan having babies. They were certainly not places where just anyone could get hold of contraceptives pills.

As for getting the Pill from a GP, guidance from the Ministry of Health was clear "… it is open to a doctor to prescribe oral contraceptives like any other on a prescription form if there are good medical reasons for prescribing - for example, in a case where pregnancy would be medically injurious to the patient's health."

GPs were not expected to prescribe the Pill purely for the simple social convenience of having an effective contraceptive. Some MPs, however, were concerned that this guidance might be ignored. One MP challenged Enoch Powell, then Minister of Health, "Can my right hon friend confirm or deny that these pills cost up to 17 shillings a month if prescribed? In view of this, will the Minister not lay down and publish very careful instructions as to when they may be used, since the prescribing of these pills could cost a lot of money if not controlled on medical grounds."

Interestingly, according to the Department of Health, the cost benefit of contraceptives would later be estimated at £11 for every £1 spent.

Enoch Powell, however, dodged the question by simply declining to interfere in doctors' clinical judgement. Powell may not have known anything about the economics of contraception, but he no doubt understood perfectly the hypocrisy that the Pill involved. Women in their thousands were flocking to their GPs to be prescribed the Pill for menstrual irregularities and GPs were complicit in the subterfuge. Meanwhile, family planning clinics took care to call every client Mrs and never Miss.

In 1964, to predictable outrage, the first Brook Street Clinic opened its door to give contraceptive advice to unmarried women. Britain would never be the same again.

A mixed blessing?
The world was going to the dogs. In 1968, Pope Paul VI issued his encyclical, Humanae Vitae, in which he condemned every form of contraceptive birth control, especially the Pill. Few women took any notice.

Denunciations, whether from pulpit or politicians, did little to stem the tide. By the end of the 1960s a million British women had been prescribed the contraceptive pill. By the turn of the century, according to the Office of National Statistics, of all British women who used contraception, a quarter were taking the Pill - making it the most popular form of contraception ever.

Yet, in truth, the Pill would turn out to be something of a mixed blessing. It provided enormous benefits, but at the same time it brought with it new health risks and novel social problems.

The church and other social commentators would be proved correct in some respects. Control of female fertility did bring in its wake sexual freedom and an increase in promiscuity, which, in turn, increased the risk to health from sexually transmitted disease.

There were also some direct risks to health. The first report of a blood clot and pulmonary embolism in a woman using the Pill was published within 12 months of the Pill being licensed.
By the end of the 1960s long-term studies confirmed that there was an increased risk of venous thrombosis amongst oral contraceptive users generally - but especially among women who smoked or had high blood pressure. Following adverse media reports the number of women using the Pill fell in the late 1960s, and in the early 1980s when the Pill was linked not only to strokes but also breast cancer.

In 1995 the Committee on Safety of Medicines (CSM) issued a much-publicised warning over thrombosis in relation to the third generation version of the Pill. This, too, caused another drop in its use - and, according to the British Pregnancy Advisory Service, it also indirectly caused an increase in terminations (up 9%). Four years later, however, the CSM modified its advice.

In reality, the Pill was increasingly safe. Ongoing research had led to its various formulations being continuously modified and improved. The "mini-pill", containing only progestin or progestogen, was introduced in the 1970s. By then most women were using oral contraceptives, which contained less than half the quantities of oestrogen previously thought necessary. Some clinical risk still remains - but according to the British National Formulary (BNF) any risk is "considerably smaller than that associated with pregnancy".

Today, as THE Pill celebrates its 50th birthday, no one can doubt its impact on the world - and that 50 years from now, practice nurses will surely still be giving advice about it.

Your comments (terms and conditions apply):

"The pill has had enormous health benefits for women throughout the world and yet it is one of the most researched drug available. Tensions continue between those who believe women and men should be able to control their fertility and those who believe the opposite. The pill is very safe but
sometimes women may have other health factors which impact on the pill or engage in activities where pill taking is best avoided e.g smoking, obesity etc etc" - Kathy French, London