Oral Contraceptives

September 18, 1999

More than a contraceptive 

What prescription medication has probably been studied the most intensively? Oral contraceptives (OCs), invented in the 1960s. They’ve been used, at one time or another, by 80% of American women. “The Pill,” as OCs are familiarly known, gives women control over their own fertility with very low risk of adverse effects. The Pill cannot be surpassed for safety and reliability (when correctly used) combined with reversibility. That is, a woman can discontinue it and become pregnant if she wishes. Unlike condoms, though, it does not protect against sexually transmitted diseases. OCs come in many different formulations and deliver much lower doses of hormones than they used to. Some combine estrogen with progestin, while some (mini-pills) have progestin only.

Yet many women fear the Pill, which has had an undeservedly bad press. Using the Pill is far less a threat to a woman’s health, generally speaking, than pregnancy and childbirth. Though there were concerns that the old high-dose Pill could increase the risk of heart disease, the new low-dose formulations contain only a quarter of the estrogen and one-tenth the progestin and have decreased the risks of all adverse effects. The surprise, though, is that the health benefits of OCs go beyond contraception, and outlast the reproductive years.

Cancer and the Pill

Ovarian cancer: It’s been known for some time that the Pill can cut the risk of ovarian cancer by half. Indeed, it’s now recommended to women at high risk for ovarian cancer because of family history and genetics. 

The longer such women use the Pill, the greater their reduction in risk, up to 60% after six years of use. And it protects low-risk women, too. This may be because the Pill reduces the number of ovulations a woman has over her lifetime. The Pill also reduces the risk of nonmalignant ovarian cysts.

Endometrial cancer: Cancer of the uterine lining, though less likely to be fatal than ovarian cancer, is more common. The Pill can reduce the risk of endometrial cancer by 50%. It protects against fibroid tumors (benign) of the uterus, and can be used to treat endometriosis, a benign but often painful condition that can threaten fertility.

The protective effect against these cancers appears to continue long after a woman stops taking the Pill.

Breast cancer: Pill users as well as scientists have worried that the estrogen in the Pill might promote breast cancer. But the news is encouraging. Most studies have found no increased risk from using OCs, especially with the new low-dose Pill. However, one study at the National Cancer Institute in 1995 did find a very slight increase in risk in women under 35 who had used OCs for at least six months. But when checked 10 years after discontinuation, the women’s risk had returned to normal. It’s not certain that the Pill really caused this small increase, which may have been more apparent than real. One possible reason for the increase: women on OCs probably get more thorough and more regular checkups. Thus the cancers were usually discovered at an early stage and were often curable. A more recent British study of 46,000 women found no increased risk.

Heart disease and the Pill

 The latest evidence shows that OCs do not put healthy women at risk for heart disease or blood clots, unless they smoke. However, a study in Circulation last year, which looked at women in California and Washington, found that low-dose OCs do not increase the risk of a heart attack even in women who smoke or have another major risk factor for cardiovascular disease, such as obesity, high blood pressure, or diabetes.

Still, the Pill is not recommended for women over 35 who smoke.

 Menstruation and the Pill 

Being on the Pill gives a woman greater control over her menstrual periods. If her periods have been irregular, the Pill can make them predictable. If she wants to postpone a period because of athletic activity or a forthcoming vacation, she can skip the blank pills and start the next month’s dose. OCs also reduce the amount of menstrual bleeding, thus reducing iron loss, and can also relieve or prevent menstrual cramps. In some women, OCs can help be an effective medication for PMS, preventing or reducing premenstrual symptoms such as bloating, anxiety, depression, mood swings and headaches.

Other uses, and some drawbacks

 And there are other benefits, too: enhanced sexual enjoyment for many women and their partners, as well as “morning after” or emergency contraception. The Pill may be helpful for acne, too.

Like all drugs, however, OCs can have side effects in some users, including headaches, weight gain and bloating, depression, and unwanted menstrual changes such as missed periods or breakthrough bleeding. Women with bothersome side effects have to weigh the benefits and risks, preferably with good advice from their physician or nurse-practitioner. There are many kinds of OCs to choose from. If one causes side effects, another may not.

Pills have to be taken regularly, every day. And OCs are expensive ($20 to $30 for a month’s supply) and not always covered by health insurance. But this is changing: some states now require coverage of OCs.

If you are on the Pill, remember that it can interact with other medications, so do remind your doctor that you take OCs when a new medication is being prescribed. In particular, some antibiotics can reduce the effectiveness of OCs.

Menopause and beyond

 It’s safe and indeed advisable for a Pill user to continue taking it right up through menopause. It can prevent or reduce un­pleasant menopausal symptoms such as hot flashes, sleeplessness, and mood swings. There’s some evidence, still not definitive, that OCs help preserve bone density.

However, once your menstrual periods have stopped and pregnancy is no longer a risk, you should stop taking the Pill and consider the pros and cons of hormone replacement therapy (HRT). 

One small study suggested that there is a small increased risk of breast cancer from taking OCs followed by HRT, but more research is needed. Taking hormones after menopause offers its own set of benefits (protection against heart disease, postponement or reduction of bone loss) and risks (an increase in breast cancer risk for some women). The dose of estrogen in HRT is only 10 to 25% as much as that in the low­dose Pill.

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