tag:theconversation.com,2011:/id/topics/contraceptive-23073/articlescontraceptive – The Conversation2018-05-15T03:37:26Ztag:theconversation.com,2011:article/924242018-05-15T03:37:26Z2018-05-15T03:37:26ZInformed consent: women need to know about the link between the pill and depression<figure><img src="https://images.theconversation.com/files/217683/original/file-20180504-153888-i3w8ij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some women are very sensitive to small shifts in oestrogen and progesterone; others aren't.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>ON THE PILL: In this <a href="https://theconversation.com/au/topics/pill-series-52834">seven-part series</a> we explore the history, myths, side-effects and alternatives of the pill, and why it’s the most popular form of contraception in Australia.</em></p>
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<p>The introduction of the contraceptive pill in the 1960s was a major milestone for female empowerment. It allowed women to separate sex from procreation, and to increase their participation in work outside the home.</p>
<p>Now, <a href="https://www.k4health.org/sites/default/files/l13.pdf">more than 100 million women worldwide</a> use the oral contraceptive pill to prevent pregnancy or control their menstruation.</p>
<p>But the pill and other hormone contraceptives are not without side effects. We usually focus on the physical health effects of the pill, yet the <a href="https://www.ncbi.nlm.nih.gov/pubmed/15236788">most common reason</a> women stop or change the pill is mental health side effects. </p>
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Read more:
<a href="https://theconversation.com/chemical-messengers-how-hormones-affect-our-mood-42422">Chemical messengers: how hormones affect our mood</a>
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<p>Depression is one of the most prevalent and debilitating mental disorders in Australia, and <a href="https://www.researchgate.net/publication/50866070_McLean_CP_Asnaani_A_Litz_BT_Hofmann_SG_Gender_differences_in_anxiety_disorders_prevalence_course_of_illness_comorbidity_and_burden_of_illness_J_Psychiatr_Res_45_1027-1035">affects twice as many women</a> as men. It is estimated that one in four women will experience depression in her lifetime. </p>
<p><a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/2f762f95845417aeca25706c00834efa/e50a5b60e048fc07ca2570ec001909fb!OpenDocument">One in four Australian women</a> between the ages of 18 and 49 use the pill, at any one time. But few are aware of the link between the pill and depression.</p>
<h2>Types of contraceptive pill</h2>
<p>There are many oral contraceptives available in Australia, with different types and doses of the hormones oestrogen and progesterone. </p>
<p>The most commonly prescribed is a combination pill, which contains an oestrogen to prevent ovulation, and a progesterone to reduce the chance of a fertilised egg implanting into the wall of the uterus. </p>
<p>Most combined oral contraceptives have a similar dose and type of oestrogen, but the progesterone types and doses vary widely. </p>
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<img alt="" src="https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Different types of contraceptive pills contain varying doses of oestrogen and progesterone.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>There are also several <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1728-4465.2005.00038.x">progesterone-only contraceptives</a> that do not contain oestrogen. These are known as the “mini-pill”, or injected contraceptive (“depot provera”), or the skin implanted “straw” (Implanon or Norplant).</p>
<h2>Hormones and mental health</h2>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/25222701">recent review</a> has shown that sex hormones have significant impact on brain areas related to emotional and cognitive functioning. Progesterones <a href="https://www.ncbi.nlm.nih.gov/pubmed/2725334">have been shown to induce depression</a>, particularly in <a href="https://www.ncbi.nlm.nih.gov/pubmed/1846872">vulnerable women</a>. </p>
<p>Synthetic progesterone (more than natural progesterone) has <a href="https://www.ncbi.nlm.nih.gov/pubmed/9044441">significant effects</a> on the brain chemicals serotonin and monoamine oxidase, resulting in depression, irritability and anxiety.</p>
<p>There is a great deal of variation in the effects of hormone shifts on mood and behaviour. Some women are very sensitive to small shifts in oestrogen and progesterone; others aren’t.</p>
<h2>What does the research say?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/17688380">Our research</a> has involved measuring the clinical impact of various types of oral contraceptive pill on mood and anxiety. Overall, <a href="https://www.ncbi.nlm.nih.gov/pubmed/24856205">we found</a> woman taking the oral contraceptive pill were more likely to be depressed than non-pill users. </p>
<p>Women taking the pills with low amounts of oestrogen had more depression than those taking higher oestrogen dose pills. </p>
<p>Certain types of progesterone were more “depressive” than other progesterones, but the progesterone-only contraceptives were the most depressive of all the contraceptives.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/biology-is-partly-to-blame-for-high-rates-of-mental-illness-in-women-the-rest-is-social-75700">Biology is partly to blame for high rates of mental illness in women – the rest is social</a>
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<p>A <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796">2016 Danish study</a> of more than one million women supports our clinical findings. The researchers found that, compared to non-users, women aged 15-34 who took the combined oral contraceptive pill were 1.23 times more likely to be diagnosed with depression and prescribed antidepressant medication.</p>
<p>Adolescents aged 15-19 who used combined oral contraceptives had an even higher rate of depression than older women. They were 1.8 times more likely to be diagnosed with depression than the non-pill using peers, and this increased to 2.2 times among adolescents using progesterone-only contraceptives. </p>
<p>The study concluded that depression is a significant potential side effect of hormonal contraceptive use, especially in adolescents.</p>
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<img alt="" src="https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Adolescents taking the pill appear to be at higher risk of depression than women in older age groups.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<h2>It’s not all bad news</h2>
<p>Emerging research <a href="https://www.ncbi.nlm.nih.gov/pubmed/24856205">by our group</a> and others suggests the combined contraceptive pill may improve “verbal memory” or memory for words and language. This is thought to be driven by oestrogen, which has been shown to positively influence memory-related brain regions. </p>
<p>Research also suggests that pills containing progesterones that are structurally more like testosterone improve visual-spatial skills (traditionally, a male-dominant skill) and pill types containing other progesterones may worsen visual-spatial skills.</p>
<h2>Finding the right contraception</h2>
<p>There are many types of hormone contraceptives and their use needs to be tailored carefully for the individual, especially among adolescents. Women and their doctors need to be aware that hormone contraceptives can contribute to mental health problems, and women should return to their GP if they experience mental health side effects. </p>
<p>The development of new hormone contraceptives that don’t impact adversely on brain chemistry is well overdue. Women must have the right to control their fertility without compromising their enjoyment of life.</p>
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Read more:
<a href="https://theconversation.com/chemical-messengers-how-hormones-change-through-menopause-56921">Chemical messengers: how hormones change through menopause</a>
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<img src="https://counter.theconversation.com/content/92424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayashri Kulkarni conducts many clinical trials and has received funding from the National Health and Medical Research Council of Australia, is on the Swisse Scientific Advisory Board, has received research grants from pharmaceutical companies – Jansen Cilag and Servier. The work presented in this article on the contraceptive pill was not funded by any external funding agencies and is completely independent research. No makers of any contraceptive pill or device has been involved in any way with this research.
</span></em></p><p class="fine-print"><em><span>Caroline Gurvich has received funding from the National Health and Medical Research Council of Australia. </span></em></p>We usually focus on the physical health effects of the pill, yet the most common reason women stop or change the pill is mental health side effects.Jayashri Kulkarni, Professor of Psychiatry, Monash UniversityCaroline Gurvich, Senior Research Fellow and Clinical Neuropsychologist, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/879402018-05-13T20:31:52Z2018-05-13T20:31:52ZNo, women don’t need to ‘take a break’ from the pill every couple of years<figure><img src="https://images.theconversation.com/files/216084/original/file-20180424-94115-scxxxt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pill is the most popular form of contraception for women under 30.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/klOo6lqKWjs">Tyler Nix</a></span></figcaption></figure><p><em>ON THE PILL: In this <a href="https://theconversation.com/au/topics/pill-series-52834">seven-part series</a> we explore the history, myths, side-effects and alternatives of the pill, and why it’s the most popular form of contraception in Australia.</em></p>
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<p>More than half of 18- to 19-year-old women in a <a href="http://www.sciencedirect.com/science/article/pii/S1049386714000097">recent survey</a> agreed that “women should ‘take a break’ from oral contraceptive pills every couple of years”. </p>
<p>You may be surprised to know there is no biological evidence for “giving your body a break” and, in fact, it could do your health more harm than good.</p>
<h2>Suitability</h2>
<p>There are many different <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">types</a> of contraceptive pills, most commonly containing both oestrogen and progestogen (called combined oral contraceptive pills). </p>
<p>Doctors use detailed <a href="https://www.clinicalguidelines.gov.au/portal/2101/contraception-australian-clinical-practice-handbook-third-edition">medical eligibility criteria</a> to assess whether a method of contraception is suitable for you on the basis of your medical history. The pill is not suitable for some people. Others may start taking it but find that it doesn’t suit them.</p>
<p>But for many women the pill provides a convenient, easily accessible method of contraception. In fact, it’s the most <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">popular</a> form of contraception for women under the age of 30.</p>
<h2>Hormone build-up?</h2>
<p>Studies in the <a href="https://academic.oup.com/humrep/article/28/6/1620/605060">United States</a>
and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26359250">Australia</a> have found that many women worry about overdosing or having a build-up of hormones in their body if they use hormonal contraception. These types of misconceptions about the way the pill works fuel the erroneous idea that it’s good to take a break from the pill. </p>
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Read more:
<a href="https://theconversation.com/mondays-medical-myth-the-pill-increases-your-risk-of-cancer-6931">Monday’s medical myth: the pill increases your risk of cancer</a>
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<p>For some people, the pill can be associated with unpleasant <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">side effects</a> such as breast tenderness, bloating, headaches and nausea. </p>
<p>But rather than being an effect of the hormones themselves, these unpleasant side effects are most commonly associated with the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26390802">hormone-free interval</a> which allows a “withdrawal” bleed to occur, mimicking a natural menstrual cycle. </p>
<p>These <a href="http://srh.bmj.com/content/39/4/237.full">side effects may be lessened</a> by new pills or pill regimes with reduced or no hormone-free intervals (and therefore fewer or no withdrawal bleeds).</p>
<p>Once a doctor prescribes the pill for you, it’s generally recommended that you keep taking it for <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/">at least three months</a> to allow any unpleasant side effects to resolve themselves. </p>
<p>Whether or not a particular pill is problematic for a woman does not change with the duration of use. In fact, any initial side effects you had on starting will be experienced again after a break. For these reasons, it’s best to find a pill that suits you and stick with it. </p>
<p>Of course, as you age your contraceptive needs will change, so it’s important to review your contraception periodically. <a href="https://www.ncbi.nlm.nih.gov/pubmed/19913147">Research</a> shows that Australian women reduce their reliance on the oral contraceptive pill over time as they try to conceive, have children, complete their families, and move towards menopause.</p>
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<img alt="" src="https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=333&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=333&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=333&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=418&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=418&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=418&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">There are many different types of oral contraceptive pill.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1061861099?src=-2eq5oPR8qcUqC3vlg4oAg-3-12&size=medium_jpg">Shutterstock</a></span>
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<h2>Serious health risks?</h2>
<p>Like all medicines, there is a small risk of serious health effects associated with the pill. The risk of serious adverse side effects is <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">highest</a> in the first few months of starting the pill, or when restarting after a break. So it may be more risky to start and stop the pill than it is to use the pill over many years.</p>
<p>Despite the very low risk of health complications associated with the pill, people’s fears are exacerbated by “<a href="https://theconversation.com/dont-panic-about-the-pill-its-safer-than-driving-to-work-42325">pill scares</a>” – misrepresented studies reported in the media – which are usually not based on an accurate understanding of the risks.</p>
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Read more:
<a href="https://theconversation.com/dont-panic-about-the-pill-its-safer-than-driving-to-work-42325">Don't panic about the pill – it's safer than driving to work</a>
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<p>One of the most serious adverse health effects associated with the pill is <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">thrombotic complications</a> such as stroke, myocardial infarction, and venous thromboembolism (VTE) – in other words, blood clots in the brain, heart, legs, arms and groin. This is why the pill may not be suitable for older women, particularly those who smoke. </p>
<p>However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29462093">the pill is suitable</a> for women in mid-life who aren’t at increased risk of heart disease.</p>
<p>Although potentially very serious, the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26390802">absolute risk</a> of blood clots is <a href="https://www.ncbi.nlm.nih.gov/pubmed/27051991">very low</a>. This risk is marginally higher than for women not taking the pill, but is lower than the risk associated with pregnancy, delivery and the postpartum period.</p>
<p>Some people may be concerned about the risk of cancer associated with long-term use of the pill. There is a slightly increased risk of <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61684-5/fulltext">cervical cancer</a> but a reduced risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/26390802">ovarian and endometrial cancer</a>. The findings about the risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/8899264">breast cancer</a> are not conclusive.</p>
<p>It’s also important to note there are a number of <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">non-contraceptive benefits</a> of the pill, including better cycle control; improved premenstrual symptoms, acne, pain, heavy menstrual bleeding and iron-deficiency anaemia; and a reduction in ovarian cysts, benign breast disease and possibly pelvic inflammatory disease. </p>
<p>These non-contraceptive side effects often form the basis for <a href="https://www.ncbi.nlm.nih.gov/pubmed/2681143">women’s choice</a> of contraception. </p>
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<img alt="" src="https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=579&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=579&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=579&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The pill can help reduce period pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1069512443?src=mwuaZZwEP1ydKP3OQTE2OQ-1-8&size=medium_jpg">Rawpixel.com/Shutterstock</a></span>
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<h2>Fertility</h2>
<p>One of the concerns women have about long-term pill use is that they will find it difficult to conceive. <a href="https://www.ncbi.nlm.nih.gov/pubmed/20818837">Research across a number of countries</a> shows women want their fertility to return quickly after they stop using the pill. </p>
<p>Many factors influence the time it takes for a woman to conceive so it’s difficult to determine the role of the oral contraceptive pill. Some <a href="https://www.ncbi.nlm.nih.gov/pubmed/19268187">research</a> documents a temporary delay in conceiving, usually only lasting a few months. </p>
<p>However, a <a href="https://www.ncbi.nlm.nih.gov/pubmed/22018120">review</a> of 17 studies found typical one-year pregnancy rates following discontinuation of the pill ranged between 79% and 96%, which is similar to women who stopped using condoms or weren’t using another form of contraception.</p>
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Read more:
<a href="https://theconversation.com/mondays-medical-myth-the-pill-affects-long-term-fertility-8150">Monday's medical myth: the pill affects long-term fertility</a>
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<h2>What should you do?</h2>
<p>If the pill suits you, <a href="https://www.mayoclinic.org/healthy-lifestyle/birth-control/expert-answers/birth-control-pills/faq-20058110">there’s no need</a> to “give your body a break”. </p>
<p>But it’s important to have regular health checks and also <a href="https://www.ncbi.nlm.nih.gov/pubmed/23210098">review your contraceptive needs</a> periodically. This is particularly relevant at significant times in your reproductive life – on becoming sexually active, being with a new partner, if you’re thinking of having a baby, after having a baby, and when you’ve decided not to have any more children.</p>
<p>It’s always worth finding out about the <a href="https://theconversation.com/explainer-what-are-the-options-for-birth-control-18613">latest contraceptive options</a> so you can be sure you’re using contraception that’s right for you.</p><img src="https://counter.theconversation.com/content/87940/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayne Lucke is the Director of the Australian Research Centre in Sex, Health and Society at La Trobe University. She receives funding from the Australian Research Council and the National Health and Medical Research Council. She has served as a Director of Family Planning Queensland and been Chief Investigator on an ARC Linkage Grant that involves cash and in-kind support from Family Planning New South Wales and Bayer Australia. The Australian Research Centre in Sex, Health and Society receives funding from diverse sources listed in the annual report available from the website: <a href="http://www.latrobe.edu.au/arcshs">http://www.latrobe.edu.au/arcshs</a>.</span></em></p>There is no biological evidence for “giving your body a break” and in fact, it could do your health more harm than good.Jayne Lucke, Professor & Director of the Australian Research Centre in Sex, Health & Society, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/904102018-01-30T11:32:08Z2018-01-30T11:32:08ZPromising male birth control pill has its origin in an arrow poison<figure><img src="https://images.theconversation.com/files/203914/original/file-20180130-89590-1n68uqn.jpg?ixlib=rb-1.1.0&rect=351%2C0%2C2144%2C1470&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Will blue packets replace pink ones soon?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-contraceptive-pill-746870245">Aleksandra Berzhets/Shutterstock.com</a></span></figcaption></figure><p>After decades of research, development of a male birth control may now be one step closer. My colleagues and I are working on a promising lead for a <a href="https://doi.org/10.1021/acs.jmedchem.7b00925">male birth control pill based on ouabain</a> – a plant extract that African warriors and hunters traditionally used as a heart-stopping poison on their arrows.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Hunters want ouabain to be deadly when used on an arrow, but no one wants a fatal contraceptive.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/poison-on-arrow-784275280">PLANET EARTH/Shutterstock.com</a></span>
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</figure>
<h2>State of the search</h2>
<p>While the birth control pill has been available to women in the United States for nearly six decades – and FDA-approved for <a href="http://www.mum.org/enovid-e.htm">contraceptive use since 1960</a> – an oral contraceptive for men has not yet come to market. The pill has provided women with safe, effective and reversible options for birth control, while options for men have been stuck in a rut.</p>
<p>Today, <a href="https://doi.org/10.4103/2230-8210.102991">men have just two choices</a> when it comes to birth control: condoms or a vasectomy. Together, these two methods account for just <a href="https://www.malecontraceptive.org/why-male-contraception-dr-john-amory/">30 percent of contraception used</a>, leaving the remaining 70 percent of contraceptive methods to women. An estimated <a href="https://doi.org/10.21037/tau.2017.07.22">500,000 American men opt for a vasectomy each year</a> – a small number given the need for contraception. Vasectomy is an invasive procedure to do that’s also difficult and invasive to reverse.</p>
<p>When it comes to birth control options for men, the need is clear. <a href="https://www.ncbi.nlm.nih.gov/pubmed/23689167">Unplanned pregnancy rates</a> remain high across the globe. It’s time for more options.</p>
<h2>Hormonal versus nonhormonal</h2>
<p>Researchers are exploring both hormonal and nonhormonal options for male birth control pills. Current <a href="https://doi.org/10.1002/14651858.CD004316.pub2">hormonal agents under study</a> involve the sex steroids progestins and testosterone.</p>
<p>While the male hormonal birth control pill option <a href="https://doi.org/10.1210/jc.2016-2141">is in clinical human trials</a> and likely closer to market, it has <a href="https://doi.org/10.1097/MED.0b013e3282fcc30d">several potential side effects</a>: In addition to potentially causing weight gain and changes in libido, it has the ability to lower the levels of good cholesterol (HDL-C) in men, which could negatively affect the heart health of users. The long-term effects of using hormones for male oral contraception are unknown, and it will likely be decades before this information is available.</p>
<p>Here at the University of Minnesota, my colleagues and I have focused on <a href="https://doi.org/10.1016/j.pep.2016.01.009">nonhormonal contraception methods</a> that <a href="https://doi.org/10.1002/cmdc.201700503">work by targeting</a> <a href="https://doi.org/10.1038/35098027">sperm motility</a> – biology-speak for the sperms’ ability to move or swim effectively. <a href="https://en.wikipedia.org/wiki/Sperm_motility">Good motility</a> is a necessary condition for fertilizing a female egg.</p>
<p>In collaboration with <a href="http://www.kumc.edu/school-of-medicine/molecular-and-integrative-physiology/faculty/faculty/v-gustavo-blanco-md-phd.html">Gustavo Blanco</a> at the University of Kansas, we’ve homed in on ouabain: a toxic substance produced by two types of African plants. Mammals also produce ouabain in their bodies, though at lower nonlethal levels that scientists think can help control blood pressure. In fact, physicians have used ouabain in very small doses to treat patients with heart arrhythmias or suffering from heart attacks.</p>
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<a href="https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=285&fit=crop&dpr=1 600w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=285&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=285&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=358&fit=crop&dpr=1 754w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=358&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=358&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A cross-section of a cell membrane shows how pumps made of protein subunits move sodium and potassium ions in and out of the cell.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:0308_Sodium_Potassium_Pump.jpg">OpenStax</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>From toxin to contraceptive</h2>
<p>Researchers know that ouabain disrupts the passage of sodium and potassium ions through cell membranes; it interferes with the proper function of proteins that transport the ions in and out of cells. Some of the ion-transporting protein subunits targeted by ouabain are found in cardiac tissue – its ability to disrupt proper heart function is what makes ouabain a deadly poison. But ouabain also affects another type of transporter subunit called α4, which is found only in sperm cells. This protein is known to be <a href="https://doi.org/10.1073/pnas.1016902108">critical in fertility</a> — at least in male mice.</p>
<p>For 10 years, my colleagues and I have been studying ouabain as a potential breakthrough in our quest for a male birth control pill. However, ouabain by itself isn’t an option as a contraceptive because of the risk of heart damage. So we set out to design ouabain analogs – versions of the molecule that are more likely to bind to the α4 protein in sperm than other subunits in heart tissue.</p>
<p>In the lab, we used the techniques of <a href="https://www.acs.org/content/acs/en/careers/college-to-career/chemistry-careers/medicinal-chemistry.html">medicinal chemistry</a> to create a derivative of ouabain that is good at zeroing in on the α4 transporter in sperm cells in rats. Once bound to those cells, it interferes with the sperms’ ability to swim – essential to its role in fertilizing an egg. Our new compound showed no toxicity in rats.</p>
<p>Because the α4 transporter is found only on mature sperm cells, the contraceptive effect should be reversible – sperm cells produced after stopping the treatment presumably won’t be affected. Ouabain may also offer men a birth control pill option with fewer systemic side effects than hormonal options.</p>
<h2>Next steps on the road to drug discovery</h2>
<p>Our results are promising because our candidate molecule, unlike ouabain, is nontoxic in rats. Our modification is a big step forward in the process of developing a nonhormonal male birth control pill. But there’s a lot left to do before men can buy this contraceptive at the pharmacy.</p>
<p>After our ouabain analog showed <a href="https://doi.org/10.1530/REP-09-0495">promise in rat studies</a> at reducing sperm motility, future studies will focus on the effectiveness of our lead compound as an actual contraceptive in animals. We need to prove that a reduction in sperm movement translates into a drop in egg fertilization.</p>
<p>Then, we’ll begin the standard steps in drug discovery such as toxicology and safety pharmacology studies as we advance toward planning and conducting clinical trials. Our team is already taking the next step to <a href="https://doi.org/10.1095/biolreprod.106.057810">test our compound in animal mating trials</a>. If things continue as planned, we hope to get to human clinical trials within five years.</p>
<p>Reversible, effective male birth control is within sight. World Health Organization numbers suggest that <a href="https://doi.org/10.1093/humupd/dmp048">reducing sperm motility by 50 percent or less</a> is sufficient to temporarily make a man infertile. Our ongoing research brings us one step closer to expanding the options for male birth control, providing the world’s 7.6 billion people with a much-needed option for safe and reversible contraception.</p><img src="https://counter.theconversation.com/content/90410/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This research was funded by the National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development.</span></em></p>Medicinal chemists are tweaking a natural molecule that can be a deadly poison – a modified version might work as a nonhormonal male contraceptive.Gunda Georg, Professor of Medicinal Chemistry and Director of the Institute for Therapeutics Discovery and Development, University of MinnesotaJon Hawkinson, Research Professor of Medicinal Chemistry and Associate Program Director of the Institute for Therapeutics Discovery and Development, University of MinnesotaShameem Syeda, Principal Scientist at the Institute for Therapeutics Discovery and Development, University of MinnesotaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/717392017-01-30T14:01:01Z2017-01-30T14:01:01ZCould a contraceptive app be as good as the pill?<figure><img src="https://images.theconversation.com/files/154742/original/image-20170130-7659-12456ih.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There’s a company that claims its smartphone fertility-tracking app is <a href="https://www.theguardian.com/lifeandstyle/2016/nov/07/natural-cycles-fertility-app-algorithm-replace-pill-contraception">as good as the pill</a> at preventing pregnancy. Women have long monitored their menstrual cycles as a method of contraception but this has often been seen as unreliable because of the <a href="https://www.plannedparenthood.org/learn/birth-control/fertility-awareness">practical difficulties</a> of sticking to the method consistently. So could <a href="https://www.naturalcycles.com/en/">Natural Cycles</a>, or other similar apps, really offer women a reliable, hormone-free way to avoid getting pregnant?</p>
<p>The basis for Natural Cycles’ claim is a study of 4,054 women aged 18 to 45 that was published in the <a href="http://www.tandfonline.com/doi/full/10.3109/13625187.2016.1154143">European Journal of Contraception & Reproductive Health Care</a>. It indicated that using the app for contraception resulted in about seven out of every 100 women falling pregnant each year. This included pregnancies that the researchers felt were due to mistakes by the users, a so—called “typical failure” rate of the method. This is similar to the “typical” failure rate of the combined oral contraceptive pill, which is about <a href="http://patient.info/doctor/combined-oral-contraceptive-pill-first-prescription">eight or nine women a year</a> and includes women who, from time to time, forgot to take the pill.</p>
<p>Among those women who used the app perfectly, around five out of every 1,000 became pregnant. The researchers found that ten out of the 143 pregnancies reported in the study were actually due to errors in the app, which caused it to misinform couples about when they were fertile. This is known as “method failure” and means unplanned pregnancy can happen even when the contraceptive is used perfectly. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/KsQgMhvkg4E?wmode=transparent&start=9" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>But again, this figure was similar to the “perfect use” failure rate for the pill, which is around three women out of 1,000 a year. So this means, that in both typical and perfect use, the study suggests the app really can be seen as as effective as the pill in preventing pregnancy.</p>
<p>So how does it work? Almost all smartphone apps of this kind rely not just on counting the time since a woman’s last period, like traditional methods, but also on monitoring the temperature of a woman’s body. The apps use this information to predict when she has ovulated and so when she is fertile or not.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">No more pills?</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>This is possible because a woman’s temperature rises slightly (about 0.3°C) around the day of ovulation and remains slightly elevated throughout the rest of the cycle. The ovum (female egg) lives for only 24 hours or so, so a couple can have sex after this time in the woman’s menstrual cycle with <a href="http://www.webmd.com/infertility-and-reproduction/fertility-awareness#1">no risk of becoming pregnant</a>. Having sex before ovulation can lead to pregnancy because the sperm can survive in the uterus for up to six days. </p>
<p>This has been known for a long time and is the basis of fertility awareness methods of contraception, where a woman takes her temperature before getting out of bed each morning and keeps a chart to <a href="http://www.nhs.uk/Conditions/contraception-guide/Pages/natural-family-planning.aspx">determine when she is fertile</a>. But it is very hard to predict the exact day of ovulation as a woman’s cycle length can vary, especially if she is stressed. And it is difficult to accurately determine whether or not a woman’s body temperature has risen enough to reliably show she is ovulating.</p>
<p>This is where technology can help. Devices such as wristband thermometers can monitor a woman’s temperature constantly so she doesn’t need to remember to measure it each morning. And the algorithms of the smartphone app can do the work of charting and calculating <a href="https://www.naturalcycles.com/en/science">which are the fertile days</a>.</p>
<p>So why is the typical failure rate of the Natural Cycles app as high as 7%? Well another major problem with any fertility awareness method is that it means you can’t have sex for several days of the month, or you have to use other contraceptives such as condoms. The study authors found that just over half of the women who did fall pregnant recorded having unprotected sex during the fertile period. So while smartphone apps may provide encouragement, they can’t stop you from wanting to have sex altogether.</p><img src="https://counter.theconversation.com/content/71739/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has received funding from Bayer. </span></em></p>New technology claims to offer an effective alternative to hormonal contraception.Susan Walker, Senior Research Fellow/ Senior Lecturer in Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/680872016-11-08T11:17:19Z2016-11-08T11:17:19ZKeeping girls at school may reduce teenage pregnancy and STIs – but sex education doesn’t<figure><img src="https://images.theconversation.com/files/144889/original/image-20161107-4694-j1mgga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's not always that simple.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=sfhd-GWa8UKfz2I16srjrw-1-13&id=115353559&size=medium_jpg">Shutterstock</a></span></figcaption></figure><p>Worldwide, more than <a href="http://en.unesco.org/gem-report/sites/gem-report/files/girls-factsheet-en.pdf">65m adolescent girls</a> have no access to school. And it’s not just poorer countries that suffer from bad education. In the UK, one in five young people don’t complete post-16 education, making it one of the worst performing countries in <a href="https://www.oecd.org/education/school/50293148.pdf">league tables</a> measuring how well young people are educated. This affects not only life chances but also health outcomes and well-being. </p>
<p>Studies conducted as far afield as the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0297.2008.02159.x/full">US, Norway</a> and <a href="http://ije.oxfordjournals.org/content/44/3/928">rural South Africa</a>, for example, have suggested that encouraging school attendance can help young people avoid early sexual activity – and girls <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-9442.2008.00563.x/full">to avoid unplanned pregnancy</a>. But this has never been confirmed by experimental evidence – until now. </p>
<p>A comprehensive <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006417.pub3/full">Cochrane review</a> of studies from around the world combined the data from more than 55,000 young people aged on average between 14 and 16. And it has shown that providing a small payment or giving away a free school uniform can incentivise the young to stay in school for longer, especially in places where there are financial barriers to attending. </p>
<p>Most significantly, it also reveals that the approach could prevent three in every ten pregnancies among that age group globally, and may also delay sexual activity and reduce sexually transmitted infections (STIs) in both girls and boys – although further high quality studies are needed to confirm this. Additionally, it suggests that the mainstay of the current approach – “sex education” – isn’t working to achieve these ends. </p>
<h2>Sex education is failing</h2>
<p>The studies in the Cochrane review were all randomised controlled trials from Europe, Latin America and sub-Saharan Africa. Most were of high quality and had follow-ups at between 18 months and seven years. </p>
<p>The sex education programmes they investigated included peer and teacher-led education and the innovative uses of drama and group work. But most of the programmes did not provide access to the necessary health services, such as condoms or other contraception, especially for the youngest age groups. </p>
<p>What is clear is that we really don’t know what works and for whom when it comes to curriculum-based sex education in schools. We are often told that <a href="http://www.sexeducationforum.org.uk/media/28306/SRE-the-evidence-March-2015.pdf">we do know</a>, but the studies quoted previously have been based on self-reported behaviours of young people which are prone to bias. </p>
<p>Sex and sexuality are sensitive topics, especially when there are legal or moral ramifications for someone admitting to having sex. This new review, by contrast, has for the first time only included studies featuring measurable biological outcomes from records or tests of pregnancy and STIs. The fact that it points to sex education not working to reduce pregnancy and STIs among the young, therefore, is all the more significant. It seems we need a radical rethink.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/144912/original/image-20161107-4676-1sxx34a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/144912/original/image-20161107-4676-1sxx34a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=369&fit=crop&dpr=1 600w, https://images.theconversation.com/files/144912/original/image-20161107-4676-1sxx34a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=369&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/144912/original/image-20161107-4676-1sxx34a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=369&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/144912/original/image-20161107-4676-1sxx34a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=464&fit=crop&dpr=1 754w, https://images.theconversation.com/files/144912/original/image-20161107-4676-1sxx34a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=464&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/144912/original/image-20161107-4676-1sxx34a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=464&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Staying at school: a healthy contraceptive?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-312295037/stock-photo-teenagers-young-team-together-cheerful-concept.html?src=xgn7eYCtwVWMAyrwN3NKmA-1-0">Shutterstock</a></span>
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</figure>
<p>But what should be done? Most people agree that sex education should start early and focus on relationships, not just on the mechanics of sex. Most also agree that it should be inclusive and sensitive to a range of sexualities, including not assuming that all young people have started to have sex. Equally, few would disagree that we need to reform current approaches to take into account new risks from digital communications and social media, and that schools are a good place to encourage the development of healthy relationships. </p>
<p>However, MP Sarah Champion, whose <a href="http://www.dare2care.org.uk/">Dare to Care</a> national action plan calls for “compulsory resilience and relationships education” in UK schools, needs to consider this new evidence. She talks about young people needing “the tools to rebuff harmful requests and behaviour from abusers”. This focus solely on an individualised notion of resilience is flawed unless it incorporates more <a href="http://resilienceresearch.org/">ecological and culturally sensitive definitions</a>, and a clear understanding that it is not at all easy to “rebuff” violent approaches, especially in young people’s intimate relationships. </p>
<p>We need to build schools that are safe, welcoming and supportive – with adults, including parents, that are open and have the skills to talk to children about sexuality. We also need to think carefully about how the sexuality education offered by schools can effectively achieve its aims.</p>
<h2>New ways of thinking about sex</h2>
<p>Certainly, current strategies are failing. Talking about sex in schools doesn’t encourage young people to have sex, but equally – as the Cochrane review shows – it is not likely to delay them having it either, as some previous authors <a href="https://theconversation.com/good-sex-ed-doesnt-lead-to-teen-pregnancy-it-prevents-it-60036">have suggested</a>.</p>
<p>Some, for example, <a href="https://theconversation.com/compulsory-sex-education-wont-reduce-rates-of-teenage-pregnancy-33340">have claimed</a> that programmes such as TeenStar, which encourage abstinence from sexual activity, are effective. But this conclusion is based on studies that are considered to have serious flaws. </p>
<p>The <a href="http://www.jahonline.org/article/S1054-139X%2804%2900163-6/abstract">Cabezon study</a>, for example, examined pregnancy outcomes from a programme in Chile that promoted abstinence from sexual activity. They suggested that the programme was successful by comparing the number of girls who were pregnant at the end of the study (19), with the number of pregnancies from a group who didn’t receive the programme (52). This made the programme look amazingly successful, but it excluded miscarriages and also illegal abortions that go unrecorded in Chile, so they were unlikely to have included all unwanted pregnancies that had occurred. The study also suffered from a number of biases including during randomisation and recruitment to the study, and selective reporting of the results. </p>
<p>In future, we need to rely on good quality evidence when developing public health policy. If sex education were to become compulsory, for example, it would be sensible to track its effectiveness <a href="http://www.bmj.com/content/350/bmj.h391">experimentally</a> to ensure that policies are working as expected. </p>
<p>While this study may highlight the failings of sex education at the moment, it also points to the effectiveness of school in general in the prevention of STIs and unwanted pregnancies. That, at least, is a good start.</p><img src="https://counter.theconversation.com/content/68087/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanda Mason-Jones does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A detailed new review should encourage us to ask some awkward questions.Amanda Mason-Jones, Senior Lecturer in Global Public Health, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/681332016-11-05T12:31:22Z2016-11-05T12:31:22ZWhy the male ‘pill’ is still so hard to swallow<figure><img src="https://images.theconversation.com/files/144437/original/image-20161103-25329-1g8fa8t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Okay for women, but what about men?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=HdRlUOkWprnSWU_oY-gDMA-1-6&id=160288271&size=medium_jpg">Shutterstock</a></span></figcaption></figure><p>A recent study looking at the effectiveness of a male contraceptive injection was abandoned after the men taking part reported <a href="http://press.endocrine.org/doi/10.1210/jc.2016-2141?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed">increased incidences</a> of acne (nearly half), mood disorders (over a fifth) and raised libido (over a third). In fact, there were 320 men in the study – and a total of 1,491 adverse events were reported. For those overseeing the trial these side effects were viewed as being more significant than the fact that the contraceptive injection appeared to work well in reducing the production of sperm – and the evidence does appear to support their concerns?</p>
<p>Nevertheless, many women will feel these side effects seem minor when compared with those of the female contraceptive pill – and they’d have a point, too. These include <a href="http://www.nhs.uk/conditions/contraception-guide/pages/combined-contraceptive-pill.aspx#Advantages%22%22">anxiety, weight gain, nausea, headaches, reduced libido and blood clots</a>. Which raises the question: why is it so hard to make a male contraceptive? And if the plug has been pulled on this one because of side effects, would the female contraceptive pill make it to market if it were released today? </p>
<p>On the face of it, regulating fertility in men should be the more obvious choice. Sperm are produced on a constant basis and not in cycles like eggs are in women. This means that, barring any underlying health problems, men are always fertile. In addition, as the biology of sperm production is <a href="http://www.open.edu/openlearn/body-mind/health/health-sciences/the-science-sperm">well-known</a>, the mechanisms of how to block it are also well-known. </p>
<p>Indeed, the current study was exploiting the well-established relationship between testosterone – the hormone that gives men their male characteristics – and sperm production. By giving men synthetic testosterone in combination with a hormone called progestogen – similar to the hormones usually found in the pill – sperm production in the testes is reduced dramatically. </p>
<p>Before the study was halted, the researchers from Martin Luther University, Germany, observed that pregnancy rates for the men on their trial fell to an equivalent of just <a href="http://press.endocrine.org/doi/10.1210/jc.2016-2141?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed">1.5 babies conceived per 100 couples</a>. Compare this with the pregnancy rate of nine babies per 100 couples for <a href="http://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/failure-rates-table">women using the combined pill</a>, and the development of such a male contraceptive seems like a no-brainer.</p>
<h2>So what’s going on?</h2>
<p>Yet, here we are at the end of another study – without being any closer to the development of a viable male contraceptive. As such, women are left once again placed solely in charge of their fertility as well as bearing the brunt of the side effects. Many women may view the side effects as the lesser evil when compared with an unplanned pregnancy, and many <a href="https://www.theguardian.com/commentisfree/2016/oct/30/will-we-believe-a-man-who-says-he-is-on-the-pill">may also question</a> whether leaving the responsibility of contraception in the hands of men will work. </p>
<p>But the side effects of the male pill could actually have been an unlikely beneficial factor. With both partners actively taking contraceptives – and sharing an understanding of the side effects – a joint sense of responsibility for the couple’s fertility would be established. Also, if one partner needed to take a break from their contraceptive, the other could start taking theirs, sharing the impact of those side effects.</p>
<p>So why has it been so difficult to develop an effective male contraceptive when women have been taking the pill, and enduring the side effects, since the early 1960s? In fact, looking at the original trial results from 1956, it’s hard to see how the contraceptive pill ever actually made it to market.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/144439/original/image-20161103-25322-71orgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/144439/original/image-20161103-25322-71orgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/144439/original/image-20161103-25322-71orgf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/144439/original/image-20161103-25322-71orgf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/144439/original/image-20161103-25322-71orgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/144439/original/image-20161103-25322-71orgf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/144439/original/image-20161103-25322-71orgf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Well, there’s always these.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-282513755/stock-photo-colorful-condom.html?src=jcARgUppDpmVvubnSo4Lkg-1-4">Shutterstock</a></span>
</figcaption>
</figure>
<p>The <a href="http://pdf.usaid.gov/pdf_docs/PNAAV359.pdf">first large-scale human trial</a> was conducted in Rio Piédras, a Puerto Rican housing project. The women taking part received little information about the product they were receiving, partly because there was little to give and partly, perhaps, because none of the people running the trial felt it necessary. Such were clinical trials in the 1950s. </p>
<p>While women even then reported side effects including headaches, dizziness, nausea and blood clots, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520685/pdf/058e757.pdf">these were largely dismissed</a>. Thankfully, since then, the pill has undergone constant refinement and modification, becoming a form of contraception now taken by an estimated <a href="http://www.un.org/en/development/desa/population/publications/pdf/family/trendsContraceptiveUse2015Report.pdf">225m women world-wide</a>. </p>
<p>The pill has unquestionably <a href="http://www.albertmohler.com/2010/04/26/the-pill-turns-50-time-considers-the-contraceptive-revolution/">changed female sexual freedom</a>, allowing women <a href="http://www.bbc.co.uk/news/uk-15984258">greater control over when to have children</a>. Indeed, in 2012, UK women voted the pill their favourite invention of the last century – ahead of leisure devices such as the <a href="http://www.thescottishsun.co.uk/scotsol/homepage/news/4239571/Women-say-the-Pill-is-their-favourite-invention.html">internet and the television</a>. </p>
<p>Consequently, it is strange that more resources haven’t been ploughed by big pharmaceutical into a male pill. Part of the problem appears to be the very success of female contraceptives. As many pharmaceutical companies make <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464843/pdf/AJPH.2012.300706.pdf">big profits from female contraceptives</a>, there is little desire to take focus away from them. </p>
<p>It also appears that there isn’t a universal desire by men for such a form of contraception. Indeed, a <a href="http://humrep.oxfordjournals.org/content/20/2/549.full.pdf+html">2005 study</a> surveyed more than 9,000 men across nine countries about their willingness to take a male pill. While approximately 70% of men in Spain and Germany stated they would be happy to take it, less than 30% of men in Indonesia displayed a positive attitude towards it.</p>
<h2>Shared responsibility?</h2>
<p>In the meantime, it seems that until there’s more demand from men for a “pill” of their own, the responsibility will be left to women. This means that the need for such a powerful regulator of fertility as the female contraceptive pill is still needed today as much as ever. </p>
<p>It should be remembered that many women take the pill for its additional benefits such a relieving heavy menstrual bleeding and pain, reducing acne and helping with <a href="http://www.nhs.uk/Conditions/Premenstrual-syndrome/Pages/Symptoms.aspx">premenstrual dysphoric disorder</a>. With the development of new and improved contraceptive pills that contain lower hormone doses, the negative side effects of the pill also appear to be reducing.</p>
<p>Indeed, in light of the enormous benefits that the contraceptive pill has brought to women and their sexual health, it would be hard to imagine a world without it. But perhaps we should also be asking why, even in the 21st century, the idea of a man taking a contraceptive “pill” remains such a big deal.</p><img src="https://counter.theconversation.com/content/68133/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Watkins does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Side effects have led to the plug being pulled on the male contraceptive injection. But what about those experienced by women on the pill?Adam Watkins, Research fellow, Cell & Tissue Biomedicine, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/572612016-07-21T17:38:59Z2016-07-21T17:38:59ZThe search for answers to hormonal contraception’s role in HIV infection<figure><img src="https://images.theconversation.com/files/131412/original/image-20160721-32610-ftsewe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Injectable progestin contraceptives are particularly popular in sub-Saharan Africa.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>About 75% of HIV-infected people in sub-Saharan African between the ages of 15 and 24 <a href="http://science.sciencemag.org/content/sci/308/5728/1582.full.pdf">are women</a>. Many factors play a role in this gender imbalance. These include gender-based social disparity and a high prevalence of intergenerational sexual partnerships. </p>
<p>But research suggests certain types of hormonal contraceptives commonly used in this region could also play a role.</p>
<p>Injectable progestin contraceptives, like Depo-Provera, are particularly popular in <a href="http://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(14)71052-7.pdf">sub-Saharan Africa</a>. They are effective and convenient. Instead of taking a daily pill, women can receive Depo-Provera injections every three months. </p>
<p>But studies suggest that women using this specific type of contraceptive are more susceptible to HIV. Most recently <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70247-X/abstract">a large-scale study</a> conducted in Africa found women using injectable progestins were twice as likely to acquire HIV than women using no hormonal contraceptive. </p>
<p>This type of study cannot <em>prove</em> a particular type of contraceptive actually makes women more susceptible to infection, as it is just looking for an association between the two.</p>
<p>To really find out if contraceptives make women more susceptible to infection, you need to see how these drugs actually affect the systems that protect the body from infection. Such studies are more difficult to do in humans, so my colleagues and I decided to explore mouse models.</p>
<h2>What we learnt from mice</h2>
<p>We used mice to learn if Depo-Provera or levonorgestrel (LNG), a progestin used in hormonal intrauterine devices, affect the genital mucosal barrier. This barrier serves as a blockade to prevents virus and bacteria from infecting body tissues. In other words, it is a first line of defense against infection.</p>
<p>Epithelial cells on the surface of genital tract tissues are a vital part of this barrier. They are held tightly together by adhesion molecules that make it difficult for pathogens to penetrate tissue and establish infection. </p>
<p>But <a href="http://www.ncbi.nlm.nih.gov/pubmed/27007679">we found</a> that mice treated with Depo-Provera or LNG have lower levels of several of these adhesion molecules. This means that genital epithelial cells aren’t held together as tightly, tissue becomes more permeable and virus more easily invades. </p>
<p>Our research shows these contraceptives increase mouse susceptibility to infection. But do similar changes in permeability also occur in women? </p>
<p>To find this out, we obtained cervical tissue from US women before and after they started using Depo-Provera. This showed Depo-Provera causes changes to adhesion molecules and tissue permeability <a href="http://www.ncbi.nlm.nih.gov/pubmed/27007679">similar to those seen in mice</a>. </p>
<h2>Where do we go from here?</h2>
<p>Sexually transmitted infection and unplanned pregnancy are interconnected public health problems. Countries with a larger burden of infection typically also have higher infant and maternal mortality rates and a great need for <a href="http://www.ncbi.nlm.nih.gov/pubmed/23871397">effective contraception</a>. </p>
<p>Since Depo-Provera and LNG provide women with effective contraception, we wanted to learn if there are ways to counteract their ability to weaken the mucosal barrier. With this in mind, we also performed studies in which mice were treated with both Depo-Provera and oestrogen.</p>
<p>This combination strengthened the genital mucosal barrier and made mice <a href="http://www.ncbi.nlm.nih.gov/pubmed/27007679">less susceptible to virus infection</a>. It also suggests a scenario in which women would receive Depo-Provera and a vaginal ring that releases oestrogen and an antiviral microbicide. </p>
<p>Before this can happen, research is needed to determine if Depo-Provera and an oestrogen-releasing vaginal ring protect non-human primates from viral infection. If positive results are seen, the next logical step would be clinical trials that explore if similar approaches also reduce a woman’s risk of acquiring HIV.</p><img src="https://counter.theconversation.com/content/57261/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas L. Cherpes receives funding from the NICHD. </span></em></p>Studies have suggested that women using a particular kind of injectable contraceptive are more susceptible to HIV infection. Research in mice offers new insights.Thomas L. Cherpes, Associate Professor in the College of Medicine, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/575462016-04-27T10:07:15Z2016-04-27T10:07:15ZHow limiting women’s access to birth control and abortions hurts the economy<p>Reproductive health isn’t <a href="https://www.guttmacher.org/united-states/abortion/demographics">just about abortions</a>, despite all the attention they get. It’s also about access to family planning services, contraception, sex education and much else.</p>
<p>Such access lets women control the timing and size of their families so they have children when they are financially secure and emotionally ready and can finish their education and advance in the workplace. After all, <a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">having children is expensive</a>, costing US$9,000 to $25,000 a year. </p>
<p>And that’s why providing women with a full range of reproductive health options is good for the economy at the same time as being essential to the financial security of women and their families. Doing the opposite threatens not only the physical health of women but their economic well-being too.</p>
<p>The Supreme Court <a href="https://www.oyez.org/cases/1991/91-744">acknowledged</a> as much in 1992, stating in Planned Parenthood of Southeastern Pennsylvania v. Casey:</p>
<blockquote>
<p>The ability of women to participate equally in the economic and social life of the nation has been facilitated by their ability to control their reproductive lives.</p>
</blockquote>
<p>However, it seems that state and federal legislators, certain politicians running for president as well as some conservative Supreme Court justices have forgotten the meaning of this sweeping language.</p>
<p>As a consequence, the right to control their reproductive health has become <a href="http://thinkprogress.org/health/2013/05/08/1979831/women-struggle-afford-abortion/">increasingly illusory</a> for many women, particularly the poor.</p>
<h2>The economics of contraception</h2>
<p>With some conservative politicians dead set on limiting access to abortion, you’d assume that they would be for policies that help women avoid unintended pregnancies. But <a href="http://www.motherjones.com/politics/2012/02/republican-war-birth-control-contraception'">conservative attacks on birth control</a> are escalating, even though <a href="http://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf">99 percent of sexually active women</a> have used <a href="https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states">some form such as an intrauterine device (IUD), patch or pill</a> at least once. </p>
<p>In addition to its widely recognized health and autonomy benefits for women, contraception <a href="http://www.theatlantic.com/health/archive/2014/07/the-broader-benefits-of-contraception/373856">directly boosts the economy</a>. In fact, research shows access to the pill <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684076/">is responsible</a> for a third of women’s wage gains since the 1960s. </p>
<p>And this benefit extends to their kids. Children born to mothers with access to family planning <a href="http://www.nber.org/papers/w19493.pdf">benefit from a 20 to 30 percent increase</a> in their own incomes over their lifetimes, as well as boosting college completion rates. </p>
<p>Not surprisingly, in a survey, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23021011">77 percent of women</a> who used birth control reported that it allowed them to better care for themselves and their families, while large majorities also reported that birth control allowed them to support themselves financially (71 percent), stay in school (64 percent) and help them get and keep a job (64 percent). </p>
<p>Still, there is a class divide in contraception access, as evidenced by disparities in the 2011 rate of unintended pregnancies. While the <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1506575">overall rate</a> fell to 45 percent (from 51 percent in 2008), the figure for women living at or below the poverty line was <a href="https://www.guttmacher.org/sites/default/files/pdfs/pubs/FB-Unintended-Pregnancy-US.pdf">five times that of women</a> at the highest income level (although also decreasing).</p>
<p>One reason for this disparity is the <a href="http://www.thenation.com/article/why-does-best-birth-control-cost-entire-months-wages/">cost of birth control</a>, particularly for the most effective, long-lasting forms. For instance, it typically costs over $1,000 for an IUD and the procedure to insert it, amounting to <a href="http://www.jahonline.org/article/S1054-139X(13)00054-2/pdf">one month’s full-time pay</a> for a minimum wage worker. </p>
<p>These costs are significant, given that the <a href="https://www.guttmacher.org/sites/default/files/pdfs/pubs/fulfill.pdf">average American woman wants</a> two children and will thus need contraception for at least three decades of her life. Unfortunately, <a href="http://rooseveltinstitute.org/wp-content/uploads/2015/11/Breaking-the-Cycle-of-Poverty-Expanding-Access-to-Family-Planning.pdf">publicly funded family planning</a> meets only 54 percent of the need, and these funding streams are under constant attack by conservatives.</p>
<p>Not surprisingly, <a href="http://www.scotusblog.com/2015/12/symposium-womens-compelling-need-for-contraception-met-by-insurers-not-objecting-employers/">health insurance makes a difference</a>, and women with coverage are much more likely to use contraceptive care. The <a href="http://nwlc.org/resources/zubik-v-burwell-non-profit-objecting-employers-should-not-be-allowed-to-make-it-harder-for-women-to-access-critical-birth-control-coverage/">Affordable Care Act is responsible</a> for part of the drop in unintended pregnancies – it expanded contraception coverage to around 55 million women with private insurance coverage. </p>
<p>Yet this coverage is also at risk for millions of employees and their dependents who work for employers claiming a religious objection. In Burwell v. Hobby Lobby, the <a href="http://www.supremecourt.gov/opinions/13pdf/13-354_olp1.pdf">Supreme Court concluded</a> that a for-profit company cannot only profess religious beliefs but also impose those beliefs on their employees by denying them certain forms of contraception. The <a href="http://kff.org/womens-health-policy/issue-brief/round-2-on-the-legal-challenges-to-contraceptive-coverage-are-nonprofits-substantially-burdened-by-the-accommodation/">Obama administration has issued regulations</a> allowing religious employers to opt out of offering contraceptive coverage. Affected employees are then covered directly by their insurers.</p>
<p>This is not enough for some. In March, the Supreme Court heard oral arguments in the case of <a href="http://www.scotusblog.com/case-files/cases/zubik-v-burwell">Zubik v. Burwell</a>, in which several religious <a href="http://kff.org/womens-health-policy/issue-brief/contraceptive-coverage-at-the-supreme-court-zubik-v-burwell-does-the-law-accommodate-or-burden-nonprofits-religious-beliefs/">nonprofits assert</a> that even the act of seeking an accommodation from the law burdens their religious consciences. </p>
<p>These religious groups argue in part that women can get their birth control from other sources, such as federally funded family planning centers. Yet at the same time, <a href="http://time.com/4264955/contraceptive-coverage/">conservatives are on a mission to slash that funding</a>, particularly for Planned Parenthood, which provides sexual and reproductive health care to almost five million people a year.</p>
<p>This makes no economic sense. Publicly funded family planning programs <a href="https://www.guttmacher.org/news-release/2015/publicly-funded-family-planning-yields-numerous-positive-health-outcomes-while">help women avoid about two million unintended pregnancies</a> a year and save the government billions of dollars in health care costs. The net savings to government are $13.6 billion. For every $1 invested in these services, the government saves $7.09.</p>
<h2>Sex education and the economic ladder</h2>
<p>Another key to reproductive health – and one that isn’t discussed enough – is sexual education for teenagers. </p>
<p>For years, the public has spent over $2 billion on abstinence-only programs, which not only <a href="http://www.jahonline.org/article/S1054-139X(05)00467-2/fulltext?mobileUi=0">fail to reduce teen birth rates</a> but also reinforce gender stereotypes and are rife with misinformation. Low-income minority teens <a href="http://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=1084&context=bjalp">are particularly subject</a> to these programs.</p>
<p>Teens without knowledge about their sexual health <a href="http://www.advocatesforyouth.org/publications/publications-a-z/597-abstinence-only-until-marriage-programs-ineffective-unethical-and-poor-public-health">are more likely</a> to get pregnant and less likely to work, spiraling them to the bottom of the economic ladder. </p>
<p>President Obama’s <a href="http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&FeatureID=2438">proposed 2017 budget would eliminate federal funding</a> for abstinence-only sex education and instead fund only comprehensive sexual education, which is age-appropriate and medically accurate. However, <a href="http://www.motherjones.com/mojo/2016/02/state-of-teen-sex-america-chart-abstinence">Congress has rejected</a> the president’s prior proposed cuts and the same result is likely for 2017. </p>
<h2>Access to abortion</h2>
<p>Then there’s the issue of abortion. Let’s start with the cost.</p>
<p><a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">Half of women who obtain an abortion</a> pay more than one-third of their monthly income for the procedure.</p>
<p>Costs rise significantly the longer a woman must wait, either because state law requires it or she needs to save up the money – or both. Studies show that women <a href="http://www.nytimes.com/2013/06/16/magazine/study-women-denied-abortions.html?_r=0">who cannot access abortion</a> are <a href="http://rhtp.org/abortion/documents/TwoSidesSameCoinReport.pdf">three times more likely</a> to fall into poverty than women who obtained abortions.</p>
<p>In addition to the financial burden, <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">many states are enacting laws</a> designed to limit abortion access. These laws hit low-income women particularly hard. From 2011 to 2015, <a href="https://www.guttmacher.org/article/2016/01/2015-year-end-state-policy-roundup">31 states have enacted</a> 288 such laws, including waiting periods and mandatory counseling sessions. </p>
<p>Moreover, <a href="https://www.guttmacher.org/sites/default/files/pdfs/spibs/spib_TRAP.pdf">24 states have enacted so-called TRAP laws</a> (targeted regulation of abortion providers), which medical experts say go far beyond what is needed for patient safety and impose needless requirements on doctors and abortion facilities, <a href="http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/ACOG-and-AMA-File-Amicus-Brief">such as requiring facilities</a> to have the same hallway dimensions as a hospital. </p>
<p>In March, the Supreme Court heard arguments in a case <a href="http://www.scotusblog.com/case-files/cases/whole-womans-health-v-cole/">challenging a Texas TRAP law</a>, <a href="http://www.reproductiverights.org/case/whole-womans-health-v-hellerstedt">Whole Women’s Health v. Hellerstedt</a>. If the court upholds the law, the entire state of Texas will be left with only 10 abortion providers.</p>
<p>A <a href="http://www.scotusblog.com/wp-content/uploads/2015/09/14-50928-CV0.pdf">lower federal appeals court stated</a> in the Texas case that travel distances of more than 150 miles one way are not an “undue burden” and are thus constitutional. This, I would argue, shows a <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2446644">complete lack of understanding</a> regarding the difficulties that poverty – especially rural poverty – imposes. Traveling long distances adds additional costs to an already expensive medical procedure. </p>
<p>The court’s decision is expected in June. <a href="http://www.slate.com/articles/news_and_politics/supreme_court_dispatches/2016/03/in_oral_arguments_for_the_texas_abortion_case_the_three_female_justices.html">Observers fear</a> that the court could split 4-4, which would leave the Texas law intact. </p>
<h2>The Hyde Amendment</h2>
<p>Another way in which U.S. policy on abortions <a href="https://www.americanprogress.org/issues/women/news/2013/05/10/62875/how-the-hyde-amendment-discriminates-against-poor-women-and-women-of-color">exacerbates economic inequality, especially for women of color</a>, is through the ban on federal funding – which some aspiring politicians <a href="http://www.motherjones.com/mojo/2016/02/donald-trump-really-doesnt-understand-how-federal-funding-works-planned-parenthood-0">seem to have forgotten</a> is still in place.</p>
<p>It has been so since the <a href="http://billmoyers.com/content/five-facts-you-should-know-about-the-hyde-amendment/">1976 enactment of the Hyde Amendment</a>, which prevents federal Medicaid funds from being used for abortions except in cases of rape, incest or when the life of the mother is at risk. The Affordable Care Act does many wonderful things for women’s health, but it also <a href="http://kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-in-medicaid-marketplace-plans-and-private-plans/">extends the Hyde Amendment</a> through its expansion of Medicaid, and it allows states to ban abortion coverage in their private exchanges. </p>
<p>Denying poor women coverage under Medicaid contributes to the unintended birth rates that are <a href="https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states">seven times higher</a> for poor women than high-income women. </p>
<h2>Economic and reproductive health</h2>
<p>Politicians cannot promise to grow the economy and simultaneously limit access to abortion, birth control and sexual education. Our nation’s economic health and women’s reproductive health are linked.</p>
<p>And as Hillary Clinton <a href="http://www.politifact.com/truth-o-meter/statements/2016/apr/15/hillary-clinton/hillary-clinton-says-democratic-debate-moderators-/">correctly noted</a> recently, it’s an issue that deserves more attention in the presidential campaign – and hasn’t received enough.</p><img src="https://counter.theconversation.com/content/57546/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michele Gilman is affiliated with the ACLU of Maryland and the Women's Law Center of Maryland.</span></em></p>Providing women with a range of reproductive health options – from abortions to IUDs – is not only essential for their financial security but good for the economy as well.Michele Gilman, Venable Professor of Law, University of BaltimoreLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/513582015-12-03T04:32:06Z2015-12-03T04:32:06ZThe all-in-one solution to sexual health is on its way<figure><img src="https://images.theconversation.com/files/104145/original/image-20151202-22448-f7rnzq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women would prefer a product that addresses multiple sexual and reproductive health risks at the same time.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>The current sexual and reproductive prevention methods have significantly improved the health and well-being of women and their families. But this is not enough. Worldwide each year there are still 85 million unplanned pregnancies, 21.6 million unsafe abortions, and nearly 300 000 <a href="http://www.guttmacher.org/graphics/ContraceptionWorks(Table).png">maternal deaths</a> from complications related to pregnancy and birth.</p>
<p>HIV remains the leading cause of death of women of reproductive age worldwide. <a href="https://www.guttmacher.org/graphics/MultipurposePreventionDevelopingWorld(IG)-800.png">Sub-Saharan Africa</a> has the highest burden. While anti-retroviral drugs are effective treatments, half of the women living with HIV in resource-limited settings can’t access them. And women’s HIV prevention technologies remain limited. Their use is often outside a woman’s sphere of control.</p>
<p>Enabling women to maintain good reproductive health requires innovative and improved prevention technologies. A revolutionary class of women’s sexual and reproductive health prevention products is being developed and may prove to be the linchpin to achieve the sustainable development goals that relate to women’s health.</p>
<p>Multipurpose Prevention <a href="http://cami-health.org/mpts">Technologies</a>, more commonly known as MPTs, are a new class of product in development. They deliver varying method combinations to simultaneously prevent HIV, sexually transmitted infections and unplanned pregnancies. </p>
<p>Although these technologies are complicated to develop, they are technically feasible. Since the field was launched six years ago, it has <a href="http://www.ncbi.nlm.nih.gov/pubmed/24188708">evolved</a> from an innovative concept. Currently there are over <a href="http://mpts101.org/mpt-database">20 products</a> being developed with nearly a dozen products in clinical trials.</p>
<h2>New methods of prevention</h2>
<p>There are many forms of innovative technologies being developed. Some combine contraception with prevention from sexually transmitted infections while others provide women who want to get pregnant with protection from HIV and other Sexually Transmitted Infections (STIs). Many do so in discrete forms that do not require partner negotiation. Some are designed to be used just before or at the time of a sexual encounter while others are long-acting products. </p>
<p><a href="http://mpts101.org/mpt-database">The innovations</a> currently being developed include:</p>
<ul>
<li><p>vaginal rings that release both hormonal contraception and an HIV prevention drug; </p></li>
<li><p>vaginal films and tablets that prevent HIV and herpes (HSV); </p></li>
<li><p>rectal suppository MPTs offering HIV and STI prevention for anyone engaging in anal sex; </p></li>
<li><p>new bio materials that will feel more like skin to make better feeling condoms; and other innovative technologies.</p></li>
</ul>
<p>The goal is to create an array of broad-spectrum prevention <a href="http://healthaffairs.org/blog/2015/11/02/mpts-combine-contraception-with-hiv-and-other-sti-prevention/#one">methods</a> which a woman can choose from to best suit her circumstances. But without increased investment in the research and development of these technologies, these powerful new prevention methods may never reach women’s hands.</p>
<h2>A benefit for all</h2>
<p>The intersecting nature of sexual and reproductive health risks is especially apparent in areas of the world where women have the least access to modern contraception and face the highest HIV and STI risks. </p>
<p>In 2012, young women in sub-Saharan Africa accounted for <a href="http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12842/full">70%</a> (25 million) of the 35.3 million people estimated to be infected with HIV globally.</p>
<p>By reducing non-HIV sexually transmitted infections at the same time as HIV and unplanned pregnancy and health costs will be cut. In addition lives can be saved. If sexually transmitted infections such as herpes, chlamydia and human papillomavirus are left untreated they can result in infertility and cancers. Herpes and human papillomavirus also put women at greater risk of acquiring HIV.</p>
<p>Sub-Saharan Africa has the highest burden of <a href="http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12842/full">herpes</a> where up to 80% of sexually active women are estimated to be infected.</p>
<p>It is no secret that improving women’s ability to plan and space children improves the economic well-being of families, saves millions of <a href="https://www.guttmacher.org/pubs/gpr/18/1/gpr180101.html">lives</a> and billions of dollars. Reducing the incidence of HIV and STIs also offers clear and well documented benefits to women, families, and economies. Doing it all at the same time will magnify these benefits. </p>
<p>And it is key to ending poverty and fulfilling the range of interlocking sustainable development <a href="http://www.un.org/sustainabledevelopment/sustainable-development-goals/">goals</a> that shape our interconnected futures. </p>
<h2>An all-in-one solution</h2>
<p>Women, providers and advocates of women’s health are enthusiastic about the multipurpose prevention technology. Combining prevention benefits into one product will be more efficient and will increase the number of women covered by this umbrella of prevention. </p>
<p>Early <a href="http://resource.cami-health.org/resources/ipsos.php">market research</a> shows an overwhelming preference for products that can address multiple sexual and reproductive health risks. And <a href="http://onlinelibrary.wiley.com/doi/10.1111/bjo.2014.121.issue-s5/issuetoc">research</a> shows that HIV stigma is a barrier that prevents many women from seeking HIV prevention. It suggests combining HIV prevention and protection from STIs with contraception delivered in family planning settings will increase HIV prevention uptake for many women.</p>
<p>Researchers, health care providers, and funders from around the globe, including China, India, Kenya, <a href="http://www.wrhi.ac.za/Pages/ClinicalTrials.aspx">South Africa</a> and the US have forged in-country collaborations to ensure multipurpose prevention technologies will be desirable and accessible to those who need it most. </p>
<p>The <a href="http://mpts101.org/infographic-mpts">social benefits</a> of these technologies are far reaching. It ranges from educational attainment to reducing child mortalities, improving incomes, reducing inequity and having a positive impact on the environment. </p>
<p>For the young women in sub-Saharan Africa who bear a disproportionate burden of HIV infection, unwanted pregnancies and sexually transmitted infections, these technologies could be life-changing. </p>
<p>_This article is a version of a <a href="http://healthaffairs.org/blog/2015/11/02/mpts-combine-contraception-with-hiv-and-other-sti-prevention/">blog</a> originally written by Professor Helen Rees and Dr Bethany Young Holt, who is the director of the IMPT (Initiative for MPTs), a project of <a href="http://cami-health.org/about">CAMI Health</a> where she serves as executive director. CAMI Health is dedicated to the health empowerment of women and girls and is sponsored by the Public Health <a href="http://www.phi.org/">Institute</a>.</p><img src="https://counter.theconversation.com/content/51358/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Rees does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Scientists are developing various products that can provide contraception and protection from sexually transmitted infections and HIV at the same time.Helen Rees, Executive Director of the Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.