The 1995 pill scare revisited: anatomy of a non-epidemic

YouTube and the implementation and discontinuation of the oral contraceptive pill: A mixed-method content analysis

BACKGROUND

Women living in high-quality healthcare systems are more likely to use oral contraceptives at some point in their lives. Research findings have sparked controversial discussions about contraception in the scientific community and the media, potentially leading to higher rates of method discontinuation. Understanding the underlying motives for method discontinuation is crucial for reproductive health equity and future programming interventions. To address this question, this study aims to explore women's experiences of oral contraceptive use and discontinuation on YouTube.

METHODS

A concurrent explanatory mixed-methods design was used to conduct content analysis of German YouTube videos. The information from 175 videos of 158 individuals was extracted through quantitative descriptive content analysis. Twenty-one individuals were included in the qualitative content analysis.

FINDINGS

The body was a recurring theme in the pill biographies. Women described, for example, bodily sensations as reasons for taking and stopping the pill. They also described positive and negative side effects while taking the pill and after stopping. The most common side effects of taking the pill mentioned by YouTubers were mood swings (76/158), weight gain (45/158), headaches (33/158), and depressed mood (45/158). The symptoms after discontinuation reported most were facial skin impurities (108/158), decreased mood swings (47/158), hair loss (42/158), and weight loss (36/158). Overall, women overwhelmingly rated their discontinuation experience as positive (87/91).

CONCLUSIONS

The study identified key symptoms of oral contraceptive initiation and discontinuation by portraying the experiences of female YouTubers, adding valuable insights to the understanding of method initiation and discontinuation. Further research is needed to explore women's personal experiences with method discontinuation beyond the YouTube platform.

The birth control pill, thromboembolic disease, science and the media: a historical review of the relationship

The introduction of the birth control pill (the Pill) in 1960 revolutionized the options for contraception, sparking vibrant discussion in the scientific and social science literature and in the media. Much attention focused on issues of women's rights, including ethics and personal choice. But the Pill also introduced new questions about risk. Shortly after its introduction, the risk of thromboembolic disease was recognized [1]. After more than half a century, controversies about the relationship between the Pill and thromboembolic disease have persisted. The scientific and media communities have been active in the discussion, debate and delivery of information about this risk. Scientific and public attention to thromboembolism and the Pill has had dramatic consequences, both good and bad. The spotlight on risk has helped to change norms regarding the public's right to know and assess dangers; it has sparked Pill scares linked to increased unplanned pregnancy, birth and abortion rates; and it has led to a change in federally mandated policies regarding how new contraceptive products are studied and brought to market. This paper charts the narrative of the thromboembolic risk of the Pill from its introduction in 1960 until today and reviews the corresponding media response to this history. How does the story of the thromboembolic risk of the Pill - explored through the lens of science, media and contemporary social dynamics - frame contemporary understanding of risk for researchers, clinicians, individuals and the public?

Should we do more to improve oral contraceptive continuation?

Oral contraceptives are commonly chosen methods whose contraceptive effectiveness is very user-dependent. Approaches to significantly improving oral contraceptive continuation have been largely unsuccessful. Long-acting reversible methods are the most highly effective reversible contraceptives, with the highest continuation rates, and should be the first-line methods offered to reproductive-aged women.

Venous thrombosis and oral contraceptives: current status

The use of oral contraceptives is associated with an increased risk of venous thrombosis. It is now generally accepted that women who use oral contraceptives that contain so-called third-generation progestins (desogestrel or gestodene) are exposed to a twofold higher risk of venous thrombosis than women who use oral contraceptives that contain the second-generation progestin levonorgestrel. Coagulation studies demonstrated that oral contraceptives increase the plasma level of prothrombin, decrease the level of protein S and induce acquired activated protein C resistance. The changes in hemostatic parameters can explain why women who use oral contraceptives are exposed to an increased risk of venous thrombosis and why the risk is further increased in third-generation oral contraceptive users.

SOGC clinical practice guideline. No. 252, December 2010. Oral contraceptives and the risk of venous thromboembolism: an update

OBJECTIVE

To provide current and emerging evidence on oral contraceptives and the risk of venous thromboembolism.

EVIDENCE

Articles published in English from 2005 were retrieved through searches of PubMed and Medline, using the following terms: venous thromboembolism, VTE, contraception, oral contraceptives, hormonal contraception. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). SUMMARY STATEMENTS: 1. Modern oral contraceptives offer highly effective contraception and a range of non-contraceptive benefits. (I) 2. Venous thromboembolism, although rare, remains one of the serious adverse consequences of hormonal contraception. Best evidence indicates that venous thromboembolism rates in non-users of reproductive age approximate 4-5/10 000 women per year; rates in oral contraceptive users are in the range of 9-10/10 000 women per year. For comparison, venous thromboembolism rates in pregnancy approach 29/10 000 overall and may reach 300-400/10 000 in the immediate postpartum period. (II-1) 3. Research demonstrates that oral contraceptives with ≤ 35 µg of ethinyl estradiol carry a lower risk of venous thromboembolism than oral contraceptives with 50 µg. (II-2) Although preliminary data suggest a possible further reduction in venous thromboembolism with oral contraceptives with < 35 µg ethinyl estradiol, robust data to support this conclusion are presently lacking. 4. Recent contradictory evidence and the ensuing media coverage of the venous thromboembolism risk attributed to the progestin component of certain newer oral contraceptive products have led to fear and confusion about the safety of oral contraceptives in general and drospirenone-containing oral contraceptives in particular. "Pill scares" of this nature have occurred in the past, with panic stopping of the pill, increased rates of unplanned pregnancy, and no subsequent decrease in venous thromboembolism rates. (II-3) 5. Two high quality research studies that addressed the venous thromboembolism risk associated with various oral contraceptives found comparable venous thromboembolism rates with drospirenone-containing oral contraceptives and other approved products. (II-1) 6. Two reports suggesting an increased risk of venous thromboembolism with drospirenone-containing oral contraceptives have significant methodological flaws that render their conclusions suspect. It seems likely that residual confounding could have distorted both the results and the conclusions of these reports. (II-3).

Clinical profile of contraceptive progestins

The term progestogen has been widely utilized to indicate the general class of agents that includes both progesterone and its synthetic analogs, whereas the term progestin refers only to synthetic progestational steroids. The development of progestins has been influenced in a major way by the search for orally active hormonal contraceptives, since it is likely that hormonal contraceptives will continue to utilize a progestin, the only possible alternative being represented by the utilization of antiprogestins. Synthetic progestogens in clinical use today belong to three main chemical families: progesterone derivatives (progesterone, retro-progesterone, 19-norprogesterone and 17alpha-hydroxyprogesterone); gonane and 19-nortestosterone derivatives (norethisterone, levonorgestrel, desogestrel, gestodene, norgestimate); a spironolactone derivative. Biological potency of progestogens varies depending on the end-point measured, usually ovulation inhibition and endometrial transformation; with both these tests, the most active compounds are all gonane derivatives, with a potency over a 100 times that of the natural hormone. When administered in adequate doses, a progestin inhibits fertility by inhibiting ovulation. This action is mainly exerted at the hypothalamic level where, physiologically, progesterone decreases the number of LH pulses. When progestogens are delivered directly to the uterine cavity, their action seems to be purely local. It has been amply proven that--even when administered in doses that do not constantly inhibit ovulation--a progestin can still remain effective as a contraceptive by acting at the level of the cervical mucus and, at least in part, of the endometrium. Progestogens utilized today differ largely in their pharmacokinetics. In general, after intake, these compounds are rapidly absorbed and distributed so that peak serum concentrations are reached between 1 and 4 h. Third-generation progestins (desogestrel, gestodene, norgestimate) have common characteristics: a higher affinity for progesterone receptors than their predecessors, a lower affinity for androgen receptors, a higher selectivity of action, a higher central inhibitory activity, a higher potency at the level of the endometrium, and an overall metabolic neutrality, in terms of effects on lipid and carbohydrate metabolism. In general, progestins can induce two types of adverse effects: changes in lipid metabolism and bleeding irregularities. Whereas the newer compounds seem to have overcome the first of these adverse effects, the second remains untouched: to this day, proper cycle control can only be achieved with combined hormonal contraceptives.

Safety of a New Oral Contraceptive Containing Drospirenone

New chemical entities must undergo rigorous, and preferably independent, safety and efficacy assessments before entry into the market. This is also true for oral contraceptives (OCs) given their extensive usage by healthy women and the safety concerns highlighted by the so-called 'third generation pill scare' in Europe a decade ago. This scare heightened patient and physician awareness of the increased risk of thromboembolic complications (mainly venous thromboembolism [VTE]) associated with OC use. Yasmin (ethinylestradiol 30 microg/drospirenone 3 mg [EE/DRSP]) is a novel OC that was demonstrated in clinical phase I-III studies to be highly effective in preventing pregnancy and to have a good safety profile. Nonetheless, clinical trials are not usually sufficiently powered to detect rare adverse events such as VTE to enable comparison with other OCs, which could allay fears and concerns about their inherent risks. Therefore, an extensive assessment of the VTE risk associated with EE/DRSP has been undertaken by reviewing data from the clinical development programme, postmarketing surveillance and spontaneous worldwide reporting, as well as information from other sources. Spontaneous worldwide reporting has revealed a VTE reporting rate of 5.1/100 000 women-years with EE/DRSP use. In contrast, 3-year interim results from a large, controlled, prospective postmarketing surveillance study suggest a VTE rate of 61/100 000 women-years for EE/DRSP, which is similar to the rates of 60/100 000 and 73/100 000 women-years for levonorgestrel-containing OCs and other OCs, respectively. When placed in context with potential biases and confounding factors that would inflate the perceived risk of VTEs with a novel OC, the VTE rate with EE/DRSP does not highlight any safety concerns. Furthermore, the risk of VTE with EE/DRSP or other OCs is far less than that associated with pregnancy and delivery (up to 800/100 000 women-years) or than other risks of daily living. Available data indicate that EE/DRSP is not associated with any increased risk of other serious adverse events such as hyperkalaemia, cardiac arrhythmia or birth defects. Nonetheless, caution should be exerted in prescribing EE/DRSP to women with conditions that predispose to hyperkalaemia.Overall, the safety data with EE/DRSP and other OCs indicate that these products have no negative impact on the risk of VTE (and other adverse events) in women who receive OCs for contraception.

Activated protein C resistance determined with a thrombin generation-based test predicts for venous thrombosis in men and women

Activated protein C (APC) resistance, determined with a thrombin-generation-based APC resistance test, may explain risk differences of venous thrombosis in users of second- and third-generation oral contraceptives (OC). To clinically validate this test, we analysed the Leiden thrombophilia case-control study (474 patients with a first episode of deep vein thrombosis and 474 age- and sex-matched control subjects). Data for men and women were analysed separately. As hormonal status in women is known to strongly influence the APC sensitivity ratio (APCsr), additional strata (OC use and menopausal state) were defined. The APCsr was higher in all patients than in control subjects. Odds ratios (OR), using the 90th percentile of all control subjects (APCsr > 4.5) as cut-off, were: 7.5 [95% confidence interval (CI) 1.6-33.8] for men, 3.0 (95% CI 1.0-8.8) for premenopausal women not using OC, 4.8 (95% CI 1.6-14.7) for premenopausal women using OC and 4.7 (95% CI 1.4-15.6) for postmenopausal women. After excluding the carriers of factor V Leiden, the OR became infinite for men (no control had an APCsr > 4.5), 1.4 (95% CI 0.2-8.2) for premenopausal women not using OC, 3.4 (95% CI 1.1-10.8) for premenopausal women using OC and 3.6 (95% CI 0.6-20.5) for postmenopausal women. A high APCsr, determined with the thrombin-generation-based APC resistance test, predicts venous thrombotic risk, in populations with and without factor V Leiden. In addition, acquired APC resistance resulting from OC use predicts an increased risk for venous thrombosis independent of factor V Leiden.

Termination of pregnancy following panic-stopping of oral contraceptives

This study assessed characteristics of women presenting for termination of pregnancy subsequent to stopping combined oral contraceptive use in response to publicity-mediated fears regarding venous thromboembolism. Records of 400 women attending for pregnancy termination assessment were reviewed retrospectively. Panic-stopping of oral contraceptives was implicated in 9.5%. Nearly 50% of combined pill users claimed their pregnancy resulted from panic-stopping because of media-promoted fear of health risks, especially 'clots.' Panic-stoppers had significantly lower identified risk factors for venous thromboembolism than pill users who had not panic-stopped. The relative safety of third-generation pills is under debate. The risk-benefit ratio of contraceptive pills is overwhelmingly positive but practitioners must be vigilant in screening for risk factors and contraindications. Panic-stopping results in unwanted pregnancies with concomitant psychological distress and potential physical morbidity. In future situations where research findings may precipitate drug scares, we recommend recall of patients by their health provider, funded by the relevant health authority or pharmaceutical companies, to allow discussion of risks before the media is enabled to have access to the information.

Oral contraceptives, thrombosis and haemostasis

The use of oral contraceptives is a well-established acquired risk factor for venous thrombosis. In 1995, a number of epidemiological studies were published which suggested that women who use third generation oral contraceptives that contain desogestrel or gestodene as progestagen are exposed to a two- to threefold higher risk for venous thrombosis than women using second generation oral contraceptives which contain levonorgestrel. In this paper, the effects of oral contraceptives on the haemostatic system are discussed. It appears that plasma from oral contraceptive users is resistant to the anticoagulant action of activated protein C (APC). This phenomenon, called acquired APC resistance, is more pronounced in users of desogestrel or gestodene-containing oral contraceptives than in women who use oral contraceptive pills with levonorgestrel. On the basis of these observations, it was proposed that acquired APC resistance may be the mechanistic basis of the increased risk for venous thrombosis during oral contraceptive use and for the further increased thrombotic risk of third generation oral contraceptive users. Furthermore, the results of a recent cross-over study are discussed. This study indicated that a large number of other haemostatic parameters were changed during oral contraceptive use. Some of these changes were more pronounced on desogestrel-containing oral contraceptives. The cross-over study also showed that the increased fibrinolytic activity during OC use is counterbalanced by an enhanced activity of thrombin-activatable fibrinolysis inhibitor (TAFI), a protein that participates in the inhibition of fibrinolysis.

Occlusive vascular diseases in oral contraceptive users. Epidemiology, pathology and mechanisms

Despite being an unprecedented departure from normal physiology, the combined oral contraceptive is not only highly effective, but it also has a remarkably good safety record. Concerns over safety persist, though, particularly with regard to venous thromboembolism (VTE), stroke and myocardial infarction (MI). Epidemiological studies consistently show an increase in risk of VTE, but the results are more contentious with regard to arterial diseases. Despite 40 years of research, the mechanisms behind these adverse effects are not understood. In this review, we integrate information from published studies of the epidemiology and pathology of the occlusive vascular diseases and their risk factors to identify likely explanations for pathogenesis in oral contraceptive users. Oral contraceptives induce both prothrombotic and fibrinolytic changes in haemostatic factors and an imbalance in haemostasis is likely to be important in oral contraceptive-induced VTE. The complexity of the changes involved and the difficulty of ascribing clinical significance has meant that uncertainty persists. A seriously under-researched area concerns vascular changes in oral contraceptive users. Histologically, endothelial and intimal proliferation have been identified in women exposed to high plasma estrogen concentrations and these lesions are associated with thrombotic occlusion. Other structural changes may result in increased vascular permeability, loss of vascular tone and venous stasis. With regard to arterial disease risk, epidemiological information relating to dose effects and joint effects with other risk factors, and studies of pathology and changes in risk factors, suggests that oral contraceptive use per se does not cause arterial disease. It can, nevertheless, synergise very powerfully with subclinical endothelial damage to promote arterial occlusion. Accordingly, the prothrombotic effects of the oral contraceptive estrogen intervene in a cycle of endothelial damage and repair which would otherwise remain clinically silent or would ultimately progress - in, for example, the presence of cigarette smoking or hypertension - to atherosclerosis. Future work in this area should focus on modification of the effects of established risk factors by oral contraceptive use rather than modification of the supposed risk of oral contraceptive use by established risk factors. Attempts to understand vascular occlusion in oral contraceptive users in terms of the general features of VTE or with reference to atherosclerosis may be limiting, and future work needs to acknowledge that such occlusions may have unique features. Unequivocal identification of the mechanisms involved would contribute considerably to the alleviation of fears over vascular disease and to the development of even safer formulations.

Emerging evidence on oral contraceptives and arterial disease

A number of case-control studies published in recent years have shown an apparent increase in the risk of venous thromboembolism (VTE) associated with the use of third-generation oral contraceptives (OCs) compared with second-generation OCs. However, it is thought that these studies were subject to a number of biases that would have increased the risk estimates for third-generation OCs while lowering those for second-generation preparations. Data on the risk of ischemic stroke and myocardial infarction (MI) show no such difference between generations of OCs, with a statistically significant reduction in the risk of acute MI from first- to third-generation in one major study. Available results indicate that there is no significant increase in the risk of ischemic stroke or acute MI associated with the use of low-dose estrogen OCs in young women who are properly screened before use, and who have no pre-existing cardiovascular risk factors, such as smoking and hypertension, for these conditions. These findings should be taken into account when interpreting the results of studies on the risk of VTE in women taking combined OCs.

Oral contraceptives and cardiovascular outcomes: cause or bias?

The 1995-1996 "pill" scare, which suggested that third-generation oral contraceptives (OCs) were associated with a greater risk of venous thromboembolism (VTE) than second-generation OCs, had serious social and public health consequences, as women discontinued OCs, resulting in unwanted pregnancies and unnecessary abortions. This article uses the Bradford Hill criteria, for diagnosing causality from an observed association, to interpret evidence from recent studies as to whether there is any difference in the risk of VTE between third- and second-generation OCs. Bias and the influence of confounders have also been examined in relation to the difference in the risk of VTE between third- and second-generation OCs reported in the 1995-1996 studies. It is clear from the results of this analysis that none of the Bradford Hill criteria are fulfilled. Thus, a causal relationship cannot be inferred from the alleged association of third-generation OCs with VTE. Indeed, it would appear that the unavoidable bias in observational research is a more likely explanation for the apparent difference in the risk of VTE between third- and second-generation OCs in the 1995-1996 studies. Recent studies, which employed more appropriate controls for these biases showed no difference in the risk of VTE between third- and second-generation OCs. A Danish study (1994-1996) demonstrated a lower risk of thrombotic morbidity and mortality with third-generation OCs compared with second-generation OCs. In addition, the Transnational study has shown that third-generation OCs have a significantly lower relative risk (0.3 [0.1-0.9]) for acute myocardial infarction (MI) compared with second-generation products. In conclusion, there is no convincing evidence for a difference in the risk of stroke or VTE between third- and second-generation OCs. Moreover, third-generation OCs may be associated with a lower risk of MI than second-generation OCs.

Low-dose oral contraceptives and acquired resistance to activated protein C: a randomised cross-over study

BACKGROUND

We have reported previously that, compared with use of second-generation oral contraceptives, the use of third-generation oral contraceptives is associated with increased resistance to the anticoagulant action of activated protein C (APC). Owing to the cross-sectional design of that study, these observations may have been subject to unknown bias or uncontrolled effects of the menstrual cycle. We aimed to overcome these sources of bias by doing a cycle-controlled randomised cross-over trial.

METHODS

The response to APC in plasma was assessed in 33 women who received two consecutive cycles of a second-generation oral contraceptive (150 microg levonorgestrel and 30 microg ethinyloestradiol) or a third-generation oral contraceptive (150 microg desogestrel and 30 microg ethinyloestradiol), and who switched preparations after two pill-free cycles. Normalised APC sensitivity ratios were calculated by measurement of the effect of APC on thrombin generation in the plasma of these women and in pooled plasma from 90 controls.

FINDINGS

Of the 33 women, five were excluded because not all required plasma samples were available. In the remaining 28 women, the normalised APC sensitivity ratio increased during treatment with both preparations. Compared with levonorgestrel, desogestrel-containing oral-contraceptive treatment caused a highly significant (p<0.0001) additional increase in normalised APC sensitivity ratio (0.51 [95% CI 0.37-0.66]). Normalised APC sensitivity ratios during oral-contraceptive treatment correlated with the values before oral-contraceptive use.

INTERPRETATION

Oral-contraceptive treatment diminishes the efficacy with which APC down-regulates in-vitro thrombin formation. This phenomenon, designated as acquired APC resistance, is more pronounced in women using desogestrel-containing oral contraceptives than in women using levonorgestrel-containing preparations. Whether acquired APC resistance induced by oral contraceptives explains the increased risk of venous thromboembolism in oral-contraceptive users remains to be established.

The differential risk of oral contraceptives: the impact of full exposure history

Previous discussions have indicated that the small increases of risk of venous thromboembolism (VTE) associated with newer combined oral contraceptives (third generation, containing desogestrel and gestodene) may be attributed to bias due to cohort effects. In a case-control analysis, this may produce an overestimate of risk of newer preparations. In 10 centres in Germany and the UK, the Transnational Study analysed data from 502 women aged 16-44 years with VTE, and from 1864 controls matched for 5-year age group and region. Information on lifetime exposure history from all subjects was added to the dataset used in previous analyses and entered into a Cox regression model with time-dependent covariates. Based on 17 622 continuous exposure episodes comprising 47 914 person-years of observation, the adjusted hazard ratio (equivalent to odds ratio, OR) of VTE for the comparison of current users of third-generation versus current users of second-generation (primarily levonorgestrel compounds) combined oral contraceptives was 0.8 (0.5 to 1.3). The OR obtained in standard case-control analysis had been 1.5 (1.1 to 2.1). Adjustment for past exposures includes more information and appears more valid than the standard cross-sectional analysis. Using this approach, the Transnational Study data show no evidence for an increased risk of VTE with third- compared with second-generation combined oral contraceptives.

Bias versus causality: interpreting recent evidence of oral contraceptive studies

Late in 1995 and early 1996, 4 epidemiologic studies were published that resulted in a crude mean weighted relative risk of approximately 2 when third-generation oral contraceptives were compared with second-generation oral contraceptives as risk factors for venous thromboembolism. This article reviews empirical evidence on bias or systematic error that may have influenced the estimates of association. The Bradford-Hill criteria to distinguish causality from an observed association were used to consider whether third-generation oral contraceptives cause an apparent excess in the occurrence of venous thromboembolism. Bias is more likely than a causal relationship to explain the associations observed for venous thromboembolism. For myocardial infarction, bias may mask the full benefit of third-generation oral contraceptives. For stroke, the question of causality is moot because statistically significant differences between third- and second-generation products have not been detected. The clinical importance and the public health significance of any differences among the various products with respect to adverse cardiovascular outcomes are trivial and undetectable because of the extremely low incidence of those disorders among users of oral contraceptives. The oral contraceptive pill is 99.9% effective when used correctly. All oral contraceptives on the market are safe and getting safer.