Birth control pills, PROS and CONS

I cannot overstress the importance of contraception. Well actually the only thing more important than contraceptive methods, is women’s knowledge about them. More than 50% of pregnancies nowadays (in the states) are unplanned, and trust me the number is certainly not lower in our Arab countries.  

In today’s post I will not be tackling all aspects of contraception (will be touched upon in future posts), yet I will focus on “the pill” with all its advantages, disadvantages, misconceptions and non-contraceptive benefits.

To take you a bit back in time, Dr. Sanger, while in her 80s, funded the research necessary to create the first oral birth control pill. And it took us 10 years for the FDA (US Food and Drug Administration) to approve the pill’s use as a method of birth control in 1960. Since that time the hormonal composition and concentration of the pills changed significantly. And nowadays we have tens of pill brands in the market (Liao PV, Dollin J. Half a century of the oral contraceptive pill: historical review and view to the future. Can Fam Physician. 2012;58(12):e757-e760.)

I will not be boring you with the exact concentration of hormones in the pills, but you should know that it has two main hormones; estrogen and progesterone hence “the pill” is called, Combined Oral Contraceptive Pill (COC).

The mode of action is simple; all COCs work by inhibiting/preventing ovulation, so users will not have eggs ready for fertilization!
But additional mechanisms to avoid pregnancy can be explained by the effect the pills have on the endometrium (the bed ready to receive the embryo) making it less receptive for implantation, on the thickening of the cervical mucous (making it less permeable for sperms) and on the impairment of normal tubal motility. So, COCs are effective methods of contraception, nevertheless you should know that with typical use the reported failure rate is around 7-9% for the first year of use, meaning that out of 100 women using the pill, 7 to 9 will get pregnant per year. This may seem too much for some, however if you compare it to condoms and coitus interruptus (“ejaculating outside”) the reported failure rates are 18% and 22% respectively (as per American College of Obstetricians and Gynecologists). Hence, the pill will enable you to engage with a more enjoyable sex and a much lower risk of failure!

After establishing the efficacy of COCs, how can you tell if you are eligible for their use?!

Well in a nutshell, all otherwise healthy women can take COCs from menarche (first period ever) until menopause (lack of period for 12 consecutive months). But the following is a list of high risk population that should NOT be prescribed the pill:

·         Age 35 or older AND smoker (cigarette or hubble bubble)

·         Multiple Risk factors for arterial cardiovascular disease (advanced age, diabetes, hypertension…)

·         Isolated severe hypertension (160/100 mmHg or more)

·         Personal history of deep vein thrombosis (blood clotting history)

·         Known ischemic heart disease (arterial heart disease)

·         History of stroke (brain vessels clotting)

·         Current breast cancer

·         Severe liver disease known as cirrhosis or liver cancer

·         Migraine with Aura known as the classic migraine (headache with sensory disturbances)

If it is hard for you to memorize these contraindications, you should keep in mind that in case of any medical history, always inform your physician and consult him/her before initiating oral contraceptive methods!

Also, keep in mind that sometimes you may fall under “risks outweigh benefits” category, so even if you do not satisfy the previously mentioned contraindications, your doctor would still prefer using other contraceptive methods as COCs can have a higher risk for complications compared to the general population. So always follow with your physician.

So why bother using COCs? They may be too risky!

Actually, in addition to high contraceptive efficacy, COCs have many other benefits.

One of the most common indications for COCs use outside of contraception is for the management of irregular menstrual cycles. Whether your cycles are too long, too short or irregular, COCs can regularize them and make them much more predictable.

Also, if you are suffering from severe pain during menses, or premenstrual syndrome (“Cranky before your period”) COCs can sort it out for you. As these pains and emotional disturbances are generally secondary to hormonal imbalances and thus proper hormonal adjustment via COCs can redeem them. To note that if you belong to the group of women with chronic pelvic pain or severe painful periods, a continuous use of COCs might benefit you more than the cyclic one, so check with your physician about that option.

Moreover, COCs (some more than the others) can be used to reduce the dermatologic manifestations of hyperandrogenism (facial and body hair, acne …). “Oral contraceptive pills work well for mitigating acne,” says Amy Derick, MD, a US board-certified dermatologist.

What about ovarian cysts?! These “fluid filled sacs” on the ovaries are normal occurrences in most premenopausal and young women! Of course, your physician is the best to judge the appearance of any cyst on your ovary, whether it is ok to keep or better to investigate and maybe remove. But you should know that all women will develop small ovarian cysts during their lifetime, and these sacs will resolve on their own with time. There is no need to use COCs to eliminate ovarian cysts. The only time I would recommend using COCs for cysts, is whenever these cysts are recurrent and causing symptoms, then COCs can prevent new cyst formation and thus protect you from their annoyances.

What about cancer risk? Can COCs cause cancer?
Well the truth is that solid data now support the use of COCs for women at high risk for both, ovarian and endometrial cancers (cancer of the ovaries and uterine bed). COCs were shown to reduce the risk of the previously mentioned cancers, especially with their prolonged use.

Now let’s shift gears and talk about the risks and side effects of the pill.

Well the most frequently reported side effects are, bloating, breast pain, and nausea. The good news is that these often resolve quickly within the first few months of use. Also, some women report irregular spotting between cycles, and here again, it typically resolves within three months of use.

COCs are also associated with an increased risk of deep vein thrombosis (clotting of blood in your vessels) hence they should not be prescribed to women at risk of such a problem (check the top for contraindications of use). The same warning applies to the risk of hypertension and cardiac diseases.

Moreover, COCs use has been linked to an increased risk of sexually transmitted infections (STIs), but the data is still controversial regarding the topic, as some studies report a positive correlation and others a negative correlation between STIs and COCs. So, the best option, in my opinion, is to combine the use of COCs with barrier contraception (such as condoms) to decrease the chance of both, unwanted pregnancies and undesired infections (especially in the setting of multiple sexual partners).

 

Finally let’s debunk some common Myths about oral contraceptive methods.

While looking at the most commonly reported myths about COCs, I checked different sources and blogs including, Cleveland Clinic, International Planned Parenthood Federation, Medical News Today, and Copeman Health Care. These are the top 10 myths, confuted!

Myth 1: Birth control pills cause weight gain

Fact 1: NO! Most studies tackling the subject did not show a correlation between COCs and weight gain. The few studies that showed a potential association, only revealed a 1.8 Kg weight increase with COC use. So, do not blame the pill for any major weight change!

Myth 2: Old people do not need birth control

Fact 2: Even though the older you get, the lower is the chance for you to conceive naturally yet this chance does not reach 0% until you have touched upon menopause which is defined as 12 consecutive months of no period!

Myth 3: Birth control pills prevent sexually transmitted infections

Fact 3: Birth control pills are NOT protective against STIs. Use barrier contraception such as condoms to decrease the risk of STIs

Myth 4: Birth control pills are 100% effective

Fact 4: With typical use of birth control pills, the failure rate reaches up to 9% during the first year of use, so whenever you miss your period while you are on “the pill”, do a pregnancy test!

Myth 5: COCs are effective immediately after initiation

Fact 5: No, COCs are not effective immediately. If you initiated the pill >5 days from your last menstrual cycle, then you should use a back-up contraceptive method or abstain for 7 days. The pill needs around a week to become effective after initiation.

Myth 6: All COCs are appropriate for all women

Fact 6: As we have previously seen in this blog, in some instances COCs are considered contraindicated

Myth 7: Birth control pills will reduce my fertility

Fact 7: On the contrary, some studies show that the use of birth control pills preserves fertility

Myth 8: Birth control pills are irreversible

Fact 8: COCs are one of the most reversible contraceptive methods as you may get pregnant during the next cycle after stopping their use

Myth 9: COCs promote promiscuity

Fact 9: No studies have linked COCs use to changes in sexual behavior!

Myth 10: COCs will negatively affect my sex drive

Fact 10: NO! solid data do not support any correlation between decreased sexual drive and COCs use.

 

In conclusion, “the pill” is one of the most effective methods of reversible contraception, with benefits spanning beyond your birth control. Moreover, you should always be aware of the general contraindications of their use and invariably inform your physician about your medical history so they can prescribe the best and safest method of contraception. And finally, even though myths are quite common and easy to believe, always search for the best evidence in order to have an informed decision about your health.

Enjoy safe sexual practices!

 

Karam