Pregnancy prevention is a tale as old as, well, sex. In the pre-prophylactic days of yore, alongside coitus interruptus (the famous “pull out method”), 18th century men used things like animal bladders as condoms. Women douched with lemons and other antiseptics in the hopes that the acidity would quell fertility. Spermicides made with crocodile dung went in and out of style as did oral birth control in the form of…poison. Long story long, we’ve been ideating on contraception since the stone ages — and yet, in spite of our apparent efforts, women were still rinsing their vaginas with tile cleaner well into the 20th century.
In fact, it wasn’t until (mortifyingly) recently that women gained access to safe, functional modes of birth control at all: The 1950s marked the FDA's first approval of the use of oral birth control — better known as “the pill” — in the United States. “The arrival of ‘the pill’ presented women, for the first time in history, with a birth control method that was discreet, convenient, almost 100% effective, and within their own control,” says historian Andrea Tone, editor of Controlling Reproduction: An American History. But that came with its complications, too: “The increased popularity of the pill quickly feminized, medicalized, and pharmacetuizalized birth control,” she says — thereby increasing women’s dependence on physicians for their sexual autonomy.
That’s not to say oral contraception has reached its final form, though. Even now, we’re making scientific advancements to “the pill.” And for all the political strongholds surrounding reproductive advocacy in the U.S. at this particular moment in time, we can take small comfort in the knowledge that the scientific community continues to make developments toward hazard-free birth control options.
So what, exactly, does the future of birth control look like? For the time being, it centers around Estetrol (E4) — a strain of estrogen approved by the FDA for the first time in 2019 with potential to shift the birth control market as we know it. “Not only do all our big studies show that new birth control pills incorporating E4 are just as effective as more traditional birth control pills, but right now, it would seem that it’s much safer,” says obstetrician and family planning specialist, Dr. Mitchell D. Creinin, M.D. “We’re seeing few recorded side effects and lesser risk of blood clots compared to other birth controls.”
Oral contraception, generally speaking, is designed to halt ovulation — which is the process by which hormones signal the ovary to release an egg to be fertilized (by sperm) in the event of a pregnancy. In order to do so, the pill uses a combination of two different hormones: estrogen and progestin (synthetic progesterone). “For the most part, it’s the progestin that prevents pregnancy because it stops your ovaries from producing the hormones that make you ovulate,” says Dr. Creinin. “But you need estrogen to help balance out that hormonal disruption in order for you to feel normal.”
As is implied by the number “4,” Estetrol is one of four different kinds of estrogen found in the body — all of which aid female sexual development and function. As Dr. Creinin explains it, Estrone (E1) and Estriol (E3) are produced during menopause and pregnancy, respectively — but Estradiol (E2), which is generated in the ovaries, is the form of estrogen most commonly used for hormonal regulation in birth control pills. “Estetrol — E4 — is produced exclusively by the fetal liver, and it’s never been used in a birth control pill before,” says Dr. Creinin. “And unlike Estradiol, which doesn't hang around very long, E4 takes quite a long time for your body to metabolize, so it doesn't do any of the bad things that you see from other estrogens when you give them orally.”
Birth controls using E4, Dr. Creinin says, don’t seem to impact the liver because, unlike most drugs, they’re not actually metabolized there. Moreover, studies have shown they’re less likely to cause blood clots — a major risk with traditional oral birth controls. “It’s the first major advancement made in the birth control market in over 60 years,” says Dr. Creinin.
Of course, there is a catch: For the time being, E4 birth control options are still fairly new to the market — and thus, most standard insurance policies don’t yet cover them. But Dr. Crenshaw is fairly certain that, in the coming years, that will change. So, in honor of oral contraception’s glistening future, we sat down with scientists, medical professors, and historians to chart the evolution of oral birth control in the U.S. throughout time — from the first-ever family planning clinic up until the discovery of E4.
According to Tone, when the 20th century rolled around, “birth control” had yet to enter the medical lexicon. The term was coined in 1914 by Margaret Sanger — a nurse and a radical feminist in the field of reproductive health — where it first appeared in her newsletter, The Woman Rebel (mind you, we’re talking pre-Substack days here), in which she offered women essential information about pregnancy prevention.
At the time, her diatribe violated the country’s obscenity laws, so like all good rebels, Sanger was indicted — a roadblock she circumvented by fleeing the country to avoid trial. In 1916, however, she made her triumphant return to open the first family planning clinic in the U.S. “The clinic was about giving people really effective contraception for the first time,” says Linda Gordon, professor of history at New York University and author of ‘90s birth control bible, Woman's Body, Woman's Right: Birth Control In America. “Diaphragms were the only birth control around then — but they had to be fitted for each woman and for the most part, they were illegal in the U.S. so Sanger had to smuggle them in illegally from Europe.” Back then, a degree called the Comstock Act, enacted in 1873, made it a misdemeanor to possess, share, or send via mail anything deemed “obscene, lewd or lascivious” — which included birth control of any form — even if prescribed by a doctor.
Naturally, as a result, Sanger’s clinic was shut down within the week — but nevertheless, it had its lingering impact. Five years later, it gave way to the formation of the American Birth Control League — later titled the Planned Parenthood Federation of America.
In 1936, Sanger lobbied to overthrow the Comstock Act — and she was successful. But much to Sanger’s chagrin, a new roadblock emerged: Pope Pius XI publicly declared birth control a “grave sin.” While technically not a legal sanction, Tone says the statement certainly deterred countless women, many of whom were made to feel that pregnancy prevention was immoral. “After World War I, courts increasingly recognized the legality and legitimacy of condoms as a medical technology that could prevent the transmission of STIs,” she says, “but contraceptives used solely to prevent pregnancy continued to be construed as sexualized objects: immoral and obscene.”
At the time, to avoid stigmatization, “feminine hygiene” became a code word for pregnancy prevention amongst women and doctors — and a result, in order to prey on birth control-hungry consumers, various brands began to market their goods as “feminine hygiene” products…in spite of the fact that they had no contraceptive benefits. “Feminine hygiene connoted birth control, but shielded manufacturers from prosecution,” Tone explains. “Although douching isn't an effective contraceptive, ads from the 1920s and 1930s convincingly suggested otherwise.”
Blissfully enough, however, in 1938, the American Medical Association finally voted to recognize birth control as a legitimate part of a doctor’s practice — which, according to Gordon, marked a major step forward for feminine health. And while there remained laws against contraception in countless states, by 1942, there were 800 birth control clinics stationed across the U.S.
It was in the ‘50s that Sanger stumbled upon the work of Gregory Pincus — a scientist with some (maudlin) cinematic aspirations: At the time, he was experimenting with the in vitro fertilization of rabbits. She approached him to discuss the use of hormones as a form of contraception — and with the aid of a number of other scientists, he did just that.
In 1956, the FDA signed off on this particular hormone pill — but not as a form of contraception. Instead, Gordon notes that it was marketed as a balm for difficult periods. Legally, the pill could be prescribed for irregular bleeding, PMS, or other menstrual disorders. And while promoting the sale of birth control was still illegal in a great number of states, following the pill’s release, there seemed to be a sudden, *mysterious* uptick in women with serious PMS symptoms (wink wink). “Basically the day the pill was put on the market, it became one of the most desirable commodities out there,” says Gordon. “Women seemed to like it more than diaphragms or condoms because you didn’t have to use it while having sex. And unlike a diaphragm or an IUD, it didn’t require medical assistance. You could take the pill in the privacy of your own home.”
1960s & 1970s
The ‘60s marked another major hallmark in the evolution of birth control: On May 9, 1960, the FDA finally approved an oral contraceptive pill that was publicly described as such: Enovid. And by 1965, Gordon says that nearly 6.5 million American women were on the pill. Later that year, the Supreme Court even repealed state laws prohibiting contraception usage among married couples (though, single folks were still out of luck).
The big shift came in 1972, when the Supreme Court ruled that states could no longer constitutionally place any restrictions on the advertisement, sale, and distribution of contraceptives — to anyone, regardless of age or marital status. Which is to say, bachelorettes could finally get in on the fun without faking hyperbolic plague-like PMS symptoms. And less than a year later, in 1973, the Supreme Court legalized a woman’s right to abortion in Roe V Wade.
In its earliest iterations, the pill — while miraculous — still had its complications. “At the beginning, the pill did have a lot of very bad side effects: Doctors didn’t yet know what dosage was necessary in order to stop ovulation, so the first birth control pills had about a hundred times the amount of hormones found in birth control pills now,” says Gordon.
Fortunately, in the 2000s, freed from most legal ramifications, the country saw a number of scientific advancements in the realm of oral contraception. In response to rising fears about blood clotting or linkage to breast cancer, she explains, newer and more balanced formulas were mastered, giving doctors a variety of pharmaceutical options for different women. At the same time, other equally accessible modes of birth control rose in popularity: hormonal patches, nuva rings, and IUDs began to spread, and even emergency contraception like Plan B.
Which brings us to the present: Just this year, Justice Thomas contended that the Supreme Court ought to reexamine American’s constitutional right to abortion, overturning Roe V Wade. And while the dystopian gravity of that decision cannot be minimized, we can look to scientists for a small splash of hope. For what it’s worth, the continual emergence of new advancements in the world of pregnancy prevention — like the use of E4 — point to one form of eternal progress toward bodily autonomy by way of birth control. “We’re not done advancing birth control technology, even now,” says Dr. Creinin. “In parts of the medical community, this will always be a priority.”