Laura Wershler is Executive Director of Sexual Health Access Alberta. Recently she wrote a critical response for the re:Cycling blog to a study published in the British Medical Journal which reported that 'Women in the UK who have ever used oral contraceptives are less likely to die from any cause, including all cancers and heart disease, compared with never users.' She has previously served on the board for the Planned Parenthood Federation of Canada (now the Canadian Federation for Sexual Health) and is a self-described opponent of menstrual suppression through hormonal birth control and advocate of body literacy. In the second part of this interview she discusses the hows and whys of coming off the Pill. Do you see an attitude in education and services that suggests the health of an individual woman is not as important as the benefits for the greater good - be that population control, or upholding sexual freedom? Much of the thinking rests on an approach to menstruation and ovulation that states they are only related to reproduction. But that's not true - the cycle is so much more. I am adamantly pro-choice and I believe hormonal contraception has a place in women's reproductive lives. There's nothing wrong with considering these methods as part of how we manage fertility. My goal is solely to acknowledge that there are young women who want to choose not to use hormonal methods and that this is a valid choice, not only based on their experience but also on evidence that it holds health benefits. Just as we have the right to choose hormonal methods, we need to have the right to not choose them. That's where sexual health clinics are falling down. If we are going to consider ourselves truly pro-choice, if we meet a woman who does not want to use hormonal methods and she has her reasons, presents them and says she doesn't want to be dissuaded then we should wholeheartedly understand what we need to provide to help young women make that choice. Otherwise, we just don't have informed choice and we are not honoring the patient. Let's not forget - she is not sick. She is looking to manage her fertility in a healthy way for her. We don't acknowledge that being on the Pill can mean taking drugs from age 15 to 40, and that most women don't want to do that. We need to be filling in the gaps, the bridge periods. We are too focused on teenage and young adult woman and as such are adamantly committed to preventing them getting pregnant. The Pill isn't the perfect answer for all women but we keep acting like it is. Do you see an effort to push women towards long-acting hormonal methods which are more 'effective' than the Pill in that they do not require the woman to remember to take a pill each day? There is a real move towards Mirena. I know people who work in abortion clinics and they say they are seeing young women taking the Pill in ways they see as appropriate and still getting pregnant. The 'typical' rate of effectiveness of the Pill is definitely dropping - but there's no acknowledgement of that. Perfect use for the Fertility Awareness Method, when women are taught how to chart their fertility, has 99.6% effectiveness, but many people give the reason for not supporting this method as being that the typical use rate is around 85%. But this 'in practice' rate is happening with the Pill right now and no one is suggesting we don't use the Pill - instead there are the implants, injections. Long-acting hormonal methods, I can't recommend them to anyone. I find them almost abusive. I think considering the side effects of Depo Provera on a 15 year-old girl (who I don't believe can be making an informed choice to take such a powerful drug) administering this method to teenagers is wrong. At the time when they are supposed to be exploring their sexuality, they are given a drug that takes the libido away and puts them into the hormonal profile of a menopausal woman. An unintended pregnancy is the only sign of health that we seem to care about. The irony here is that they want to give out the injection because they think young women can't take a pill every day, but now we know they need to take a calcium supplement when on the injection every day and if they're not going to remember the Pill, they're not going to remember the calcium supplement. It's a sledgehammer method. If a woman chooses to come off the Pill after five years, a decade of use, what might she expect? If hormonal birth control does not work out for a woman then she needs to have the sense of something to go back to. She needs to be connected to her body, know how it works, how her body feels. Many women don't know what is happening with their bodies when they come off the Pill - say, why they have acne, have developed ovarian cysts, or have irregular periods - so there's a sense that there is something wrong again and many of them end back up on the Pill. At some point if you want to be fertile you have to establish fertility, and I think because many women don't understand their bodies this can be a terrifying experience. The Planned Parenthood site is providing excellent information on the Fertility Awareness Method, and it even suggests where you might go to learn the method, but the question is: Are Planned Parenthood clinics actually offering secular training in the method in their clinics? The other issue of concern is that there is no real acknowledgment of how dismissive sexual health care providers can be and often are when a woman asks about the method or looks for support to learn and use it effectively. So, in essence we are paying lip service to fertility awareness while not really doing anything concrete or proactive to remove the barriers that are keeping women from being able to learn and use the method. We are not advocating on women's behalf for access to information, support and services to use these methods effectively and confidently. In fact, mainstream sexual and reproductive health organizations are partly responsible for these barriers. Limited, if any, access to training, negative attitudes, and lack of knowledge about the methods are some of these barriers. There is little support out there for women coming off the Pill, even if they want to get pregnant. We don't show what happens in the progression towards fertility. We don't teach how they might chart their return to fertility, or change up their diet to redress the balance. Ignorance is not bliss, ignorance can be terrifying. Physicians and sexual health suppliers need to be more knowledgeable about what young women might experience coming off the Pill. We are leaving women high and dry in situations that cause a lot of concern, fear and anxiety, that could be done away with if we strove for all women to have body literacy.