Book Review

This Man's Pill: Reflections on the 50th Birthday of the Pill

N Engl J Med 2001; 345:1918-1919December 27, 2001

Article

This Man's Pill: Reflections on the 50th Birthday of the Pill
By Carl Djerassi. 320 pp. New York, Oxford University Press, 2001. $22.50. ISBN: 0-19-850872-7

Carl Djerassi's illuminating scientific and autobiographical memoir begins 50 years ago, when as a steroid chemist he participated in the birth of “the Pill” in Mexico City. Djerassi is a professor of chemistry at Stanford University, as well as an author of novels, poems, and plays — particularly what he calls “science-in-fiction.” He has also written about the social-welfare aspects of the Pill.

A brief, useful history of the sex steroids, delineating their biologic activity for female and male reproductive ability, prefaces the Pill's history. The breakthrough was the discovery by Russell Marker in the late 1930s and early 1940s that progesterone could be prepared in large quantities from an inedible yam (dioscorea species) growing wild in Mexico. A small laboratory, Syntex, in Mexico City began to process progesterone from this cheap plant.

In 1945, Djerassi was a 22-year-old, newly naturalized U.S. citizen (he was born in Vienna, Austria) with a Ph.D. from the University of Wisconsin and a strong interest in steroids. In 1949, he was offered a research position at Syntex. His colleagues considered him mad to move to a backwater laboratory in Mexico City, but as Djerassi recounts, he never regretted the decision, and his fortune (literally) began with his arrival at Syntex.

He and his colleagues developed the first orally active progestational steroid at this small laboratory. He describes the steps involved in the Pill's development and the crucial role of a biologist, Elva G. Shipley, at a commercial laboratory in Madison, Wisconsin, who established the activity of orally administered norethindrone. The first clinical trials were conducted by the endocrinologist Gregory Pincus, whom Djerassi calls “the father of the Pill,” and John Rock. Equally important is the history of the public reactions, pro and con, to this new contraceptive for women. As Djerassi sets forth, the four decades since the Pill became a household word have witnessed a flood of books and articles on the societal effects of the Pill, ranging, as he says, from the unreservedly laudatory to the totally condemnatory, with every possible nuance in between. The book highlights the new freedom of women who use this type of contraceptive, the separation of sex from conception, and side effects of the Pill, especially in its early high-dose versions, which had 10 times the strength of later versions. This undoubtedly explained the high dropout rates from family-planning programs in many developing countries, particularly in Asia, where women weighed 10 to 15 kg less than women in the United States but no adjustment was made in the dose given.

As Djerassi describes in detail, a barrage of liability suits beginning in the 1960s led to the withdrawal of firms in the United States from contraception-related research and development; their hesitancy to engage in such research continues to this day. Only one of the eight largest pharmaceutical companies in the United States sells contraceptive drugs or devices, and only one conducts contraceptive-related research and development. These companies now focus on drugs for the diseases of aging and other types of deterioration in the health of the affluent, aging populations of developed countries, to the detriment, according to Djerassi, of the needs of the poor developing countries of Latin America, Asia, and Africa. He concludes that all we can expect in the beginning decades of this century are minor modifications of existing methods of contraception.

An important exception to this pattern of neglect was the development of the “morning after” pill, which contains a high dose of conventional combined oral contraceptives and can prevent implantation if it is used within 72 hours after unprotected intercourse. It took until 1995 for the World Health Organization to list the morning-after pill as an essential drug. The Food and Drug Administration approved it in 1997, but a doctor's prescription for it is necessary in the United States, except in the state of Washington. It is available in the United Kingdom without a prescription for women older than 16 years of age. As Djerassi points out, if this pill were available in this country without a prescription, it would reduce the incidence of abortions.

Djerassi turned to writing fiction in order to illustrate the human side of scientists, their personal conflicts, and the implications of science for society. He has published six novels, two plays, and three nonfiction works, including The Politics of Contraception. His scientific publications include 1200 papers and 7 monographs.

The literary works were an outgrowth of his decision in 1969 to leave the scientific research that had occupied him for “26 hours in a 24 hour day” as well as the chairmanships of three corporations in order to concentrate on public-policy publications espousing a global view of contraception for the rapidly growing populations of developing countries. Djerassi is convinced that politics rather than science will have the dominant role in the future of birth control. Samples of some of his pertinent provocative writings on the subject are reprinted in This Man's Pill.

In 1972, Djerassi began lecturing in the human-biology program at Stanford University on the “biosocial aspects of birth control.” His aim was to encourage undergraduate students to think seriously about public policy and about bridging academia and industry.

The final chapter of the book is a sober review of the present status of the Pill worldwide and its remaining side effects. The major established health risks include circulatory diseases. Over the years, reduction of the doses of estrogen in the Pill has diminished the incidence of these side effects, but risks remain, including the long-term risk of breast cancer if the Pill has been used during the previous 10 years.

On the other hand, the Pill is protective against ovarian and endometrial cancers and loss of bone mineral density, and as Djerassi points out, its most important effect is the prevention of unplanned and unwanted pregnancy and therefore the reduction in the incidence of abortions. It thus permits planning and provision for desired children.

Djerassi's wide-ranging interests include art — specifically, the paintings of Paul Klee, which he collected for many years. In 1982, he founded the Djerassi Resident Artists Program, which provides residences and studios for artists in the visual arts, literature, choreography, the performing arts, and music. The breadth of Djerassi's interests and the energy he has devoted to them are imparted through this important memoir of the birth of the Pill.

Rose E. Frisch, Ph.D.
Harvard Center for Population and Development Studies, Cambridge, MA 02138