“I stopped taking my birth control about a week ago. I am feeling better, I just wish I knew how much of an impact it was going to make on my entire body.” So commented a Virginia woman on a citizen’s petition to the FDA filed in May 2019 to consider more transparent warnings to women about the side effects and health risks of hormonal contraceptives.

“We are told about the benefits but aside from an impossible to read pamphlet no one is really counseled on the dangers,” the woman continued in her public comment on the petition that is still under FDA review. “I thankfully have not had anything catastrophic by the drug companies views (stroke, blood clots); but I have lost my hair, my love for life and I am weak.”

This citizen’s petition is part of a broader movement in recent years to reevaluate the impact of hormonal birth control. In June 2019, writer Anna Silman explored why women are opting to get off the Pill for New York Magazine’s The Cut:

Some women who’ve quit the Pill told me they’ve seen a reduction in anxiety or depression; some have seen an increased libido. For others, the effects were more nebulous: I heard phrases like “more alive,” “more clear,” “more myself,” and “like a fog had lifted.” The more I spoke to people, the more obsessed I became with the idea that one little tweak to my hormonal network could be affecting everything I take for granted about myself. What might hormonal contraception be doing to our minds, our moods, our behavior?

Silman’s expose in The Cut came just two months after Scientific American spent its entire May 2019 issue, entitled “Inconceivable,” scrutinizing the Pill. “The science of women’s reproductive health has huge gaps,” the cover reads. “What we don’t know is hurting all of us.”

A few months after Scientific American’s “Inconceivable” dropped, Dr. Sarah E. Hill made a valuable contribution to this reevaluation of hormonal birth control with her book This Is Your Brain on Birth Control. It’s enough to make any woman who has ever been on the Pill, or knows and loves someone on it (which is to probably about 99 percent of us), pause and take a closer look. Given what so many women are experiencing on birth control, the book could have been just as aptly called “This Is Who You Are on Birth Control.” Because the overwhelming point made by Hill is that women are quite literally different versions of themselves while on birth control.

This Is Your Brain on Birth Control is no “anti-Pill polemic,” as other recent books bemoaning the less-than-savory side effects of birth control have been labeled. Hill, an evolutionary psychologist, credits much of women’s professional success in recent history (including her own) to their ability to reliably restrict their fertility via the Pill. But rather than presenting a laundry list of issues caused by the Pill, Hill takes an even-handed approach and explains why some women might make certain trade-offs when it comes to the Pill and its myriad effects both positive or negative. Her overall goal is an admirable one: to alert women to the reality that their birth control is likely affecting much more than just their fertility—even if they aren’t acutely aware of it—and to make informed, data-driven, and personalized family-planning decisions based on that knowledge.

What we don’t know about birth control

Apparently the birth control many women have been taking since puberty—whether in an attempt to reduce acne, PMS, or the chance of pregnancy—has come with physical and mental trade-offs.

“Because there are hormone receptor sites on virtually every cell you have,” writes Hill, “the impact of your hormones on what you think, how you feel, and what you do is nothing short of pervasive.” This is especially true of women’s sex hormones—in particular, estrogen and progesterone. “Your sex hormones influence how you think, how you feel, how you see the world, how you behave, how you look, how you smell, the excitability of your brain cells, what your immune system does, how much you eat, and just about anything else you can possibly imagine.”

Hill spends the entirety of her book unpacking these claims, which is a tall order, and, for the most part, she has the data to back them up. I say for the most part, because perhaps what is most startling about Hill’s book is the revelation that as much as we do know about how hormonal contraception affects women, there is still so much more that we do not know. Many of the studies and theories presented in Hill’s book are highly preliminary—and so she cautions anyone from jumping to concrete conclusions about whether the Pill might be the culprit behind things like increasing rates of autoimmune disorders, infertility, anxiety, and depression—even rising divorce rates and falling marriage rates. But using her background as an evolutionary psychologist, Hill is able to make a fairly convincing case that the conclusions of the preliminary data make sense in light of the way both our brains and evolution work.

Getting birth control’s benefits without its costs

Hill's comprehensive presentation of the effects of the Pill—both good and bad—might seem to present a tragic dilemma: choose the benefits of the Pill or avoid its risks, but you can't have both. The problem is, it’s not a dilemma at all. There are more than these two options. Many of the reasons that Hill lists for why women may choose hormonal contraception despite its negative effects (e.g.: the ability to pursue education and career success unencumbered by fear of pregnancy; the mood stability some women experience from suppressing natural cyclic changes in hormones; relief from PMS/PMDD symptoms), are issues that growing numbers of women are resolving without any of the trade-offs of pharmaceutical birth control.

In September 2019, the New York Times published an article by Rachel Mans McKenny entitled, “Why Fertility Awareness Is My Birth Control of Choice.” McKenny notes that while she has been mocked by physicians who confuse fertility awareness-based methods with the rhythm method, there’s a difference: “The rhythm method pretends women run like clocks, while fertility awareness means paying attention to the sometimes unpredictable signs and symptoms that come along with hormonal changes.”

For McKenny, fertility awareness has helped her to have four planned and wanted pregnancies and three children alive today. Since natural family planning (as fertility awareness is sometimes called) can be a taboo subject, McKenny felt lonely using natural family planning but ultimately found support in online social-media groups. “Fertility awareness taught me that I should trust myself, even when it scares me. I know my body. I hope that in the future, the medical community will learn more about modern fertility awareness and that women, whatever their chosen method of family planning, find respect when communicating with their physicians and partners.”

While fertility awareness is based in the science of women’s cycles, there is still a significant lack of knowledge about it in the medical community. But the tide may be changing; as more women are turning from the Pill, more research is coming out on fertility awareness in mainstream scientific journals.

In July 2019, the journal Nature published an “Assessment of Menstrual Health Status and Evolution through Mobile Apps for Fertility Awareness” produced by researchers at Stanford University. “Modern methods developed in the last quarter of the twentieth century take advantage of the precise description of [biological measures],” the researchers explained in the abstract, “and have defined a set of rules that allows the identification of the fertile window around ovulation, so that couples can adapt their sexual behavior according to their reproductive objectives.” The researchers point out that the more than 200 million women now charting fertility data in apps provide an “accumulation of menstrual-related data from a diverse population of users at different stages of life.” They add that their “digital epidemiology approach . . . can help to lead to a better understanding of menstrual health and its connection to women’s health overall, which has historically been severely understudied.”

While not all fertility apps are based in a scientific method of fertility awareness (and can therefore vary widely in terms of efficacy for pregnancy prevention), modern, science-backed methods of fertility awareness are highly effective. In fact, two of the most popular methods (the Sympto-Thermal Method and the Creighton method) enjoy both perfect use and typical use efficacy rates for pregnancy prevention similar to those of the most popular contraceptive drugs and devices on the market. Case in point: the “method” or “perfect-use” effectiveness is about 99 percent for both the Sympto Thermal Method and the Creighton Method, and “user” or “typical-use” effectiveness is about 98 percent for both as well. Contrasted with the typical-use effectiveness of the IUD (99 percent), birth control pill (91 percent), and condom (85 percent), modern methods of fertility awareness are on par with (or more effective than) the more popular chemical, hormonal, and barrier methods of family planning available to women and couples today.

Beyond pregnancy prevention 

According to a 2010 study, only 3 to 6 percent of physicians know the effectiveness of fertility awareness-based methods in avoiding pregnancy. It would seem even fewer know the health benefits that women can gain using information they receive from cycle charting.

Consider the relatively common reproductive disorder of endometriosis, for instance. Modern medicine still does not understand why endometriosis happens and is still largely at a loss for how to recognize, diagnose, or effectively treat the disease. The same can also be said for polycystic ovarian syndrome (PCOS). The sad truth is that it is much quicker, cheaper, and all-around easier to put a young woman on the Pill and perhaps makes her life more manageable in the short term, than to investigate and treat any underlying conditions. Perhaps this is why it takes, on average, eight years for a woman to receive a diagnosis of endometriosis—a condition that affects more than 6 million American women.

Perhaps the most damning fact is that an estimated 70 percent of teenage girls who present with dysmenorrhea (painful menstrual cramps) are eventually diagnosed with endometriosis. Yet, it is medical protocol that when young women complain of cycle irregularity and painful menstruation, their doctors prescribe hormonal contraceptives to “regulate” the female cycle. These same women, who have been on some variation of the Pill since they began cycling at 12 or 13, may be on hormonal contraception for well over a decade (with varying degrees of efficacy when it comes to symptom management), before going off of it (perhaps in the hopes of becoming pregnant), only to find that their endometriosis is still uncontrolled—and may now be much worse than when it first began.

Doctors who are trained in fertility awareness—particularly Natural Procreative Technology (NaPro) physicians—are able to spot the biological signs of endometriosis and PCOS in a woman’s chart of menstrual cycle symptoms, and they are able to treat both issues without suppressing the woman’s cycle or masking her symptoms. Fertility awareness opens a world where a young woman can receive early diagnosis and treatment for debilitating menstrual disorders like endometriosis and PCOS, instead of suffering through them for decades. 

Cycle charting can also help women in general health management and fitness. The Chelsea women’s soccer team made headlines recently as the first professional women’s sports organization to harness the power of a woman’s cycle in order to enhance training. The team’s manager, Emma Hayes, says that the team has been using a fertility-tracking mobile application, and with permission from players for trainers to view their data, players are receiving training tailored to their cycles. Because of the association between anterior cruciate ligament (ACL) injuries and soft tissue injuries with hormonal fluctuations, trainers hope that they can better train their athletes in order to protect players’ health and optimize their performance. Considering tens of thousands of female high school athletes suffer from ACL injuries every year in the United States alone, it would seem that we’re just at the surface of understanding the range of health benefits women can gain from understanding more about their cycle health.

Dr. Hill doesn’t mention fertility awareness in This Is Your Brain on Birth Control, but perhaps she should have. Given the small but steady rise in women dropping the Pill and turning to fertility awareness, it seems like the next natural step for women looking to feel more themselves—and their best. 

Grace Emily Stark, assistant editor of Natural Womanhood, is a 2019 Robert Novak Journalism Fellow investigating the effects of birth control. 

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