The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health. Men and women have been trying to prevent pregnancy since the dawn of time by using whatever device, potion, or magical charm was in favor at the time. Women in the sixth century were told to wear cat liver in a tube on their left foot while Islamic women in the thirteenth century favored peeing into the urine of a wolf to avoid pregnancy.

Women also ingested recipes made from leaves of ivy and willow plants as well as other far more dangerous chemicals that were thought to prevent pregnancy. In the middle Ages women ingested lead, arsenic, mercury, and strychnine, all of which were thought to act as birth control.

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health
The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

Other women chose barrier methods instead and inserted all kinds of things into their vaginas to stop sperm — wool tampons soaked in wine, sponges, elephant dung, and gold balls were apparently popular in the time of Casanova (Connell, 1999).

In the modern age, we know better than to drink strychnine or stick excrement in our vaginas as a form of contraception and we would certainly think twice before using a douche containing Lysol®, a sperm-killing practice that was popular as recently as the 1950s (Connell, 1999). Despite our increase in knowledge and caution, many worry that even our modern methods of contraception are not safe.

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

There are fears that the pill causes cancer, that implants will get stuck in a woman’s arm requiring major surgery, and that IUDs will cause infertility. Though these fears are grounded in the inauspicious history of some of these methods, the truth is that today’s versions of each of these contraceptives are thought to be safe for most women.

This entry reviews the history of the birth control pill, other hormonal methods, and IUDs in order to explain the origin of the safety concerns and the best science that we have today which, again, suggests these methods are safe for most women. As a caveat, we want to stress that by saying these methods are safe we are not attempting to say that they have no side effects or that they will be appropriate for every woman. We would always encourage women and their partners to talk to a health care provider about what method might be best for them.

The Birth Control Pill
In 1960, the first oral contraceptive pill was approved for sale in the United States after what many saw as a very short period from conception (pun completely intended) to market which took just 10 years. (In contrast, the implant that we talk about later began development in 1960 and wasn’t on the market until 1990; Watkins, 2010). As the pill represented an entirely new way of preventing pregnancy — suppressing ovulation — there were many concerns about the health risks in both the long and short term. People wondered whether preventing ovulation for long periods of time would cause fertility problems when a woman decided to get pregnant and whether the hormones would increase risk of cancers.

Combination oral contraceptives (COCs) like the ones that were first available contain both estrogen and progestin, a synthetic version of the hormone progesterone. Early birth control pills contained significantly higher doses of both of these ingredients than those currently on the market. In fact, drug companies learned quickly that smaller amounts of the active ingredients were necessary to suppress ovulation. The first pill, Enovid-E, contained 150 μg estrogen and 9.85 mg progestin.

When it was revised just 5 years later this was down to 100 μg estrogen and 2.5 mg progestin (Tyrer, 1999). Today, COCs contain as little as 20 μg estrogen (Nelson and Cwiak, 2011). There are also pills on the market today that only contain progestin — these are sometimes called the mini-pill. Most of the research we are talking about here, however, has been done on COCs, which contain both hormones.

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

The first generation pills did cause a lot of side effects. Women reported headaches, dizziness, and nausea. Within 2 years of the pill’s release, there were also reports of serious adverse effects such as stroke, venous thromboembolism events (VTE), which is a blood clot in the veins, and myocardial infarction, which is the medical term for a heart attack. Though this was likely the result of the high doses of hormones in these early pills, it also reflected a lack of knowledge on the part of health care providers about who was not a good candidate to take birth control pills.

Studies carried out since the introduction of the pill suggest that women with certain health conditions like high blood pressure, women who have had cardiovascular issues in the past, and heavy smokers are at increased risk of these side effects. For this reason, some health care providers suggest women with these histories avoid the pill and other hormonal methods (Tyrer, 1999).

While the pill has become safer over the years, its reputation for being dangerous continues and various myths and misperceptions have developed. Contraceptive Technology, one of the pre-eminent publications on the topic used frequently by health care providers, has a very good overview of the persistent myths surrounding the pill and we would like to share some of these with our readers.

To prevent confusion for those readers who are merely skimming this chapter (not that anyone would do so), we present each topic with a positive, truthful statement rather than highlight the myth itself.

The Pill Does Not Cause Infertility.
There is a persistent fear that the pill will permanently impact a woman’s fertility. Research has shown this is not the case. A comprehensive review of all studies that were published between 1960 and 2007 found that fertility returns very quickly in women who stop using the pill in order to get pregnant. Most women who stop the pill will get their periods within 2 weeks. In fact, the study found that between 74% and 94% of women who discontinued the pill to conceive became pregnant within 1 year (Nelson and Cwiak, 2011).

The Pill Does Not Cause Breast Cancer.
Those older pills that included higher doses of hormones were found to increase a woman’s chance of getting breast cancer slightly. The newer, lower dose pills that were introduced after 1975, however, have not been found to do so. Numerous studies have been carried out on this topic with varying designs and varying results. A case-controlled study found no difference in pill use among women who had breast cancer and women who did not.

A large study, conducted by the Royal College of General Practitioners (RCGP) in England, found no increase in the risk of breast cancer between those who had ever used the pill and those who never had. In fact, research has found that even women who carry the BRCA1 and BRCA2 genes (which are known to increase breast cancer risk) and women with a family history of breast cancer do not increase their risk by taking the pill (Nelson and Cwiak, 2011).

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

Interestingly, the pill actually provides a protective factor against ovarian cancer (cancer of the ovaries) and endometrial cancer (cancer of the lining of the uterus). Women who use COCs are significantly less likely to get ovarian cancer, which is considered the most lethal of gynecological cancers because it is often not caught until late stages. Research has shown that women who use certain types of the pill for at least 10 years can reduce their risk of developing ovarian cancer by 80%. A study by the RCGP that followed women for up to 39 years also found that those who had ever used the pill were 47% less likely to die from ovarian cancer than those who never had (Nelson and Cwiak, 2011).

Similar results have been found for endometrial cancer which occurs in over 40,000 women in the United States each year. Use of COCs for just 1 year reduces a woman’s chance of getting this kind of cancer by 40% whereas use for 10 years can reduce the risk by 80% compared to a woman who has never used the pill. Moreover, the protective factor can stay with a woman for as long as 20 years after she stops taking the pill (Nelson and Cwiak, 2011).

The Pill Does Not Ruin Most Women’s Libido.
This is a tricky one because, as we know, everyone experiences side effects from medications differently and some women have reported a decrease in sexual desire when they are on the birth control pill. We do not want to dismiss these women’s complaints or suggest that low libido is something they (or anyone for that matter) should just live with. Women who experience this side effect should talk to their health care provider. Sometimes a change in the brand or dose of pill can get rid of any side effects (be it loss of libido, moodiness, or breast pain).

We would like to reassure our readers that for most women this is not an issue. In fact, clinical trials have found that loss of libido is experienced by only 1–5% of users. A study of women taking a certain kind of pill (one containing drospirenone) found that they had significant improvements in sexual enjoyment, satisfaction, and frequency of orgasm but no change in libido (Nelson and Cwiak, 2011).

The Pill Does Not Cause Weight Gain in Most Women.
Some women have complained that they gain a lot of weight the minute they go on the pill. Clinical trials may appear to back this up but that is because any weight gain a woman does experience while in the trial is attributed to the pill (even if it’s really just the freshman 15 or the result of an expired gym membership). Unlike clinical trials for efficacy, studies that look at noncontraceptive benefits of the pill can use a placebo design which allows for better study of some side effects. These studies have found that the percentage of women who gain an excessive amount of weight is similar in the pill group and the placebo group (Nelson and Cwiak, 2011).

We do want to underscore, however, that like all medications the pill does have side effects — some annoying and some serious. Even at today’s lower doses, the pill does increase the risk of blood clots for women with certain risk factors including older age, obesity, heavy smoking, and genetic predispositions. The risk of blood clots is greatest in the first 3–12 months that a woman is on the pill.

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

For this reason, health care providers suggest that new users (or those who have recently changed formulations of the pill) should watch out for certain symptoms including abdominal pain, chest pain, headaches, eye problems (like loss of vision), and severe leg pain. These symptoms are presented this way because if you put the first letters of each together it spells ACHES. Hopefully, this can help women remember what to look for.

Recent Research on Certain Hormonal Contraceptive Methods
Concerns about the pill have seen new life lately because of attention the media has paid to a number of studies and lawsuits involving the brand name pills Yaz and Yasmin, the contraceptive ring NuvaRing, and the contraceptive patch sold as Ortho Evra. These represent the three newest hormonal methods of contraception that have been released. Anecdotal stories have suggested that each of these methods puts women at much greater risk of blood clots than older versions of the pill.

In addition, there have been several high profile cases of fatal blood clots in otherwise healthy young women and lawsuits have been filed against the manufacturers of these products, alleging they knew of the increased risk and should have warned women.

Much of what has been written about this has been quite sensational. In December 2013, Vanity Fair ran a headline online asking “Why is a potentially lethal contraceptive NuvaRing still on the market?” which linked to a full article by Marie Brenner called “Danger in the Ring.” That same month, the Huffington Post ran an article called “Side effects may include death: The story of the biggest advance in birth control since the pill.”

Both articles hint at a conspiracy to cover up data from the original drug trials which suggested a higher risk of blood clots for ring users than pill users. Siddiqui also notes that Food and Drug Administration (FDA) officials were concerned that an otherwise healthy young woman in the initial clinical trial experienced a blood clot but that negotiations with the manufacturer ultimately result in no additional warnings being included on the label (Brenner, 2014; Siddiqui, 2013).

We don’t feel in a position to comment on the conspiracy theory and assume that more will be written as the lawsuits proceed. However, we do want to provide our readers with the latest research information on these methods.

Part of the problem is that research results have been mixed. Of eight studies completed by 2013 on DSRPs (formulations of the pill, like Yaz and Yasmin, that rely on drospirenone/ethinyl estradiol), five have shown an increased risk of VTE (remember from earlier that this is venous thromboembolic events or blood clots in the veins) compared with women on low dose COCs that have been on the market longer. Three of the eight studies showed no increased risk.

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

As for the contraceptive patch, two out of five studies showed an increased risk of VTE but three did not. There has also been a recent study that found a slightly increased risk of VTE with the contraceptive ring (Sidney et al., 2013).

In an effort to clear up the confusion, Sidney et al. looked at the medical records of over 573,000 new users of either low dose COCs or one of the newer hormonal methods between 2001 and 2007. They chose new users because most blood clots take place in the first 3–12 months of use. They found that women using the ring or the patch were at no higher risk of blood clots than women using low dose COCs.

Women taking DSRPs, however, were at a significantly higher risk of blood clots than those on older types of pills. This study concluded that “initiation of new use of DRSP-containing CHCs was associated with a 77 percent increase in the risk of hospitalization for VTE relative to the use of a comparator group of four low-dose estrogen CHCs” (Sidney et al., 2013).

Another study released in 2013 compared vaginal ring users with those who used COCs. It followed 33,295 users of the vaginal ring or COCs recruited by 1661 study centers in both the United States and Europe. The women were followed for 2–4 years. Researchers were particularly concerned with cardiovascular issues the women might have, specifically venous and arterial thromboembolism (VTE and ATE). They found similar rates in the two groups of participants and concluded that “vaginal ring use and combined OCP use were associated with a similar venous and arterial thromboembolic risk during routine clinical use” (Dinger et al., 2013).

So, despite the headlines, the best evidence right now is that all hormonal birth control methods increase a woman’s risk of blood clots slightly when compared with those women not on hormonal birth control. The newer DSR pills seem to increase this risk over women taking regular COCs. The patch and the ring, however, do not.

We want to acknowledge that research continues to be conducted and released and the current thinking might change. In the meantime women who have concerns about this should talk to their health care provider. Though some would say that this is comparing apples with oranges, we also think it’s worth noting that what puts women at the most risk of blood clots is pregnancy and childbirth. This is not to dismiss the risks of hormonal contraception but to remind readers that preventing unintended pregnancy is important for many reasons.

Contraceptive Implants
Implants are a form of hormonal contraception that are categorized as longacting reversible contraceptives (LARCs). (IUDs are the other form of birth control referred to as a LARC.) They consist of one or more thin rods that are inserted under the skin on a woman’s upper arm which continually release hormones for a number of years. They need to be inserted and removed by a health care provider.

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

The first implant released in the United States was Norplant which was approved by the FDA in 1990. Norplant was hailed as a breakthrough in contraception because once it was inserted a woman was protected from pregnancy for 5 years without having to do anything as potentially difficult as remembering to take a pill every day. For a few years, health care providers and women agreed that this was a great new option — in 1992 sales of Norplant reached $120.7 million (Watkins, 2010).

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health
The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health
The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

The negative press around Norplant, however, started early and continued to grow as it focused on three separate issues — civil rights, cost, and side effects. It became clear early on that some states were looking at Norplant as a way to control birth rates in women on welfare and low-income women, who were also disproportionately women of color.

In 1992, the Mississippi legislature, for example, introduced a bill that would require women with four or more children to get Norplant in order to receive public aid. In fact, that year 13 states considered bills that involved Norplant — some made it a condition for receiving welfare, others would have provided financial incentives for women to choose the method, and still others attempted to require the implant as a condition of parole or probation. None of these measures passed but the public debate over Norplant had begun in a bad light (Watkins, 2010).

Congress then became involved in a different issue surrounding the new method — cost. Hearings asked why the same device that cost $23 overseas was being sold to American women for $365. Family planning clinics pointed out that it made more financial sense for them to provide birth control pills to many women than Norplant to just a few (Watkins, 2010).

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

What may have received the most attention, however, were the reports of side effects. Though researchers knew, and women were told, that the implant would likely disrupt their menstrual cycle and that this was normal, many users complained about it. For some women, Norplant completely stopped their periods while others found they bled or spotted for many days of the month.

Many women found this more disruptive than they had anticipated. Other side effects included those that are common to all hormonal methods such as headaches, acne, and mood changes. One issue exclusive to Norplant, however, was the removal process. As women began to remove the implants — either because the 5 years were up or because they decided they didn’t want to continue using it — there were reports that it was difficult to take out, that not enough providers were trained in removal techniques, and that what should be a 15-minute procedure was turning into a painful 2-hour operation (Watkins, 2010).

Not surprisingly, a number of lawsuits were filed against the manufacturer. The negative press led to diminished demand but the final nail in Norplant’s coffin turned out to be manufacturing issues. In 2000, the manufacturer announced that some of the implants it had made the previous year might have a shorter shelf-life than the promised 5 years. They stopped shipping new supplies out, suggested women who had received the implant in 1999 use back-up birth control, and told clinicians to stop inserting them.

Two years later, the company announced that due to “limitations in product component supplies” it was going to stop manufacturing the implant altogether (Watkins, 2010).

This complicated history is fascinating and may help explain why people are wary of the newer implants on the market. That said, today’s implants have none of the problems of Norplant. The FDA approved Implanon in 2006. This newer version consists of just one rod which makes it less obtrusive and ensures that insertion and removal are much easier.

In trials in the United States and Europe, for example, the average insertion time for Implanon was 1 minute and removal time was 3 minutes. In contrast, Norplant required up to 10 minutes to insert and 1 hour to remove (Darney, 2006).

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

The company that made Implanon has since developed Nexplanon which is even easier to insert and remove. Nexplanon also contains barium which makes the rod detectable by X-ray in cases of deep insertion. Implanon remained safe and continued to be used in the United States until supplies ran out at which point it was replaced by Nexplanon. Implanon and Nexplanon last for 3 years (Mansour, 2010).

Implants are safe and, because they contain only progestin (no estrogen), they do not carry the same risks of blood clots, stroke, or heart attack that other combined contraceptive methods do. They do still change women’s menstrual bleeding patterns — some women bleed much less and less frequently, while others have prolonged or frequent periods. There are no health implications for this but some women find it annoying.

The other question many people have about implants is whether they cause weight gain. In 11 clinical trials that included 942 women the median weight gain was less than 5.6 pounds over a period of up to 3 years. There is no way to know, however, if this weight gain was caused by the implant or would have occurred anyway (Raymond, 2011).

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health
The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health
The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

IUDs
The first intrauterine device (IUD) was made in 1909 out of the gut of a silkworm. More sophisticated versions were introduced in the 1920s and 1930s but they fell out of favor until modern, all plastic models came on the market in the 1960s (Connell, 1999). The IUD is an interesting method of birth control because with all the science and research we have on it there are still some questions about how exactly it works. One of its mechanisms for action is what’s known as the “foreign body effect” — our bodies are naturally programmed to react to something foreign by releasing white blood cells.

A foreign body in the uterus causes an inflammatory reaction that is toxic to both sperm and egg which prevents implantation.

Modern IUDs, which are sometimes referred to as intrauterine contraceptives (IUCs), also contain chemicals — either copper which impairs sperm function or hormones similar to those in the some birth control pills which thicken cervical mucus — both of these mechanisms can help prevent fertilzation (Dean and Schwarz, 2011). But before we get to today’s generation of IUCs, we have to talk about the 1970s. By that decade there were 17 models of IUDs on the market manufactured by 15 different companies. The fourth one to be released was the Dalkon Shield made by A.H. Robins.

The Dalkon Shield looks a little like the shell of a horseshoe crab that you would find washed up on the beach except miniaturized, and instead of one large spike out of the top it has five short spikes off each side.

These spikes were meant to keep the IUD in place. They turned out to be very irritating to the lining of the uterus and caused many users to develop pelvic inflammatory disease (PID) which in turn caused infertility. The Dalkon Shield also had a higher failure rate than other IUDs meaning some women became pregnant. Those who did were at risk of septic miscarriage, a miscarriage followed by a severe infection. Eighteen women who used the Dalkon Shield died from this (Couzin-Frankel, 2011).

In 1974, A.H. Robins took it off the market but stories of complications and negative press continued to roll in and more than 400,000 lawsuits were filed, which kept the story in the headlines. In 1986, a public service announcement that aired on television implored women to have their Dalkon Shields removed. A year earlier the manufacturer had gone bankrupt.

Ultimately, a $3 billion fund was set up to compensate women who had had issues with the IUD. Though only the Dalkon Shield was implicated in these medical issues, the impact was felt by all IUDs. By 1986 there was only one IUD on the market and few women were using it (Couzin-Frankel, 2011).

Today, however, there is a new generation of IUDs that are very safe and effective. The first to be introduced was ParaGard, which is a small T-shaped device made of plastic wrapped in copper. The second was Mirena, which releases a continuous amount of the synthetic hormone levonorgestrel (LNg) which is found in some birth control pills. Originally, these methods were approved for use only in women who had already had children as people were
still wary of what happened in the 1970s. But as research came out it became clear that these models were safe for women of all ages regardless of whether they’d been pregnant or given birth.

In 2011, the American College of Obstetricians and Gynecologists (ACOG) revised its official practice guidelines on LARCs, including implants and IUDs. After reviewing the latest available research, the guidelines concluded that, “Nulliparous women and adolescents can be offered LARC methods, including IUDs” (ACOG Practice Bulletin, 2011). These guidelines represent the best practices in obstetrics and gynecology and strongly influence what health care providers recommend to patients.

In fact, the manufacturer Bayer recently released a new version that is smaller and specifically designed to be inserted in young women and those who have not had children (such women tend to have smaller uteruses). The new version, Skyla, also releases LNg.

Despite the fact that these new IUDs are safe and effective, uptake has been slow. Many believe that this is because so many myths exist about IUDs.

Contraceptive Technology does a good job of dispelling these myths. Again, we flipped them around so that the truth is highlighted rather than the misperception.

IUDs Do Not Cause Pelvic Inflammatory Disease.
The IUD itself does not increase the risk of PID. There is a slight risk that during the insertion process bacteria could be introduced to the upper genital tract that might cause PID but this risk is so small that experts do not even suggest prophylactic antibiotics (Dean and Schwarz, 2011).

IUDs Do Not Cause Ectopic Pregnancy.
An ectopic pregnancy is one that implants and starts to develop outside the uterus, most often in the fallopian tubes. An ectopic pregnancy cannot survive and can pose a danger to women if not caught early. By preventing conception, IUDs, like other birth control methods, actually reduce the risk of ectopic pregnancies. And IUDs are one of the most effective forms of contraception — a woman with an IUD has just a 0.1–0.5% chance of getting pregnant in the first year of use. A woman who does get pregnant while she has an IUD is at a higher risk of ectopic pregnancy (Dean and Schwarz, 2011).

IUDs Can Be Used by Teenagers.
IUDs are safe for use in women of all ages regardless of whether they have had children. ACOG recommends IUDs as a first line choice for sexually active adolescent women. A concern with this age group is that IUDs raise the risk of STIs. While this is not true, it is important that all women who use IUDs understand that they do not provide any protection against STIs and that women and their partners should continue using condoms. Writing for the Contraceptive Journal of the Association for Reproductive Health Professionals (ARHP), experts Speidel et al. write: Unfortunately, outdated perceptions about appropriate patient candidates for LARC among health care providers continue to negatively impact their use.

The Pill and Other Birth Control Methods Are Actually Dangerous to a Woman’s Health

An emerging body of research has disproved a number of contraindications to IUC use. Specifically, women of any age or parity and those who are postpartum or post first or second trimester abortion are eligible for IUC. The benefits of IUC also outweigh the risks of a wide variety of medical conditions that might contraindicate the use of combined hormonal contraceptives.

IUDs Do Not Cause Abortions.
As we mentioned earlier, the exact method of action for IUDs is a bit of a mystery which has left room for speculation and discussion about whether IUDs could be considered an abortifacient — something that ends an established pregnancy. Experts say this is not the case. In Contraceptive Technology, Dean and Schwarz write simply, “IUC’s prevent fertilization and thus are true contraceptives.” A nurse practitioner friend of ours said it was helpful to think about an IUD like a goalie. Sperm are trying to get into and past the uterus to get to the egg while it’s still in the fallopian tubes — through various methods discussed earlier, the IUD blocks that path.

Moving Beyond the Myths
Again, our goal with this entry is not to dismiss concerns over the safety of contraceptive methods. We think that women (and men, of course) should be informed consumers which means, in part, understanding the risks of any medicine or device they use as all do come with some risks. We also understand the desire for caution especially based on the history of some methods. Nevertheless, we are confident that, as of now, the best science suggests that modern methods of contraception are safe for most women.

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