A health perspective of hormonal contraceptives.

Abstract

Initial discussion in this health perspective on hormonal contraceptives is directed initially to combined estrogen-progestogen oral contraceptives (OCs) providing a medical and social perspective and then reviewing the literature concerning the side effects of cardiovascular diseases neoplasia congenital defects metabolic effects the less serious conditions which may be caused or precipitated by OC use and the positive and negative medical aspects. The discussion then turns to the risk perspective methods of evaluating risks and minimizing contraceptive risk and improving safety. Overall disease of the circulatory system is the most important deleterious effect of combined OC use. Yet deaths from cardiovascular disease are the most easily preventable of OC complications since at least half of the deaths would be prevented if women did not smoke cigarettes. The risks are dramatically concentrated in women aged over 40 years and to a lesser extent over 35 years who smoke cigarettes and who have other cardiovascular risk factors such as hypertension hyperlipidemia a strong family history of cardiovascular disease or who have diabetes. Despite strenuous efforts on the part of various journalists to persuade otherwise at this time there is no clear evidence that use of combination OCs predisposes to any type of malignancy. A small number of studies have pointed towards a very low grade risk of certain congenital anomalies in women who are inadvertently exposed to OCs during the early part of pregnancy. Since the trends are not confirmed in all studies it is not absolutely clear that OCs actually do contribute to some congenital anomalies. There is now good evidence to indicate that the incidence of gall bladder disease is about doubled during the 1st year of OC use. There is no evidence of a continuing effect. Liver diseases which may be precipitated or exacerbated by OC use include severe congenital enzyme defects obstetric cholestasis porphyria and active hepatitis. Prolonged post pill amenorrhea occurs in about 3-5/1000 users. There is now good evidence that combined OCs reduce milk volume in lactating women and they also produce some changes in milk composition. A wide range of metabolic changes have been demonstrated by laboratory tests. Most of these are dose related and have been minimized by the modern trend toward very low dose steroidal preparations. The aim is to identify those women who initially have high risk factors for hormonal contraceptive use or who develop risk factors or complications during use. Overall combined OCs and long acting progestogen-only methods show a high benefit to risk ratio in all but a small number of high risk women. For the great majority of women the combined OC appears to be 1 of the safest medications which can be taken on a longterm basis.