The Contraceptive Conundrum

In the past 30 years, numerous chemicals and devices that manipulate women’s reproductive systems have arrived on the market. Currently, oral contraceptives are one of the most widely used drugs among women in the western world. In Canada, an estimated 18 percent (1.3 million) of women aged 15 to 49 use oral contraceptives.

Most oral contraceptives contain both estrogen and progestins (synthetic progesterone) which, depending on the type of progestin in the pill, are known as either second or third generation. Contraceptives may exert their contraceptive action in at least four ways:

1. by inhibiting ovulation
2. by causing endometrial changes hindering ovum implantation
3. by altering the properties of the cervical mucus, inhibiting sperm penetration and/or
4. by causing changes in the hypothalamic-pituitary-ovarian axis and corpus luteum (interrupting natural hormone production).

Oral contraceptives are a very effective method of birth control and provide non-contraceptive benefits such as decreased incidence of ovarian cysts and tubal pregnancy, regulation of menses, and decreased incidence of endometrial and ovarian cancers. Many women choose to take the pill for various reasons. Before prescribing a contraceptive, your doctor is required to discuss the options with you, explaining the risks and benefits so you can decide which contraceptive method is best for you.

Rating the Risks

In the 1960s, oral contraceptives contained about 10 times the progestin and four times the estrogen of today’s pills. However, current birth control pills are not without risks. Common side-effects include spotting, nausea, headaches, decreased sexual desire, vomiting and other stomach complaints, weight gain, breast changes, water retention, vaginal or bladder infections, skin rashes, and changes in the eyes that cause some to become intolerant of contact lenses.

The most serious known side-effect is abnormal blood clotting.This risk increases with age from 30 years onwards. Cigarette smoking also increases the risk substantially. Other more serious risk factors are heart attack, high blood pressure, high cholesterol, diabetes, elevation of cortisol (stress hormone) and prolactin levels, changes in thyroid hormones, and uterine and cervical cancer. A recent study in The Lancet (April 5, 2003) reports that risk of cervical cancer increases the longer you take the pill. Women with the common sexually transmitted human papillomavirus who took the pill for five years were three times more likely to develop cervical cancer. Some researchers, including Dr. Louise Brinton, epidemiologist at the National Cancer Institute, also suggests that taking oral contraceptives for five years or more increases estrogen levels which is associated with breast cancer.

The federal government recently published its biennial “Report on Carcinogens,” adding steroidal estrogens used in hormone replacement therapy and oral contraceptives to its official list of “known” human carcinogens (cancer-causing agents). You should also be aware that certain drugs (including antibiotics) decrease effectiveness of birth control pills, while the pills themselves modify the action of other drugs (including insulin). For a complete list of drug interactions, please refer to Managing Contraceptive Pill Patients by Richard P. Dickey (EMIS Inc, 1999).

Since the pill depletes the body of vitamins C, B₂, B₆, B₁₂, folic acid, magnesium, and zinc, it would be wise to supplement your diet with a multivitamin containing high levels of B vitamins, as well as extra vitamin C (500 to 1,500 mg a day), folic acid (800 mcg) and a calcium/magnesium supplement (a 2:1 ratio of calcium to magnesium citrate using 400 to 600 mg calcium daily). I would also suggest a friendly bacteria acidophilus/bifidus product to prevent yeast infections (follow label recommendations for dosage).

These suggestions may help counteract the negative effects of oral contraceptives. Consider this as well: the shorter the time you take the pill, the less risk there is for the more serious side-effects. If you do decide to forgo birth control pills, other methods of birth control are available. The accompanying chart provides a semi-complete list. Ultimately, a woman’s birth control decision, in which weighing risks and benefits is a must, is as individual as it is personal.

Beware of Blood Clots

Blood clots associated with oral contraceptives occur in the veins of legs and are called thromboembolisms or VTE. These clots cause a blockage in the vein, and in some cases, the clots dislodge and travel to the lungs, heart, or brain. While most women recover completely from VTE, some have ongoing health problems. About three per cent of women die.

Your risk of having a blood clot can also be temporarily increased, for example, by a long flight, childbirth, bad varicose veins, some blood disorders, being overweight or being immobilized by injury or illness or surgery.

Taking a combined oral contraceptive increases the risk of developing a clot by three to four times if you are on a second generation pill, six to eight times if you are taking a third generation pill, and possibly more than eight times for women on pills containing cyproterone (Diane 35). Women using progestin-only pills are at little or no increased risk of blood clots. The symptoms of a blood clot in the leg are swelling, tenderness, and pain, but a blood clot may occur without symptoms. Breathlessness and sharp chest pain can occur with a blood clot in the lungs. If you develop partial vision loss, double vision, swelling of the eye, aggravation of migraines, or the development of a severe headache with a new pattern, stop the pill and see your doctor immediately.

What Your Doctor Should Know

Before your doctor prescribes oral contraceptives, he/she should request information about your physical and mental health, family, and personal history. Well-recognized contraindications to oral contraceptive use are:

1. a history of blood clots
2. stroke or heart attack
3. benign or malignant liver conditions
4. lipid metabolism disorders (high cholesterol)
5. herpes during pregnancy
6. breast, cervical, ovarian or endometrial cancer
7. undiagnosed vaginal bleeding
8. hypertension
9. migraine headaches
10. jaundice and
11. breastfeeding

You should also tell your doctor if you smoke or have uterine fibroids, gallbladder problems, diabetes, asthma, kidney disease or any form of depression or epilepsy. Tell you doctor if you are taking any other medications.

A physical examination should be performed including blood pressure and breast, liver and pelvic exams. If a patient is sexually active, a Pap smear should be taken. The first follow-up should be done three months after oral contraceptives are prescribed and thereafter at least once a year and more frequently if indicated. During each annual visit, examination should include all of the above procedures.

See table Common birth control options