Marissa is 35 years old, married, with a first grader and a stressful job as a sonographer. To take the edge off, she watches TV — soapy dramas on Hulu, mostly, like Shadowhunters and Motherland: Fort Salem. During the pandemic, she started to see this one particular commercial a lot. It takes place in a cavernous room draped in shades of pink chiffon, and stars Schitt’s Creek actress Annie Murphy.
“Welcome to my vagina,” coos Annie Murphy, reclining on a plush, blush-colored sofa. “In here, I make the rules. Rule one: no hormones.” It’s an advertisement for Phexxi, which Murphy goes on to describe as “a revolutionary hormone-free birth control gel.” The concept is simple: you insert the gel into your vagina before sex, and it, ostensibly, prevents pregnancy.
As Murphy speaks, a disclaimer runs along the bottom of the screen: “86% effective with typical use. 94% effective with perfect use.” “The commercials made it seem like you put it in, and that’s it: you don’t get pregnant,” says Marissa, whose name has been changed for this story.
Marissa is one of a growing number of women seeking non-hormonal alternatives to the pill for a wide range of reasons, from hormones’ impact on their mood or sex drive to broader health concerns. Common complaints about hormonal birth control include headaches, nausea, bleeding between periods, and mood changes, and there is evidence taking birth control pills for an extended period of time may increase one’s risk for certain kinds of cancer.
But there aren’t many options for people like Marissa, and the ones that do exist — condoms, diaphragms, the copper IUD — have their own drawbacks. That’s why the announcement in 2020 that there was a new FDA-approved non-hormonal birth control on the market attracted such positive attention, from a plug in the Washington Post, to a New York Times profile of Saundra Pelletier, the hard-charging, fiercely feminist CEO of Phexxi’s manufacturer, EvoFem Biosciences.
“One of the things that we know is that there’s 23 million women who will not use hormones,” Pelletier, an energetic blonde in thick-frame glasses, tells Rolling Stone. “When we did research with them, they said, ‘Look, we tried pills and patches and IUDs. And the side effects were real for us. And we don’t have hormones in our milk. We don’t have hormones in our meat.’ And so we wanted a product… for the women who won’t use hormones and really want the empowerment of having something on-demand.”
But some women who have chosen Phexxi as standalone birth control have reported a problem: they say that, even after diligently following the directions, they’ve ended up pregnant after just a few uses. No birth control method is perfect, but with stakes of an unplanned pregnancy higher than ever, those women are raising questions about whether, in post-Roe America, the product should be on the market at all.
Marissa had only been using Phexxi for two months when she started to feel weird. “I thought I better go take a pregnancy test. Lo and behold, it was positive.” Shocked as she was — she still believes she used Phexxi exactly as directed — Marissa remembers thinking: “‘Maybe it was just my case’…Then I went onto websites to look at reviews and realized I was not the only person.”
Describing Phexxi’s technology as “revolutionary,” as Murphy does in the commercial, may be overstating the case a bit: its active ingredients are lactic acid, citric acid, and potassium bitartrate. (Representatives for Murphy did not respond to an inquiry from Rolling Stone.) In an interview with Rolling Stone, Pelletier emphasized the safety of Phexxi’s ingredients relative to other products. “These are food grade products,” she said. “I mean, I wouldn’t make it in my bathroom — but I could.” (Marissa was taken aback when she realized Phexxi’s mechanism for preventing pregnancy, which she now thinks of as “basically like putting lemon juice in your vagina and hoping for the best.”)
It works, essentially, by lowering the pH of a woman’s vagina to make it less hospitable to sperm. Pelleteir emphasizes that Phexxi works to keep the vagina at its normal pH — 3.5 to 4.5 — to counteract the effects of ovulation and the presence of semen, both of which raise the pH, but the outcome is essentially the same.
Dr. Wipawee Winuthayanon, a professor at the University of Missouri who studies non-hormonal contraceptive development, says that conceptually, Phexxi makes sense. “Sperm is very finicky: any acidic environment, and they are not going to swim at all — technically, theoretically — it should work.” And, in fact, Phexxi has similar ingredients to two existing over-the-counter gels available in Europe: Caya Gel and Contragel — both of which are designed to be used in conjunction with a diaphragm. “Every time I give a talk, I say: ‘You cannot use gel alone,’” Winuthayanon says.
But EvoFem Biosciences has mounted an aggressive marketing campaign, presenting Phexxi as a standalone birth control — the Annie Murphy commercial racked up more than 2 billion impressions. And with its popularity on TikTok, where videos tagged #phexxi have a combined 2.3 million views, there is high demand for the product. According to the company, a little more than 100,000 women hold Phexxi prescriptions today in the United States.
Yet in crowd-sourced databases and online forums, alongside some rave reviews of Phexxi, are dozens of women reporting pregnancies while using the drug. WebMd — where, as of press time, Phexxi has a rating of 3.3 out of 10 based on 96 reviews — has more than 30 stories from users who have ended up pregnant. (“Used it for one month exactly as prescribed and got pregnant;” “Used for 3 months, and now I’m pregnant;” “After 4 months of use I got pregnant.”) The online database Drugs.com, where the gel currently has a rating of 4.2 out of 10, there are 10 reports of pregnancies in 18 reviews. (“No side effects such as a UTI or burning. But the main side effect is that I ended up getting pregnant,” one user wrote.) Reddit, too, has also become a repository for such cautionary tales. (“Baby is now a month old and I will never not be pissed about their false advertising,” one Redditor fumed. “As effective as condoms my fucking ass.”)
Representatives for the company insisted the product is effective when used correctly; some common mistakes they cited are inserting the gel more than 60 minutes prior to sex, or inserting it after sex, when it would not be effective at all. On Phexxi’s website, EvoFem lists a phone number users can call to report any adverse events they experience while using the drug — the company is required to report those incidents to the FDA — and while representatives for EvoFem conceded Phexxi users have reported pregnancies, they declined to share with Rolling Stone the number of calls they’ve received.
“I would never use this in a red state, if you were looking for absolute contraception”
“It’s not surprising to hear about contraceptive failures with Phexxi,” says Mary Jane Minkin, MD, a practicing gynecologist and clinical professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the Yale University School of Medicine. While she says it is “better than not using anything,” the 86 percent effectiveness rate would give her pause in terms of recommending Phexxi as a standalone method of birth control.
“I would never use this, for example, in a red state, if you were looking for absolute contraception,” she says.
Dr. Carolyn Westhoff, professor at Columbia University in OB-GYN, epidemiology, and population and family health, says that Phexxi’s 86 percent effectiveness rate among “typical” users is “pretty good… in the upper range of less effective methods,” behind the most effective contraceptives like implants or IUDs, as well as what she calls “tier 2” contraceptives like birth control pills or Depo-Provera. (“Typical use” refers to how people most often use contraceptives, leaving room for user error; “perfect use” describes effectiveness when a contraceptive is used exactly as directed.)
Phexxi, she says, falls in the third category, alongside methods like condoms, which are 87 percent effective with typical use. (Westhoff’s team was initially involved in early clinical trials for Phexxi, but withdrew due to being unable to recruit the requisite number of participants for the study.)
In an interview with Rolling Stone, representatives for EvoFem explained that its advertised effective rates are based on a clinical trial that, instead of Pearl Index, used the Kaplan-Meier estimate — a statistical technique often used to measure the survival rate of cancer patients. “It’s not very commonly used in a contraceptive space,” Deedee Asuamah, director of medical information at Evofem Biosciences, acknowledged, but she added, “The FDA agreed that the Kaplan-Meier assessment would be the most appropriate because it was an on demand method, and because of the duration of time of the study.” (Westhoff, for her part, confirmed that the use of Kaplan-Meier is “not a red flag,” adding she thought the clinical study was “trustworthy and done according to contemporary standards.”)
Emma (also not her real name), a married health care executive, also has questions about Phexxi’s effectiveness rate. She first read about Phexxi in the New York Times. From ages 24 to 28, Emma was on the copper IUD, which, she says, gave her “incredibly long and heavy periods.” From 28 to 33 was on a hormonal IUD, which “was great,” she says, until she started to worry about its long-term effects.
Emma used Phexxi for three months before she realized she was pregnant. When the reality of her situation started to sink in, she googled “Phexii efficacy” and found a number of women on WebMD and Reddit saying they’d gotten pregnant like her. That’s when she says she started getting angry.
“It really pisses me off that they are packaging themselves as ‘feminist’ for a product that doesn’t work at a time when [abortion] access has shrunk in certain parts of the country,” Emma says.
She says she’s angry less about her own personal situation than she is about the implications of Phexxi being on the market in such a tenuous political landscape. “I have the money for an abortion if I need it. I live in a state where abortions are legal,” she says. “But thinking about this ineffective birth control method coming out right before Roe was overturned, billing itself as a wellness- or feminist-focused brand, but then getting people pregnant? That makes me incredibly angry.”
Over the last year, EvoFem has worked to convince insurers to cover Phexxi. It’s had some success: Prime Healthcare covers Phexxi, as does Zinc, CVS’s group purchasing organization. Katherine Atkinson, EvoFem’s chief commercial officer, says that according to company data, starting this year eight out of 10 women in childbearing years “should be able to get access to Phexxi at a very affordable rate.”
“I think that when women live in those oppressive states — if you live in a state like that, I think you’re using it correctly”
In January, EvoFem also announced that starting this year, Phexxi will be covered by Medicaid plans in a number of states where abortion is banned or severely restricted — including Georgia, where abortion is illegal after 6 weeks, Indiana, where the state legislature passed new laws banning nearly all abortion last summer (the law is currently on hold during a pending court decision), and Mississippi, where virtually all abortions are now illegal.
Pelletier expressed no reservations about the company’s efforts to make the drugs available to low-income women in states with restrictive abortion laws. “I think that women are smarter than they’ve ever been,” she says. “I think they’re more empowered than they’ve ever been. I think that when women live in those oppressive states — if you live in a state like that, I think you’re using it correctly,” Pelletier says. “And if you’re using it correctly, it’s working. That’s really what I think.”
Westhoff, who prescribes Phexxi to some of the patients in her practice, agrees that increasing availability of non-hormonal contraceptive methods can only be a good thing, even in states with restrictive abortion laws. “Not all women are interested or able to use more effective methods. This is way, way better than nothing,” she says. “If it’s a method that women prefer, and they have all the information on risks, benefits, and alternatives — I think having more methods available is better than having fewer methods available.”
Marissa, the 35-year-old sonographer who went on Phexxi after seeing Hulu ads for the drug, lives in a state where abortion is still legal. When she found out she was pregnant in December 2021, she called her local Planned Parenthood, and took the abortion pill. “I was very relieved not to be pregnant anymore,” she says.
Still, she’s angry she ended up in this position at all. She’s angry at EvoFem — at one point, she even considered filing a lawsuit against them, an idea she’s since dropped — and she’s angry at herself. “I should’ve done more research. I should’ve read reviews — I read Amazon reviews for my toaster! I could’ve done that for Phexii and realized people were getting pregnant,” she says.