What's Up With the Pill?
The pill at 40
By Gina Shaw
Reviewed By Gary Vogin
What do you know about oral contraceptives -- the pill? What do you think you know? The pill's been around for 40 years, first in its early, high-dose forms and now with lower levels of hormones ("low-dose" and "mini" pills), but four decades of research on its use haven't been enough to stem the myths and controversies associated with this method of contraception. What's true, what's not, and what's new?
Risks, Myths, and Legends
Does the pill lead to an increased risk of breast cancer? Reports from a 10-year European study, released in March, have had this concern in the news again. Researchers found a 26% higher risk of breast cancer among women in the study who reported ever using the pill compared with those who hadn't. The risk appeared to shoot up to 58% higher among women who used the pill for all 10 years of the study.
One of the best studies on the subject to date, published in the Lancet in 1997 by the Collaborative Group on Hormonal Factors in Breast Cancer, found a small increased risk of breast cancer -- about 24% -- among pill users. But women who've taken the pill appear to be less likely, overall, to die of breast cancer than women who haven't taken it. "There's a small overall increased risk of breast cancer, but a lower incidence of metastatic breast cancer, among pill users," says David Grimes, MD, vice president of biomedical affairs for Family Health International. That, he says, jibes with the results of a recent study of hormone replacement therapy that had the same results -- a slight increase in breast cancer risk, but a lower rate of breast cancer death.
And in the June 27, 2002, issue of The New England Journal of Medicine, researchers reported that current or former pill use did not increase the risk of breast cancer in the more than 9,000 women they studied. This was true even for women with a family history of the disease and those who began taking the pill at a young age. The women were aged 35-64 and from various ethnic groups.
Some studies have also claimed that pill use can increase a woman's risk of heart disease, but this is a tough one to document. "Heart disease, in women under the age of 40, is so rare that when you start to do number crunching, it's hard to find a difference that you can say is statistically sound," says Mitchell Creinin, MD, associate professor of obstetrics, gynecology, and reproductive sciences and director of family planning and contraceptive research at Magee-Womens Hospital of the University of Pittsburgh. "Some European studies suggest that there might be a small added risk with some birth control pills, but there's really no physiologic basis for that to happen, and no U.S. studies have found this."
Perhaps the biggest "pill risk" myth: infertility. Nearly one-third of women in a recent Harris poll believed that infertility is a risk of taking the pill. Absolutely untrue, say experts. "Birth control pills do not cause infertility," says Grimes. "There can be a short-term delay in the return of ovulation; higher-dose pills have a one-month longer delay than the lower-dose pills."
Many doctors now prescribe the pill for women entering perimenopause, not just as a contraceptive, but also as a way to relieve some of the symptoms of this transitional stage. "It relieves irregular bleeding and decreases the risk of fractures as a woman goes into menopause," Creinin says. Hormone replacement therapy, often also prescribed for perimenopausal women, can provide the same protection against osteoporosis but has no effect on bleeding. Nor does it have the other beneficial effects the pill offers.
Oral contraceptives have been shown to prevent endometrial and ovarian cancers, cutting the risk of these diseases by some 40-50% -- with protective effects lasting as long as 15 years after a woman stops taking the pill. "There's been new data showing that we get the same kind of protective effect with new low-dose pills as with the older pills," Creinin says.
The pill also helps to prevent ectopic pregnancies, pelvic inflammatory disease (PID), benign breast disease, cramps, and iron-deficiency anemia.
This doesn't mean that the pill is perfect. Perhaps its greatest flaw is that it relies on the human memory too much. "The pill has a relatively high failure rate for a highly effective method. That's because it requires daily compliance. If you ask somebody to do something at the same time every day, it's very difficult to do, every study shows," Creinin says. "So the pill is still fraught with failure when used under real-world conditions." Several new options -- either recently available or preparing to make their debut -- may offer many of the pill's benefits without the need for a daily memory jogger to be effective.
Set to reach the market soon are new contraceptive products that offer combination hormones in a patch and an insertable ring. EVRA, the contraceptive patch, due to hit the market within days if it hasn't already, is changed weekly. The NuvaRing, approved by the FDA last October and expected to be available for routine sale within the next two months, is changed monthly. "They hold a lot of promise, and offer the same protections as the pill," Creinin says.
Another option: the new hormone-releasing IUD, Mirena. More effective than tubal ligation, but reversible, Mirena is inserted for up to five years. "I've put in tons of Mirenas, and women love it," says Creinin. "But it's not a cure-all end-all. It doesn't hold the same benefits for ovarian cancer, though it probably would for endometrial cancer. With all methods, we have to look at their risks and benefits, both contraceptive and noncontraceptive."
Originally published June 24, 2002.
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