The safety of oral contraceptives: epidemiologic insights from the first 30 years

Health benefits of combined oral contraceptives - a narrative review

PURPOSE

This review presents an update of the non-contraceptive health benefits of the combined oral contraceptive pill.

METHODS

We conducted a literature search for (review) articles that discussed the health benefits of combined oral contraceptives (COCs), in the period from 1980 to 2023.

RESULTS

We identified 21 subjective and/or objective health benefits of COCs related to (i) the reproductive tract, (ii) non-gynaecological benign disorders and (iii) malignancies. Reproductive tract benefits are related to menstrual bleeding(including anaemia and toxic shock syndrome), dysmenorrhoea, migraine, premenstrual syndrome (PMS), ovarian cysts, Polycystic Ovary Syndrome (PCOS), androgen related symptoms, ectopic pregnancy, hypoestrogenism, endometriosis and adenomyosis, uterine fibroids and pelvic inflammatory disease (PID). Non-gynaecological benefits are related to benign breast disease, osteoporosis, rheumatoid arthritis, multiple sclerosis, asthma and porphyria. Health benefits of COCs related to cancer are lower risks of endometrial cancer, ovarian cancer and colorectal cancer.

CONCLUSIONS

The use of combined oral contraceptives is accompanied with a range of health benefits, to be balanced against its side-effects and risks. Several health benefits of COCs are a reason for non-contraceptive COC prescription.

"I don't want my marriage to end": a qualitative investigation of the sociocultural factors influencing contraceptive use among married Rohingya women residing in refugee camps in Bangladesh

BACKGROUND

The timely provision of comprehensive contraceptive services to Rohingya women is impeded due to a lack of clarity and understanding of their traditional beliefs and cultural frameworks. Recognizing this challenge, our paper aims to explore the socio-cultural factors influencing the utilization of contraceptives among married Rohingya women living in the refugee camps of Cox's Bazar, Bangladesh.

METHOD

A qualitative study was conducted in two unregistered Rohingya camps (Camp 7&14) located in Ukhiya Upazila, Cox's Bazar from January 10th to 20th, 2022. A total of 14 In-Depth Interviews (IDIs) were conducted among married Rohingya women of reproductive age (15-49 years), along with 16 Key Informant Interviews (KIIs) involving stakeholders engaged in reproductive healthcare provision. Participants were selected using purposive sampling. All interviews were conducted in the local language, recorded, transcribed verbatim, and subsequently translated into English. The data were analyzed using NVivo (Version 11), and the analysis process followed Neuman's three-phase coding system.

RESULTS

Five broad themes were identified: Sociocultural expectations and values attached to births, power imbalances within marital relationships, the role of religious beliefs, fear of side effects, and misperceptions about contraception. Having a larger number of children is viewed positively as it is believed that children play a crucial role in preserving the lineage and contributing to the growth of the Islamic population. Despite expressing an inclination towards contraception, the disapproval of husbands becomes a significant barrier for women. Defying their husbands' wishes can result in instances of Intimate Partner Violence (IPV) and even marriage dissolution within the camps. Moreover, the fear of side effects, such as a particular method would cause infertility, discourages women from using contraception. Many of these fears stem from myths, misconceptions, and mistrust in the existing medical system.

CONCLUSION

Addressing the socio-cultural barriers that prevent women from using modern contraception will have important public health implications. These findings can support in crafting culturally sensitive programs and educational interventions. These initiatives can assist Rohingya refugee women in planning their pregnancies and reducing high-risk pregnancies, ultimately leading to a decrease in maternal mortality rates within the community.

No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the availability of cited contraceptive methods in Canada.

EVIDENCE

Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed.

VALUES

The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Over the counter: The potential for easing pharmacy provision of family planning in Senegal

Background: This research assessed the potential for expanding access to family planning through pharmacies in Senegal, by examining the quality of the services provided through pharmacies, and pharmacy staff and client interest in pharmacy-based family planning services. Methods: This was a cross-sectional, descriptive study conducted in eight urban districts in and around Dakar employing an audit of 250 pharmacies, a survey with 486 pharmacy staff and a survey with 3,569 women exiting pharmacies. Results: Most (54%) pharmacies reported offering method-specific counseling to clients. Family planning  commodities were available in all pharmacies, and 72% had a private space available to offer counseling. Three quarters (76%) did not have any counseling materials available. 49% of pharmacists and 47% of assistant pharmacists reported receiving training on family planning during their professional studies. Half had received counseling training. Few pharmacists met pre-determined criteria to be considered highly knowledgeable of the oral contraceptive pill (OCP) and injectable contraceptive provision (0.6% and 1.1%). Overall, 60% of women surveyed were current family planning users; of these, 11% procured their method through the pharmacy. Among non-users of family planning, and current users who did not obtain their method through a pharmacy, 47% said they would be interested in procuring a method through a pharmacy. Conclusions: Senegal’s urban pharmacies are well-positioned to meet the country’s increasing desire for modern contraception. With proper training, pharmacy staff could better provide effective counseling and provision of OCPs and injectables, and lifting the requirement for a prescription could help support gains in contraceptive prevalence.

Implications of employer coverage of contraception: Cost-effectiveness analysis of contraception coverage under an employer mandate

OBJECTIVES

Mandatory employer-based insurance coverage of contraception in the US has been a controversial component of the Affordable Care Act (ACA). Prior research has examined the cost-effectiveness of contraception in general; however, no studies have developed a formal decision model in the context of the new ACA provisions. As such, this study aims to estimate the relative cost-effectiveness of insurance coverage of contraception under employer-sponsored insurance coverage taking into consideration newer regulations allowing for religious exemptions.

STUDY DESIGN

A decision model was developed from the employer perspective to simulate pregnancy costs and outcomes associated with insurance coverage. Method-specific estimates of contraception failure rates, outcomes and costs were derived from the literature. Uptake by marital status and age was drawn from a nationally representative database.

RESULTS

Providing no contraception coverage resulted in 33 more unintended pregnancies per 1000 women (95% confidence range: 22.4; 44.0). This subsequently significantly increased the number of unintended births and terminations. Total costs were higher among uninsured women owing to higher costs of pregnancy outcomes. The effect of no insurance was greatest on unmarried women 20-29 years old.

CONCLUSIONS

Denying female employees' full coverage of contraceptives increases total costs from the employer perspective, as well as the total number of terminations.

IMPLICATIONS

Insurance coverage was found to be significantly associated with women's choice of contraceptive method in a large nationally representative sample. Using a decision model to extrapolate to pregnancy outcomes, we found a large and statistically significant difference in unintended pregnancy and terminations. Denying women contraception coverage may have significant consequences for pregnancy outcomes.

A qualitative analysis of accounts of hormonal contraceptive use: experiences and beliefs of British adolescents

OBJECTIVES

Britain has high rates of unintended adolescent pregnancy compared to other European countries. Relatively little is known about the beliefs, attitudes and experiences of using hormonal contraceptive methods amongst middle-class adolescents, and mention of their views in the literature will add to the knowledge in this area. The current qualitative study addresses these issues to some extent.

METHODS

Middle-class 16-18-year-old men and women were interviewed about their understanding and use of hormonal contraceptives. The interviews were transcribed verbatim and transcripts subjected to an adaptation of interpretative phenomenological analysis (IPA).

RESULTS

Six emergent themes represent important aspects of these adolescents' experiences: negative experiences, experiences unrelated to pregnancy prevention, mistrust of the pill, risk reduction, issues of communication and trust, and perceptions of pill promotion by adults.

CONCLUSIONS

The findings illustrate the complexities inherent in contraceptive health care in relation to hormonal methods and highlight not only potential targets for enhancing effective use, but the importance of the way such information is disseminated.

Over-the-Counter Access, Changing WHO Guidelines, and Contraindicated Oral Contraceptive Use in Mexico

This study examines the prevalence of contraindications to the use of oral contraceptives in Mexico by sociodemographic characteristics and by whether this family planning method was obtained with or without a doctor's prescription. Using data on smoking behavior and blood-pressure measurements from the 2000 Mexican National Health Survey, the authors found that, under the 1996 World Health Organization (WHO) medical eligibility guidelines, the prevalence of contraindications is low and that no significant differences in contraindications exist at any level between those who obtain oral contraceptives at clinics and those who obtain them at pharmacies. In 2000, however, WHO substantially revised its criteria regarding the level of hypertension that would constitute a contraindication for oral contraceptive use. Applying the new guidelines, the authors found that 10 percent of pill users younger than 35 and 33 percent aged 35 and older have health conditions that are either relative or absolute (Category 3 or 4) contraindications. The relevance of these findings to the larger debate concerning screening and over-the-counter access to oral contraceptives is discussed.

Hormonal and barrier methods of contraception, oncogenic human papillomaviruses, and cervical squamous intraepithelial lesion development

We assessed the influence of hormonal (oral, injectable, or levonorgestrel [Norplant, Wyeth-Ayerst, Philadelphia, PA]) and barrier methods of contraception on the risk of cervical squamous intraepithelial lesions (SIL), while adjusting for high-risk (HR) HPV infection. Subjects were women receiving family planning services through the state health department clinics from 1995 to 1998. We selected 60 cases with high-grade cervical/SIL (HSIL) and 316 with low-grade cervical/SIL (LSIL) and controls (427 women with normal cervical cytology) and analyzed cervical DNA for HR-HPV, using Hybrid Capture I (Digene; Gaithersburg, MD). When assessing ever use, duration, recency, latency, and age at first use, neither oral contraceptives (OC), Norplant, nor injectable use was associated with an increased risk of SIL development after adjusting for age, age at first sexual intercourse, and HR-HPV positivity. Among HR-HPV-positive women, longer duration barrier method use was associated with a reduced risk of SIL. This finding has important clinical implications for SIL prevention among HR-HPV-infected women.

Perceptions of hormonal contraceptive safety and side effects among low-income Latina and non-Latina women

OBJECTIVES

We explored perceptions of the safety and side effects of oral and injectable hormonal contraceptives among low-income women at high risk of unintended pregnancy.

METHODS

Overall safety perceptions, specific health concerns, and the relationship between these safety perceptions and contraceptive choices were determined by focus groups and questionnaires obtained from white non-Latina (n = 19), English-speaking (n = 21), and Spanish-speaking Latina women (n = 19).

RESULTS

Uncertainty or ambivalence about the safety of oral and injectable contraceptives was reported by 41% and 70% of respondents respectively, while 20% considered these methods to be mostly harmful. Personal experiences and stories from social networks proved to be more salient than medical opinions in shaping safety perceptions. Side effects and concerns about long-term health effects were common themes. While white non-Latina women focused predominantly on physical side effects, emotional side effects also contributed to Latinas' decisions about contraceptive switching. Spanish-speaking Latinas differed from English-speaking Latinas in other attitudinal dimensions, contraceptive use prevalence, and access to contraceptive services.

CONCLUSION

Low-income mothers lacked confidence in method safety and had many concerns about the side effects of oral and injectable contraceptives. Because such concerns can be a barrier to contraceptive use, these perceptions need to be corrected to encourage more effective use of hormonal methods and to prevent unintended pregnancies. Culturally appropriate interventions should focus on client-provider interactions, social networks, and access to care.

Nationwide audit of pill knowledge amongst family planning users in Scotland

OBJECTIVES

The primary objective of this study was to estimate knowledge about oral contraceptives amongst oral contraceptive users within family planning clinics in Scotland and to ascertain if this was due to clinicians not attempting to convey certain information or to a lack of understanding of teaching.

METHOD

This was a criterion-based audit using three separate questionnaires to estimate the agreement of senior staff with criteria set by a multi-disciplinary expert panel, actual routine clinical practice and user knowledge.

RESULTS

Senior clinical staff within family planning clinics in Scotland agreed with 12 out of 15 criteria set by a multidisciplinary panel in over 85% of cases. For six out of 15 criteria, there was a discrepancy of more than 30% in what clinicians did in practice compared to what senior staff thought they ought to do. For a further two criteria, there was a deficiency of over 30% between the number of clients who understood the criteria and the number of clients the clinicians thought they had taught. Most importantly, these latter criteria included the rules for safe and effective pill taking.

CONCLUSION

An improvement in user knowledge is required to achieve effective and reliable use of oral contraceptives. Methods of doing this, such as staff and client prompts, should be further explored.

Current reversible contraceptive methods: a global perspective

Since the 1960's, there have been important gains in the efforts to make the benefits of family planning accessible to people around the world. However, prevalence of contraceptive use is still low in some areas, especially in sub-Saharan Africa. Making contraceptives accessible through good quality services should be a goal for reproductive health programs. In the absence of an ideal method of contraception which would suit every individual, there is a variety of contraceptive methods with advantages in some aspects and disadvantages in others from which people should be able to choose according to their particular characteristics and needs. Important aspects to take into consideration include effectiveness, convenience, and safety. In general, the most effective methods are more likely to have some side effects and method-related complications. However, when weighing the risks and benefits, the most effective methods have greater benefits on the health of women by protecting them better from the health risks of unwanted pregnancies. Most methods also have non-contraceptive benefits - for instance, combined oral contraceptives (COCs) provide important degrees of protection against endometrial and ovarian cancers, benign breast disease, pelvic inflammatory disease (PID), and ectopic pregnancy. They also reduce menstrual blood loss. Although barrier methods have lower effectiveness against pregnancy, their most important advantage is the protection they can provide against sexually transmitted diseases. The male condom in particular (and probably the female condom) has the special value of providing protection against HIV infection. This paper describes reversible methods of contraception including possible health risks and contraindications. Adequate counseling, however, is essential for people to make an appropriate choice of contraception and to secure safe and effective use of the method.

Contraception in the patient with liver disease

Selection of a method of contraception in patients with liver disease can be complicated. Tubal ligation should be considered in the setting of chronic liver disease for those patients who have completed families. Multiple reversible methods of contraception are currently available but may affect hepatic disease. Estrogen-containing contraceptive methods are contraindicated in patients with acute liver disease. Progestin contraceptives appear to be safe and multiple delivery systems are available. With rare exception, barrier methods and the intrauterine device may be offered as alternative methods.

The cardiovascular safety of triphasic contraceptive steroids

It was hypothesized that estrogen-induced cardioprotection is mediated by up-regulation and down-regulation of expression of nitric oxide (NO) and P-selectin, respectively. Published data on circulating levels of the vasodilator NO, atherogenic glycoprotein P-selectin, and lipoprotein-a [Lp(a)] in users of triphasic contraceptive steroids are lacking. A total of 30 healthy women (nonusers, controls) and 82 women using oral triphasic contraceptive steroids (ethinyl estradiol and levonorgestrel: Triovlar, Schering AG) for 18 to 24 cycles participated in this study. Fasting blood samples were obtained from users and nonusers for the determination of P-selectin and Lp(a) by enzyme immunoassay and NO by a colorimetric method. The serum Lp(a) levels in OC users were significantly higher than those of nonusers. On the other hand, the serum NO levels in OC users were significantly elevated when compared to nonusers. Plasma P-selectin was significantly lowered in OC users p < 0.005. These results demonstrate the beneficial effects of ethinyl estradiol in the triphasic contraceptive regimen. Ethinyl estradiol may afford a degree of anti-atherogenic-cardioprotective effect by up-regulation of the expression of the vasodilator NO and down-regulation of the expression of the atherogenic P-selectin. This may outweigh the cardiovascular risk of the increased atherogenic Lp(a). This study may explain the very low rate of mortality from venous thromboembolism in OC users, which compares favorably with the risks that many people accept in daily life.

Sex hormone preparations and retinal vein occlusion

Retinal vein occlusion (RVO) is most commonly seen in middle-aged or older patients and is associated with underlying cardiovascular risk factors. It is much less common in younger patients. Use of the oral contraceptive pill (OCP) is known to be a risk factor for cardiovascular and cerebrovascular disease. There have previously been a few isolated case reports of patients sustaining an RVO whilst taking the OCP. The aim of this study was to investigate patients sustaining an RVO whilst taking the OCP or hormone replacement therapy (HRT). From a large series of 588 patients, we found 11 with an RVO associated with sex hormone preparations. Of these, 6 had taken the OCP and 5 were HRT users. From this large group there were only 9 female patients aged under 35 years who sustained an RVO. Of these, 6 were associated with use of the OCP. All patients were investigated for recognised medical risk factors for RVO. None of these factors were identified in the patients who had used the OCP. Of the patients taking HRT, 4 of the 5 had other potential risk factors. From our large series, the prevalence of RVO in female patients under 35 years taking the OCP was 66%. There is a 30% uptake of the OCP in the general population. These data support the view that RVO is a contraindication to the use of the OCP. Additionally, it would appear (albeit from limited data) that patients who sustain RVO may continue with their HRT, as HRT is not a major single risk factor for RVO.

Contraception. A clinical review for the internist

Effective use of contraception allows couples to control their fertility and, in certain instances, is associated with important noncontraceptive benefits. Surgical sterilization offers safe, effective, and permanent contraception for women and men. Low-dose OCPs offer safe, effective contraception for most women able and willing to take pills consistently. In addition, their use confers a variety of important noncontraceptive benefits. The availability of long-acting progestin injectable and implantable methods has made highly effective and convenient birth control available for women who are not good pill takers as well as for those for whom contraceptive doses of estrogen are contraindicated. Barrier methods are readily available and provide protection against STDs; unfortunately, erratic use is all too often associated with inadequate contraceptive efficacy. IUDs offer convenient, highly effective contraception for appropriate candidates.

Long term sequelae of sex steroid treatment in the management of constitutionally tall stature

AIM

To evaluate possible long term side effects of high doses of sex steroids in the management of constitutionally tall stature, with special attention to hypothalamic-gonadal function.

METHODS

Sixty four tall adult men and 180 tall adult women, who received supraphysiological doses of sex hormones during puberty, were interviewed in a standardised way at a mean follow up period of 10 years after cessation of treatment. Sixty one untreated tall adult men and 94 untreated tall adult women served as controls.

RESULTS

The majority of the subjects were satisfied with their decision regarding hormone treatment. Seventy seven per cent of the women and 78% of the men reported one or more side effects during treatment. Most side effects were mild. In women, only 3% stopped treatment because of an adverse event; in men, the reported side effects never stopped treatment. The frequency of reported side effects in women was higher during treatment with high doses of oestrogens than during oral contraceptive use, indicating a dose dependent relationship. Amenorrhoea of longer than six months after cessation of therapy was found in 5%. Menstrual cycle characteristics of previously treated women were comparable with controls. Malignancy was not reported. Information about a total of 127 pregnancies was obtained and revealed no distinct differences in details and outcome between previously treated women and men, and controls.

CONCLUSIONS

At a mean follow up of 10 years there is no evidence that pharmacological doses of sex hormones have a long term effect on reproductive function. However, this period is still too short to draw definite conclusions.

Advances in Hormonal Contraception

Breakthroughs involving innovative methods of hormonal and nonhormonal birth control have been severely limited in the United States over the last 30 years. This trend has changed with the introduction of new choices in birth control in the 1990s. This article focuses on these advances in hormonal contraception and provides information on the use of oral contraceptives, hormonal implants, and injectable methods of contraception currently available in the United States. Each method is assessed and recommendations are made for proper patient and method selection. This information is intended to supply the pharmacist with sufficient information to appropriately counsel patients on the use of hormonal contraception in the 1990s.

Should oral contraceptives be available without prescription?

In this paper, it is argued that oral contraceptives should be available without prescription. Prescription status entails heavy costs, including the dollar, time, and psychological costs of visiting a physician to obtain a prescription, the financial and human costs of unintended pregnancies that result from the obstacle to access caused by medicalization of oral contraceptives, and administrative costs to the health care system. After a review and evaluation of the reasons for strict medical control of oral contraceptives in the United States, safety concerns anticipated in response to the proposal discussed here are addressed. Also, concerns that prescription status is necessary for efficacious use are evaluated. It is concluded that neither safety nor efficacy considerations justify prescription status for oral contraceptives. Revised package design and patient labeling could allow women to screen themselves for contraindications, to educate themselves about danger signs, and to use oral contraceptives safely and successfully. Several alternatives to providing oral contraceptives by prescription with current package design and labeling and selling them over the counter are suggested; the proposals discussed would make these safe and effective contraceptives easier to obtain and to use.