For a long time, people have been trying not to get pregnant. In 500-100 CE, European women tied weasel testicles around their legs during sex to prevent pregnancy. Ancient Egyptians stuck a honey and crocodile dung mix up their vaginas to block sperm from entering. And in imperial China, sex workers were encouraged to drink liquid mercury (which might have stopped them from getting pregnant, but often killed them, too). Despite the obviously high demand for contraceptive options, it would take another couple of centuries until humans got their hands on a safe and effective birth control method. 

Nowadays, there are several female contraceptives to choose from, including the widely popular “pill”. But for people who might desire a hormone-free option for medical or religious reasons, the pickings are slim. “Birth control development is a prime symbol of the lack of innovation in women’s health,” says Kelly Culwell, an OB-GYN and head of Research and Development, Women’s Health for Sebela Pharmaceuticals.

With recent research making strides toward hormone-free birth control for men, why do female contraceptives feel so outdated? Here are three reasons.

The effectiveness of hormonal birth control

One of the big reasons why female contraceptives skew toward hormonal drugs is because of their proven effectiveness. Jill Purdie, an OB/GYN and the medical director at Pediatrix Medical Group, says there’s not much motivation for industries to invent a non-hormonal safeguard when they have repeatedly been less protective than hormonal birth control. “When you look at non-hormonal options, they are around the 80 to 89 percent range while your hormonal options are all going to be 95 percent or better.” The one exception is the non-hormonal copper IUD, which is 99 percent effective for up to 12 years after being implanted.

Costs of testing contraceptives

In the 1970s and ‘80s, Culwell says a lot of attention was focused on making lower doses of hormonal birth control pills to lower the risk of severe side effects such as dizziness and vomiting. Doing so was thought to be more cost-effective than starting from scratch. Even in the ‘90s and early 2000s, she says there weren’t many changes to the birth control method. While female birth control was designed in different forms, like rings, IUDs, and patches, Culwell says it still followed the same process of using synthetic versions of estrogen and progesterone hormones to prevent ovulation. “It’s really a capitalistic process for private companies,” she explains. “There’s a lot of research development going on in ‘big money categories’ like in the fields of cancer and neurology. Birth control doesn’t tend to bring the same level of monetary return.”

Sexism in research

Like many corners of innovation, medical research on contraceptives has a deep-seated gender gap problem. In the 1900s women were often excluded from participating in clinical trials or experiments, making it difficult to understand how birth control affected the female body. Culwell says scientists were concerned about enrolling women because there was a risk of getting pregnant, opting to use animal models like rats and rabbits instead. When women were involved in birth control trials, it was through unethical methods such as enrolling individuals hospitalized in mental institutions or recruiting poor Puerto Rican women without telling them what the medications did. It was not until 1994 that the Food and Drug Administration (FDA) made policy changes requiring all drug trials to enroll women in their studies.

Future birth control options

Both experts say there’s been a massive push for more effective non-hormonal contraceptives in the past decade. The overturning of Roe v. Wade has made Americans more vocal in having more options to prevent unwanted pregnancies.

Ironically, research on male contraceptives is helping to widen the field. Culwell says some of the hormonal side effects participants faced during a 2016 trial for shots that lowered sperm counts brought more attention to pursuing non-hormonal contraceptive choices. In response, the National Institute of Health has provided more grants towards research on new types of hormone-free birth control for both sexes, which Culwell says helps to fund innovations pharmaceutical companies initially passed on.

[Related: Everything you need to know about male hormonal birth control]

There are some new non-hormonal options already available and some currently in development. The FDA approved the vaginal gel Phexxi in May 2020. The contraceptive works by changing the pH of the vagina to stop sperm from moving around and reaching an egg. A phase 3 clinical trial with more than 1,300 individuals estimated Phexxi to be 86-percent effective in preventing pregnancy. For comparison, the hormonal pill is 99-percent effective when used properly.

Sebela Pharmaceuticals is also in phase 3 clinical trials of a new version of the copper IUD. It would be smaller, flexible, with half the amount of copper than the current copper IUD on the market. Culwell says that if the FDA approves the product, it could be on the market as early as next year. If so, “it would be the first new non-hormonal IUD in 40 years,” she explains.

While still years away from hitting pharmacy shelves, there is potential for a non-hormonal contraceptive that releases antibodies targeting sperm. Deborah Anderson, a professor of medicine at Boston University who is leading the research on this product, says it’s a topical film that can be inserted in the vagina before intercourse. Seconds after dissolving, it releases antibodies that bind and cause sperm to stick together until they can no longer move. The proteins then trap the bound sperm in the cervical mucus, the gatekeeper standing in the way of the ovaries. With more trials underway and a long FDA-approval process, Anderson gives a rough estimate of 10 years before you see these in the shelves of your local pharmacy.

“The field is getting back in gear as the NIH is putting a lot of money into it and looking for industry engagement again,” says Anderson. “[We] should look forward to more contraceptive productions in the future.”