Introduction and Historical Context

• Episode from June 19, 2018 on "How the pill changed the world"
• Hosts: Josh Clark and Charles W. Chuck Bryant
• The pill so famous it's called "the pill" - no other medication has this distinction
• First medication designed for non-therapeutic purpose
• Released in 1960, monumentally impactful like antibiotics

Pre-Pill Era Contraception Challenges

• Women had to coordinate with husbands/partners for condom use
• If men refused, women had limited options
• Social double standards: only single men "allowed" premarital sex
• Before Industrial Revolution: folk remedies, herbal douches
• By depression era: "gynecological aids" or "feminine hygiene" products
  • Some worked, some didn't, some caused chemical burns or death
• 1950: 30 states + federal government banned contraceptives
  • Couldn't obtain or learn about contraception from doctors/schools
• 1960: pill released
• 1962: 5 million American women using it for contraception

Margaret Sanger and Early Development

• Margaret Sanger: controversial founder of Planned Parenthood
• 1912: wrote about theoretical "magic pill" to prevent conception
• Coined term "birth control" in 1912
• 1914: started newsletter "The Woman Rebel" - first publication using "birth control"
• Anti-abortion stance, promoted prevention over termination
• Controversial eugenics connections

Scientific Breakthroughs

• 1920s: identification of progesterone and estrogen
• Initially studied as fertility drugs, then noticed suppression effects
• 1941: Dr. Russell Marker discovered synthetic progesterone (progestin) from wild yams
• Made hormones cheaper and easier to obtain for research

Key Developers and Funding

• Margaret Sanger partnered with biologist Gregory Pinkus
• Katherine McCormick (McCormick spices fortune) provided significant funding
• Dr. John Rock joined forces in 1950s
• Faced legal roadblocks, had to cut corners for trials

Clinical Trials and Development

• Puerto Rico trials: different attitudes toward birth control than US
• Didn't inform participants this was clinical trial
• Also tested at women's mental asylum in Massachusetts without informed consent
• Accidental estrogen contamination reduced side effects
• Two competing companies: Searle and Syntex
• Searle partnered with Sanger and Rock

FDA Approval and Market Release

• 1961: FDA approval for gynecological disorders
• Within one year: 500,000 women using for "gynecological problems" (actually contraception)
• Searle initially had no expectations for success
• 1962: Syntex released competing version
• After contraception approval: 1.2 million American women on pill first year
• Searle thought women wouldn't want daily pill - were completely wrong

Safety Concerns and Backlash

• Early pills contained dangerous levels of estrogen
• Caused cancer, blood clots, heart attacks, hypertension, stroke
• 1969: "The Doctor's Case Against the Pill" by Barbara Seaman
• Senator Gaylord Nelson read book, initiated Senate hearings

Senate Hearings and Birth of Informed Consent

• January 1970: Senate testimony about pill safety
• All witnesses and testimony by men only
• Alice Wolfson and DC Women's Liberation group attended
• Women had never heard about dangerous side effects from doctors
• Medical establishment believed women shouldn't know - too "suggestible"
• No side effects listed on bottles
• Expert testified: "estrogen is to cancer what fertilizer is to wheat"
• Alice Wolfson stood up screaming: "Why are you using women as guinea pigs? Why are you letting drug companies murder us for profit and convenience?"
• Media attention led to consumer health movement
• Birth of informed consent requirements
• Requirement for side effects on bottles
• 87% of women aged 18-49 followed hearings
• 18% stopped taking pill, but overall popularity remained

How the Pill Works - Menstrual Cycle Science

• 28-day cycle (varies by individual, same as lunar cycle)
• Pituitary gland releases follicle stimulating hormone (FSH)
• FSH stimulates ovarian follicles to grow
• Follicles release estrogen
• Pituitary releases gonadotropin releasing hormone (GnRH)
• Triggers rise in luteinizing hormone (LH)
• LH causes dominant follicle to develop into egg
• Egg pops off, other follicles wither and die
• Egg travels down fallopian tube (ovulation)
• Uterine lining (endometrium) thickens
• Vaginal mucus thins to help sperm passage
• If fertilized: egg attaches to uterus, grows into child
• If not fertilized: egg dissolves, endometrium sheds (menstruation)

Pill's Mechanism of Action

• Pill introduces synthetic progesterone (progestin) and estrogen
• Keeps hormone levels high constantly
• Body thinks it already released egg (mimics corpus luteum)
• Prevents ovulation
• Progestin thickens vaginal mucus, making sperm passage harder
• Still have withdrawal bleeding (not true menstruation)
• Generally lighter, shorter periods
• 3% failure rate with perfect use

Menstrual Cycle Design Decisions

• Developers could have eliminated periods entirely
• Chose 28-day cycle to seem "natural"
• Dr. Rock (Catholic) hoped Catholic Church might approve
• Thought women would prefer maintaining regular cycle
• Could have eliminated periods but didn't

Period Necessity Debate

• Modern women have ~450 periods vs ~160 for ancestors
• Ancestors: more pregnancies, longer breastfeeding, shorter lifespans
• Scarring from ovulation can lead to ovarian cancer
• Endometrium shedding can cause scarring
• Benefits: iron deficiency reduction, lower blood pressure during certain weeks
• 10% lower stroke/heart attack risk during reproductive years
• Dr. Susan Rothenberg called period-eliminating pills "greatest unregulated medical experiment of all time"
• No long-term studies on menstrual suppression
• 2/3 of women would eliminate periods if safe
• Research doesn't include women under 18

Side Effects and Pill Evolution

• Common negative effects: nausea, weight gain, spotting (breakthrough menstruation), headaches, breast soreness, acne, depression, moodiness, decreased libido
• Original formula (Enovid): 10mg progesterone, 0.15mg estrogen - "nuclear bomb"
• Modern pills: much lower doses (micrograms of estrogen, 2.5mg progesterone)
• Placebo pills: 7 inert pills to maintain daily habit
• Recent Taytulla recall: inert pills accidentally placed at beginning instead of end

Types of Birth Control Pills

Combination Pills (most common)

• Monophasic: same hormone dose in all 21 active pills
• Biphasic: two different hormone levels
• Triphasic: three different hormone levels
• Bi/triphasic designed for minimum effective hormone doses

Progestin-Only (Mini Pill)

• For breastfeeding women (estrogen affects milk)
• Makes endometrium too thin for egg attachment
• Thickens vaginal mucus
• 28 active pills
• Less effective than combination pills

Extended Release

• Seasonal/Seasonique: 4 periods per year
• Lybrel: 365 days, no periods
• 84-day cycles for quarterly periods

Synthetic Hormones

• Progestin type varies between pills
• Estrogen type consistent: ethinyl estradiol
• Lower hormone amounts generally better for side effects and cancer risk

Social and Political Impact

Catholic Church Opposition

• John Rock's hope for approval completely failed
• Church maintained opposition

Black Power Movement Concerns

• Late 1960s: men in movement called pill "Black genocide"
• Evidence of forced sterilizations of Black women in hospitals
• Black women had easier access to birth control than other healthcare
• Early trials showed racist attitudes - testing on "backwards Puerto Ricans of color" to prove inner-city women could use pills

Anti-Abortion Groups

• Consider pill an "abortifacient"
• Argue it makes uterus hostile to fertilized eggs
• Prevents implantation = abortion in their view
• Debate remains unsettled

Milestone Achievements

• 10-year anniversary of Stuff You Should Know
• First podcast to reach 500 million downloads/streams on Apple platform
• Announced at Apple's WWDC developers conference