Recently, a public interest group with no anti-choice agenda that I'm aware of filed a petition with the FDA requesting that the contraceptive patch be pulled from the market, saying that the patch's uneven distribution of hormones that varies from woman to woman made it too dangerous for use. Without getting into the debate over whether or not the group, Public Citizen, successfully made the case in their complaint, I can say that the whole situation has highlighted a situation in contraception development that I'd like to call the "Tex-Mex Factor". In Texas, we make cracks about how the diversity of the cuisine called Tex-Mex is an illusion: it's all rice, beans, cheese, meat, tortillas and chilis, and you just call it different names depending upon how you roll it. That's fine if you like those ingredients, but if you don't like tortillas, for instance, you won't find much to eat in Tex-Mex.

Women seeking a contraceptive method that's effective, reversible, and doesn't require you to fiddle with devices in the middle of a sexual encounter seem to have a myriad of options: the pill, the patch, shots, implanted devices, cervical rings. But like with Tex-Mex, it's all the same thing, just called different names depending upon how you roll it. All these methods are variations on the original earth-shaking and still controversial birth control pill. It's great if you're good with hormones, but like a person who wants Tex-Mex but doesn't like tortillas, you're out of luck if hormones don't work well with your body (IUDs have filled in the gap for some women, but they are uncomfortable to insert and still have a bad reputation, despite huge improvements in the technology.)

Most adaptations on the hormone theme are driven by the question of how to conquer the problem of inconsistent use, which is no small problem. As a recent Guttmacher report shows, half of women who intend to avoid pregnancy put themselves at risk every year through inconsistent contraception use. And the pill, for all that it beats the shot and the patch for dosing women just right, also lends itself to inconsistent use. Taking a pill every day at the same time can be hard to remember to do, and as the report shows, big life changes that mess up your daily schedule--moving, a job change, or a personal crisis--makes it even more difficult to keep a consistent dosage routine. The beginning or end of relationships also present an opportunity for inconsistent use. When transitioning from "coupled" to "single" in either direction and the frequency of your sexual contact changes, a daily pill can seem like a mismatch for your needs. I can attest that when you're single and not getting laid a whole lot, you begin to wonder why you're bothering to swallow a pill every day. If you remember it, you do it for the same reason you get dressed every day even when you work at home--a combination of optimism and propriety. (Read the whole report and the PDF as well, because there are many more reasons for inconsistent use I don't delve into here.)

So clearly, getting women to use their contraception more consistently is a major priority. The fact that drug companies try to address the problem by developing variations on the pill geared towards giving you less opportunities to screw it up is a good thing. Still, I can understand why some women who can't use hormones get annoyed when faced with this illusion of diversity. Why can't we have something that's like the pill in terms of ease of use and effectiveness but that works differently than fiddling with hormones?

The short answer is, not to be facetious, that we're lucky to have the pill. We live in an era of so many earth-shattering inventions that we sometimes forget you can't just snap your fingers and get a new one. At the time of its invention, the birth control pill was, like the vaccine, a godsend invention, and, like the vaccine, it relies on the body's innate biological tendencies to work (vaccines depend on the immune system's learning capacities, and the birth control pill relies on the hormone levels which signal to the body not to ovulate.)

The invention of the birth control pill was such a unique and momentous event that this pill ended up earning the moniker of "The Pill." You know, out of all the pills in the world. Even the Bible rarely gets called The Book, and needs the clarifying adjective "good." Erectile dysfunction drugs have contended for the Most Famous Pill Ever throne (I'm detecting a theme), but still not a one has laid down a real challenge to dethrone that pill which we call The Pill. If lightning hasn't struck again to create a non-hormonal version of hormonal contraception, should we attribute that to laziness or sexism on the part of researchers, or the fact that coming up with something even better might require a lot more knowledge and time than we've had up until this point?

Of course, the entire discussion around improving women's ability to control unwanted pregnancy neglects to include STD protection. This brings up a related question about how hard it is to improve upon the already marvelous invention of the humble latex condom. As with the pill, most condom failure is user error, but unlike with the pill, you can't fiddle with dosage schedules in hopes of reducing the opportunities for inconsistent users to screw it up. Next week's column will be "all about condoms" and what sex educators, condom sellers, and activists can do to encourage people to use them right every time.