What the Dog Saw [45]
In 1958, Pope Pius XII approved the Pill for Catholics, so long as its contraceptive effects were “indirect” — that is, so long as it was intended only as a remedy for conditions like painful menses or “a disease of the uterus.” That ruling emboldened Rock still further. Short-term use of the Pill, he knew, could regulate the cycle of women whose periods had previously been unpredictable. Since a regular menstrual cycle was necessary for the successful use of the rhythm method — and since the rhythm method was sanctioned by the Church — shouldn’t it be permissible for women with an irregular menstrual cycle to use the Pill in order to facilitate the use of rhythm? And if that was true, why not take the logic one step further? As the federal judge John T. Noonan writes in Contraception, his history of the Catholic position on birth control:
If it was lawful to suppress ovulation to achieve a regularity necessary for successfully sterile intercourse, why was it not lawful to suppress ovulation without appeal to rhythm? If pregnancy could be prevented by pill plus rhythm, why not by pill alone? In each case suppression of ovulation was used as a means. How was a moral difference made by the addition of rhythm?
These arguments, as arcane as they may seem, were central to the development of oral contraception. It was John Rock and Gregory Pincus who decided that the Pill ought to be taken over a four-week cycle — a woman would spend three weeks on the Pill and the fourth week off the drug (or on a placebo), to allow for menstruation. There was and is no medical reason for this. A typical woman of childbearing age has a menstrual cycle of around twenty-eight days, determined by the cascades of hormones released by her ovaries. As first estrogen and then a combination of estrogen and progestin flood the uterus, its lining becomes thick and swollen, preparing for the implantation of a fertilized egg. If the egg is not fertilized, hormone levels plunge and cause the lining — the endometrium — to be sloughed off in a menstrual bleed. When a woman is on the Pill, however, no egg is released, because the Pill suppresses ovulation. The fluxes of estrogen and progestin that cause the lining of the uterus to grow are dramatically reduced, because the Pill slows down the ovaries. Pincus and Rock knew that the effect of the Pill’s hormones on the endometrium was so modest that women could conceivably go for months without having to menstruate. “In view of the ability of this compound to prevent menstrual bleeding as long as it is taken,” Pincus acknowledged in 1958, “a cycle of any desired length could presumably be produced.” But he and Rock decided to cut the hormones off after three weeks and trigger a menstrual period because they believed that women would find the continuation of their monthly bleeding reassuring. More to the point, if Rock wanted to demonstrate that the Pill was no more than a natural variant of the rhythm method, he couldn’t very well do away with the monthly menses. Rhythm required “regularity,” and so the Pill had to produce regularity as well.
It has often been said of the Pill that no other drug has ever been so instantly recognizable by its packaging: that small, round plastic dial pack. But what was the dial pack if not the physical embodiment of the twenty-eight-day cycle? It was, in the words of its inventor, meant to fit into a case “indistinguishable” from a woman’s cosmetics compact, so that it might be carried “without