Everything but the kitchen sink: The evolution of birth control

Forget scented candles and mood lighting. In Ancient Egypt, nothing got hearts racing like the sweet smell of honey and crocodile faeces. Instructed by the Kahun Papyrus, Egyptian women would combine items like the fruit or gum of the acacia (uh-kay-shuh) plant with honey, sour milk, and crocodile dung to create a makeshift contraceptive tampon or diaphragm. This pungent mixture was thought to be toxic to sperm — or perhaps the smell of it was enough to put a stop to anything before it had the chance to begin. The Ancient Egyptians may have been onto something.  Acacia ferments into lactic acid; an ingredient being tested in modern spermicides because it helps maintain vaginal acidity to kill sperm.

So we’re off to a not so terrible start, but our use of plant material as an effective and safe contraceptive would prove to be hit-or-miss…

Nothing spices things up like a bit of danger,  but for women in Ancient Greece and Rome who used pennyroyal oil as a contraceptive, that danger was life-threatening kidney damage. Just half a teaspoon of oil could be fatal thanks to its ingredient, pulegone. Pulegone stimulated menstruation, but when concentrated enough, unleashed seizures, hallucinations, suffocation, and liver and kidney failure on some unfortunate maidens. At this time, the lack of knowledge around pregnancy duration led to a rather blurry line between contraceptives and abortifacients (compounds that terminate pregnancy). Pennyroyal was widely used for both, and even promoted in popular culture — the 421 BCE play Peace by Aristophanes was a story of war and amity (with a hint of family planning).

If the thought of essentially ingesting poison doesn’t do it for you, then never fear, the much safer Queen Anne’s lace was available — provided you didn’t get it mixed up with its deadly lookalike, poison hemlock. If you chose correctly *fingers crossed*, Queen Anne’s lace was an effective and generally safe contraceptive often administered as a tea. At the time, of course, how this plant worked was a mystery, but we now know it inhibits the implantation of an embryo by suppressing the hormone progesterone. Hormones would not be discovered for another 2000 years, but ancient methods such as these unknowingly used one of the same mechanisms found in modern contraception.

Barrier contraception has existed longer than we think, and just like the dung-laced tampons of their Egyptian counterparts, Ancient Romans had their own creative methods of preventing sperm getting from A to B. Looking like a mouldy donut, this bronze pessary from between 200 BCE and 400 AD would have once rested comfortably(?) at the entrance to the cervix to stop sperm in their tracks. But beyond its mechanism as a physical barrier, using a metal like bronze may have had an added benefit. Bronze is mostly made of copper, a metal we now use in IUDs specifically because it slows sperm down or kills them. The spermicidal effect of copper would not be officially discovered by scientists until 1850 AD.

Yet another delightful object to stuff internally – sponges soaked in various liquids! There are examples from across Ancient Greece, Islamic and Slavic countries, and Japan, amongst others. Each country had their own favourite materials. The Greeks preferred cotton for their sponges, the Slavs liked linen, and the Japanese found bamboo fibres most suitable. Lemon juice was often used to soak these sponges, with its citric acid creating an environment unfriendly to alkaline (low acid) sperm. Other liquids used such as iodine, quinine, and alcohol also wreak havoc on sperm health. But of course, no historic contraceptive is complete without the potential to cause serious bodily harm — some sponges were dipped in carbolic acid, a nasty liquid that burns skin to the point of gangrene (don’t Google that)…

Busting the stereotype of men being clueless about female anatomy, Gabriele Falloppio was the first to describe the fallopian tubes (guess who he named them after?) and corrected many misconceptions about the female reproductive system. In the mid-1500s, Falloppio suggested that men wrap themselves up like a present with a ribbon-secured penile cover of soaked linen to protect themselves, never mind women, from syphilis. Despite initially not being used for contraception, condoms made of animal guts (sorry vegans) would eventually be developed for this purpose within the next two centuries, as theories like those above began to associate sperm-egg interaction with conception.

Lactational amenorrhea, translating into plain English as the absence of periods due to breastfeeding, was first acknowledged by 17^th and 18^th century doctors. Wealthy women, who had very short breaks between children compared to the poor, often employed wet-nurses to breastfeed infants so their fertility would return quicker — for producing more male heirs, of course. In the early 19^th century, this idea was dismissed as nothing more than a foolish wives’ tale, but it has since proven to be 98% effective (for contraception, that is, not for producing sons). This is because breastfeeding prevents ovulation, the release of an egg, by sending signals to the brain to suppress the hormones needed for it to occur. However, when used today, it is highly recommended that breastfeeding is used as a contraceptive for only six months following birth.

Casanova: adventurer, lover, birth control pioneer. When life gave him lemons, he gave his female companions a citrusy contraceptive. We already know that lemon juice was in the ancient contraception toolbox, with its high acidity being toxic to alkaline (low acid) sperm. Fast forward to the 18^th century and Casanova took this one step further by recommending the squeezed lemon half be inserted to block the cervix. Although it’s not known if this fruity diaphragm stayed in place, we can at least find comfort in knowing that it definitely smelled better than its ancient counterpart laced with dung and sour milk…

Pictured here is silk-worm thread wrapped in silver wire, the “Gräfenburg ring”, developed by Ernst Gräfenburg in 1929. This was the first IUD that was scientifically proven to be effective, with Gräfenburg reporting a three percent failure rate, meaning only three women out of every 100 with it inserted became pregnant. He believed that his IUD prevented an embryo implanting in the uterus, which is one of the mechanisms that current IUDs work through. Unlike the stem pessary of the 1800s, Gräfenburg’s ring didn't carry the same risk of infection as it stayed solely in the uterus (reliable and safe — what a revolutionary combination). P.S. Gräfenburg would also go on to discover the female G-spot, so we have more than one thing to thank him for...

It can be easy for us to assume that giving women control over if or when they conceive was the only motivation behind developing better contraception, but there is a darker side to the story. Pictured here, this rubber cap or diaphragm which blocked sperm from entering the uterus was adapted by Dr Marie Stopes — a British birth control pioneer who was also a eugenicist. It was a widely held belief in the early 20^th century that reliable contraception would allow selective breeding to reduce the birth rates of the poor or other “undesirables” within society. Thankfully, following the revelations of Nazi atrocities committed during World War II, eugenic opinions regarding class and race became increasingly condemned both morally and scientifically.

At this point, you’ve probably realised that anything goes, so the use of Coke as a vaginal douche in the 50s and 60s may not surprise you. It was believed that its acidity and high sugar content could kill sperm, and a study has since been conducted to test just this. Not only did it find that Coke is not an effective spermicide, but it also damages the vaginal wall, making it more susceptible to infection, and messes up its delicate ecosystem of beneficial bacteria. So, instead of being “really refreshed”, this douche of desperation would have left you feeling rather itchy due to the yeast infection you’d likely develop… anti-fungal cream, anyone?

Finally - something we may all recognise! So revolutionary that it needs no descriptive name, just a capital ‘P’, the Pill changed everything when released in the early 1960s. What once seemed impossible was now a reality: reliable contraception. When the pill is taken, progestogen and oestrogen travel through the bloodstream to signal to the hypothalamus to decrease its production of gonadotropin-releasing hormone (GnRH), which in turn signals to the pituitary gland to stop producing FSH. This prevents an egg from growing and the endometrium from thickening, and with no egg ready, there is no LH surge to induce ovulation. Progestogen also functions to thicken cervical mucus, making the uterus a no-go-zone for sperm. No egg available + thin endometrium + impenetrable cervical mucus = pregnancy averted = happy pill-taker.

Gräfenburg’s IUD would be replaced by varying plastic IUDs from the 60s onwards… with mixed results. Pictured here, the Dalkon Shield was a plastic IUD released in 1971 — and its design would turn out to be a real pain for two reasons. One, the multiple “fins” on its fishhook-like body made pulling it out of the uterus difficult (*cringe*). Second, its tail of multiple woven fibres essentially created a ladder for bacteria to enter the uterus from the vagina. Thankfully, this disastrous IUD was pulled (sorry, too soon?) from sale globally in 1975, but the damage was already done. Thousands of women had experienced serious complications like pelvic disease, sterility, septic abortion, and ectopic pregnancy, with some even dying. What would follow was one of the largest civil-wrong lawsuits in history… lesson learned.

Luckily, the Dalkon Shield fiasco didn’t completely ruin the IUD's reputation (permanently, anyway). Pictured here, this non-hormonal copper IUD was released in the mid-1970s as a form of long-acting reversible contraception (LARC). All IUDs produce an inflammatory response in the endometrium which changes its cellular structure to make embryo implantation difficult; but add in copper and you have another weapon in your contraception arsenal. Copper is toxic to both sperm and eggs (fertilised and unfertilised) and also interferes with embryo implantation. One huge benefit of the copper IUD is that it can be left in for 10 years! I’d talk about convenience…but one of the main side-effects of this IUD is heavy periods, which scientists hypothesise may be due to its copper ions altering endometrial blood vessels.

If copper, or excessive menstrual blood, aren’t to your liking, you can always rely on our hormonal friend, progestogen. The hormonal IUD was developed and released shortly after its copper cousin in an attempt to address the bleeding associated with plastic IUDs. It prevents pregnancy by creating an inflammatory uterine response and the progestogen it contains thins the endometrium and thickens cervical mucus. Although this LARC can only be left in for half as long as the copper IUD, it has an added benefit. Because it thins the endometrium it leaves less to be shed during menstruation, making it a suitable option in managing heavy periods. Preventing pregnancy and making periods more tolerable… we have come a long way.

If taking a pill every day is inconvenient, or if the thought of having an IUD inserted into the depths of your uterus makes you shudder, never fear, another option is here! First released in 1983, the implant is another LARC, so like an IUD, it’s a fit-and-forget option. Once in place in your upper arm, it releases progestogen, like the hormonal IUD, and you’re good to go for five years. But big needles aren’t for everyone, and a rather chunky one is required for inserting the implant. This may make the Depo Provera injection more suitable, which looks like a standard injection, but it delivers a dose of progestogen to keep pregnancy off the cards for three months at a time.