In the 1960s, manufacturers of the new birth-control pill imagined their ideal user as feminine, maternal and forgetful. She wanted discretion. She was married. And she wanted visible proof that her monthly cycle was normal and that she wasn’t pregnant.
In 2019, the user of the pill is perceived as an altogether different person. She’s unwed, probably would prefer to skip her period and is more forthright about when it’s that time of the month. As such, many birth-control brands now come in brightly colored rectangular packs that make no effort to be concealed. But one part of the equation remains: the week of placebo pills, in which hormones are abruptly withdrawn and a woman experiences what looks and feels a lot like her regular period — blood, cramps and all — but isn’t. Physicians have widely described this pseudoperiod as medically unnecessary. So why do millions still endure it? That’s largely the legacy of two men: John Rock and David Wagner.
First there’s Rock, a Harvard fertility expert and a developer of the pill. There’s a longstanding myth that Rock, a Catholic, designed the pill in the 1950s with the church in mind and included a week of hormonal withdrawal — and therefore bleeding — to make his invention seem more natural. In fact, the thought never crossed his mind, the Rutgers University historian Margaret Marsh says. Instead, it was Gregory (Goody) Pincus, the other developer of the pill, who suggested that the pill be given as a 20-days-on, 5-days-off regimen. Pincus wanted to provide women in his trials with reassurance that they weren’t pregnant, and to know himself that the pill was working as a contraceptive. Rock agreed.
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After the F.D.A. approved the pill in 1960, however, those few days of light bleeding took on a new significance. Anticipating the church’s opposition, Rock became not just a researcher but also an advocate. In his 1963 book “The Time Has Come: A Catholic Doctor’s Proposals to End the Battle Over Birth Control,” he argued that the pill was merely a scientific extension of the church-sanctioned “rhythm method.” It “completely mimics” the body’s own hormones, he wrote, to extend the “safe period” in which a woman could have intercourse and not become pregnant. “It must be emphasized that the pills, when properly taken, are not at all likely to disturb menstruation,” he wrote. “It has been my consistent feeling that, when properly used for conception control, they merely serve as adjuncts to nature.”
He was stretching the truth. Rock knew that the pill’s synthetic hormones caused the lining of a woman’s uterus to thin out, making it inhospitable for a fertilized egg. During the off week, when the hormones were withdrawn, her body got the signal that it was time to shed the lining. But because this event didn’t involve ovulation, it was better described as withdrawal bleeding than menstruation. In 1968, Pope Paul VI rejected Rock’s creative logic and deemed all contraceptives “intrinsically wrong.” But by then, it hardly mattered: More than 12 million women were on the pill.
The other half of the story — how placebo pills entered the picture, and stayed there — revolves around Wagner. In 1961, Wagner had concerns that his wife, Doris, wouldn’t reliably take her new birth-control pills, which came in a glass bottle with a complex set of instructions. She was to begin taking a five-milligram tablet on the fifth day of her period, continue taking one a day for 20 days, then take five days off, at which point her bleeding would start. “I was constantly asking her whether she had taken ‘the pill,’ and this led to some irritation and a marital row or two,” he later recalled.
So Wagner, a product engineer for Illinois Tool Works, came up with a solution: a pill dispenser in the shape of a round plastic disc, which could be rotated to reveal the dose you were to take on any given day. It held 20 pills, plus a week’s worth of pill-size dimples that indicated the off week. His jerry-built design — he fashioned it out of a child’s toy, sheets of clear plastic and double-sided tape — was quickly picked up by Ortho Pharmaceuticals, and in 1963, the company began selling the pill in a Dialpak, a round foil blister pack with pills labeled with the days of the week. “The package that remembers for her,” the company advertised in 1964. “Easy for you to explain … for her to use,” another ad promised.
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Once the Dialpak went onto the market, it wasn’t long before other companies realized that putting physical placebo pills into the regimen would simplify the user experience: In 1969, Searle released Ovulen-28, a monthly pack of pills that included 21 hormonal tablets, followed by a week of inert pills, and in 1971, Mead Johnson’s Oracon-28 also came with the option of a week of placebo pills.
As more companies bought into the idea, the week of placebo pills was here to stay. Doctors liked that they made explaining the instructions to women easy. Women liked having one fewer thing to remember about their birth control. Few questioned why women on the pill should be having a “period” at all. Today there are a small handful of options that reduce or eliminate monthly bleeding: Seasonale, a form of the pill sold in packets of 84 active pills and seven placebos that make it so bleeding happens just four times a year, became available in 2003. In 2007, the F.D.A. approved Lybrel, the first oral contraceptive to provide continuous active pills, with no breaks for withdrawal bleeding. Doctors agree that a menstrual cycle can be a useful indicator of overall health, and yet it still isn’t necessary. When Dr. Lori Picco’s patients ask if they can skip the inactive pills, she says she tells them to go right ahead. “It’s completely fine — there’s no medical concerns,” says Dr. Picco, a gynecologist at Capital Women’s Care in Washington and a fellow of the American College of Obstetrics and Gynecology. “Honestly, I would think people would want to do it all the time.”
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