Dr Katie Musgrave asks whether our eagerness to make contraception and HRT easily accessible has gone too far
Over 60 years ago, the contraceptive pill was available on the NHS to married women whose health was put at risk by pregnancy, at a doctor’s discretion. Today, hormonal contraception is broadly available to any woman of child-bearing age (given there are no significant contraindications), not least as pregnancy is always considered to pose a potential threat to women’s health. Today, society’s consensus is that women should have control of their reproductive rights.
I do sometimes wonder, however, if – in our eagerness to make contraception and HRT easily accessible – the pendulum might have swung too far? Have we medicalised womanhood, and somehow communicated the message that all women need to use a form of hormonal contraception during their child-bearing years, followed by HRT to navigate the menopause?
Many of my generation were taken to a GP in our teens and started on a pill ‘just in case’ we might become sexually active. It is still common practice for teenage girls or their parents to contact GPs about period problems, with the presumption that a doctor will immediately suggest the pill. Naturally, there will be some youngsters who are discreetly trying to access contraception, which should be explored and usually supported. However, I often see girls presenting with heavy or painful periods, where parents firmly believe that a contraceptive pill is the natural first step, or somehow a rite of passage to adulthood.
I wonder if we are informing young women how unpleasant the side effects of hormonal contraception can be? That they might suffer with significant mood swings, acne, breast tenderness (to name a few of the many possible side-effects)? That their libido may fall through the floor? That there are risks with using these medications (such as increased rates of breast cancer)? Or that having an unmedicated monthly cycle may be a positive thing- and some women genuinely enjoy the rhythm and mood changes that occur naturally? I am not sure we have been.
Of course, I’m not suggesting that women shouldn’t have easy access to contraception of all types; or that for certain groups these interventions don’t offer enormous benefits. I do think, however, that more women should understand that hormonal manipulation is not an essential part of womanhood. It is, for example, perfectly reasonable for women to opt to use barrier contraception (highly effective if used properly), or to monitor their cycles to help avoid unwanted pregnancy. Likewise, shorter bursts of contraception might be a preferred option over decades on a pill.
I daren’t stray too far into the menopause (lacking personal experience yet to draw on), but, clearly, medication is not always an essential part of passing through this life stage. The pharmaceutical industry may be keen that as many women use HRT (and now testosterone) as possible. The publishers of menopause books, apps, or prescribing guides also have skin in the game, and generally promote the medicalisation of this period of female lives. As GPs we are supposed to prescribe HRT for as long as we feel the benefits outweigh the risks (yet, in most cases, neither can be reliably quantified).
Women’s bodies have evolved to perform amazing feats. Menstrual cycles, pregnancy, childbirth, breastfeeding… These experiences are messy, often painful and difficult, but they can also be wonderful. I wouldn’t give up any of them, and if my body is destined to change in middle age – then so be it. It was worth it.
Medicine, within limits, can help us to live fulfilling and healthy lives. But it can overreach, even causing harm. I don’t believe it is necessary for women to start on a hormonal contraceptive aged 13, only to transition to a form of HRT in middle age, then perhaps stay on this decades. Where possible, women should be educated and helped to benefit from medical advances, without facing the hard sell of (potentially unnecessary) medication. Our hormones and bodies should not be viewed as an industry, ripe for exploitation. I am yet to be convinced we have found the right balance.