The New Phexxi Birth Control Gel Ad Isn’t Great — But How’s The Actual Product?

Photo: Courtesy of Phexxi.
I first heard about Phexxi, a non-hormonal birth control gel, shortly after it was approved by the Food and Drug Administration last May. I was interested in it: If it didn’t use hormones, how did it work? But I didn’t think much about it again until a few days ago, when I stumbled upon a commercial Phexxi had recently released. 
Simply put, I had some issues with it. The ad opens with a shot of a person who's labeled “Condom Cait” making a salad. “No way would she put hormones in her body!” the narrator says. But, she doesn’t like “relying on her man” to use protection. All contraception “comes with compromises” — except for, it’s implied, Phexxi. Personally, I'd consider the side effects that may be caused by Phexxi — including vaginal burning, UTIs, and itching — "compromises," too.
I get that it’s an advertisement, but Phexxi's bashing of other forms of birth control and the use of hormones in medicine is a problem. Having options is crucial, since a method that works for one person might not be right for another. If one of those options is Phexxi? Fine. But is it necessary to even obliquely cast doubt on the safety of hormonal contraceptives or condoms when promoting your own product? 
“The campaign was designed to highlight some of the compromises women may wrestle with in everyday life,” Saundra Pelletier, chief executive officer of Evofem Biosciences (which makes Phexxi), said, when I asked her for comment about the commercial's strategy. “There hasn’t been a new kind of birth control in decades… The brand’s goal is to empower women to be in control of their body, sex life, and pregnancy prevention.”
I wasn’t the only one who took issue with the commercial. One of my coworkers, who had seen the ad on Hulu, said she “hated it,” and another called it "weird," and pointed out: “It was like one second of ‘there's a new type of birth control!’ And then the entire rest of the commercial was warnings about side effects."
Soon, though, our conversation about Phexxi's ad shifted to how the birth control gel works, exactly. When do you use it? How do you use it? I tapped a few of my favorite OB/GYN sources for the answers. 

How does Phexxi work?

“Phexxi is a non-hormonal birth control gel that works to immobilize sperm and prevent pregnancy by maintaining a woman’s natural vaginal pH,” Pelletier explained. PH uses a scale of 0 to 14 to rank how acidic or alkaline an environment is, with 0 being more acidic and 14 being more basic. The pH for a healthy vagina is usually within the 3.5 to 4.5 range, although it might be higher if you’re going through menopause. Sperm temporarily makes vaginal pH more alkaline (about a 7.2 to 7.8), which allows for pregnancy. But if you insert Phexxi before sex, it keeps vaginal pH in an acidic range. The sperm can’t thrive, thereby lowering the chance it will meet an egg, said Karen Duncan, MD, OB/GYN, an assistant professor at New York University Langone Health. 
The nice part about the applicator-inserted gel is that you have control over when you use it. But it must be used within an hour of having sex; if you don’t have sex within 60 minutes, or if you have sex a second time, you’ll need to use a second applicator. Phexxi isn’t effective at all if you use it after sex, and it doesn’t prevent STIs. 

What are the side effects of Phexxi?

In two studies of 2,480 people using the birth control, 18% of participants reported burning in the vulva and vagina, 14% had itching, 9% got yeast infections, 9% got urinary tract infections, and 8.4% experienced bacterial vaginosis. The studies had no control group (so it's unclear how many participants would have experienced these symptoms without Phexxi), and only 2% of the participants experienced such bad side effects that they dropped out of the study. The research excluded women with a history of UTIs, since vaginally inserted forms of BC (like the diaphragm) are known to increase UTI risk, Pelletier said. For that same reason, people who have a history of recurrent UTIs or urinary tract abnormalities should avoid using Phexxi.  
While Dr. Duncan said that she'd worry that a product meant to alter vaginal pH could disrupt vaginal bacteria levels, which is "important for keeping the homeostasis," in a statement to Refinery29, Kelly Culwell, MD, the chief medical officer of Evofem Biosciences, said the product “is not expected to disrupt the normal flora of the vagina.”

How effective is Phexxi? 

When used perfectly, the FDA found Phexxi had a 7% pregnancy rate. But people aren’t perfect, and when accounting for “typical use,” Phexxi had a nearly 14% pregnancy rate for women who had sex three or more times a month throughout the seven months of the study, Dr. Duncan pointed out. That’s fairly high. And if you extrapolate that to one year, the pregnancy rate is even higher — a whopping 27%, noted Jen Gunter, renowned OB/GYN, on her Vagenda blog. To compare, condoms have a 13% pregnancy rate over a year, per the CDC; combined oral contraceptives have a 7% failure rate; and intrauterine contraception have a failure rate of less than 1%. “Maybe it could be used as a secondary birth control method, as a backup paired with a condom or the birth control pill,” Dr. Duncan suggested. 
“Efficacy is similar to what would be expected with other on-demand contraceptive methods,” Dr. Culwell said, in her statement. “It must also be considered against the risk of pregnancy with no contraceptive use, which is 85% in one year.” 

How much does Phexxi cost?

In her blog post Dr. Gunter also questioned whether insurance companies will cover Phexxi. “If you are buying it yourself, it’s approximately $267.50 for a box of 12,” she pointed out. “'Sure, he’s nice, but is he Phexxi-worthy?’ could replace the Elaine Benes sponge-worthy test from the TV show Seinfeld. After all, it’s about as effective as the sponge." 
Photo: Courtesy of Phexxi.
“Currently, more than two-thirds of all women have insurance coverage for Phexxi, and we encourage everyone to check and confirm this directly with their own insurance providers,” Pelletier noted in her statement to Refinery29. “Should your insurance plan not cover Phexxi, women may be eligible to participate in our Phexxi co-pay savings program, where eligible patients may receive $0 co-pay for their first fill and pay as little as $30 on future prescriptions.” 
However, she noted, folks who are insured by any state or federal government programs — Medicaid, for example — can’t participate in their co-pay savings program by law. The Phexxi team is working to make the product available under the Affordable Care Act

So, should I try Phexxi? 

Maybe. If you’ve decided to pass on hormonal birth control, this is one option. It can be used as needed, much like a condom, which is a plus. It’s a prescription, of course, so talk to your doctor about it and potential side effects before taking the plunge. 
But Dr. Duncan, at least, thinks the research behind the new birth control is a little light. “Before I recommended Phexxi to patients I’d want to see more research and more long-term studies,” she said. Dr. Gunter said something similar in her blog post: “None of the data show harm to the vaginal ecosystem, but the studies are small and they weren’t designed to look at long-term issues or to determine the rate of BV and UTIs."
Of course, Phexxi might be the right choice for some, and, if so, that’s fine. Unlike Phexxi’s commercial, we’re not here to judge. “Some women are tired of hormonal birth control... and are looking for other options,” says Charis Chambers, MD, OB/GYN, who has a partnership with Phexxi. “The best contraception is the one a woman wants to use.”

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