In reply—Contra Contraception

Abstract

We thank Dr Nelson for his interest in our article “Current Issues in Contraception,” published in the March 2013 issue of Mayo Clinic Proceedings,1Marnach M.L. Long M.E. Casey P.M. Current issues in contraception.Mayo Clin Proc. 2013; 88: 295-299Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and for sharing his perspectives on this topic. We respectfully disagree that contemporary oral contraceptives are linked with breast cancer. In our previous article,2Casey P.M. Cerhan J.R. Pruthi S. Oral contraceptive use and the risk of breast cancer.Mayo Clin Proc. 2008; 83: 86-91Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar we analyzed key epidemiological studies and found no evidence that such a relationship exists with today’s low-dose estrogen oral contraceptive formulations. Of note, Kahlenborn and associates’ statements regarding breast cancer risk, contained in a July 2008 Letter to the Editor in Mayo Clinic Proceedings3Kahlenborn C. Modugno F. Severs W.B. Oral contraceptives and breast cancer [letter to the editor].Mayo Clin Proc. 2008; 83: 849-850Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and referenced in Dr Nelson’s correspondence, were specifically refuted in our response to the their letter.4Casey P. Cerhan J.R. Pruthi S. Oral contraceptives and breast cancer [reply].Mayo Clin Proc. 2008; 83: 850-851Abstract Full Text Full Text PDF Scopus (1) Google Scholar Further, the recent trends toward long-acting reversible contraception options (eg, contraceptive implants and intrauterine contraceptives) allow for long-term contraception without estrogen and without the need for daily actions by the user.5American College of Obstetricians and GynecologistsACOG Practice Bulletin No. 121: Long-acting reversible contraception: implants and intrauterine devices.Obstet Gynecol. 2011; 118: 184-196Crossref PubMed Scopus (291) Google Scholar, 6Winner B. Peipert J.F. Zhao Q. et al.Effectiveness of long-acting reversible contraception.N Engl J Med. 2012; 366: 1998-2007Crossref PubMed Scopus (827) Google Scholar Maternal death is still the sixth leading cause of mortality in reproductive-aged women in the United States.7Centers for Disease Control and Prevention. Leading Causes of Death by Age Group, All Females-United States, 2009. CDC website. http://www.cdc.gov/women/lcod/2009/09_all_women.pdf. Updated January 2, 2013. Accessed May 5, 2013.Google Scholar Pregnancy and the postpartum period pose a much greater risk of venous thromboembolic events, hemorrhage, infection, and cardiovascular complications than any method of contraception, including hormonal contraception.8Dinger J.C. Heinemenn L.A. Kühl-Habich D. The safety of a drospirenone-containing oral contraceptive: final results from the European Active Surveillance Study on oral contraceptives based on 142,475 women-years of observation.Contraception. 2007; 75: 344-354Abstract Full Text Full Text PDF PubMed Scopus (361) Google Scholar There are many medical conditions in which pregnancy is not advised and that can be frankly life threatening. Should we deny these women and their partners a healthy sex life, which has been shown to positively enhance quality of life and a sense of well-being for both men and women?9Laumann E.O. Paik A. Glasser D.B. et al.A cross-national study of subjective sexual well-being among older women and men: findings from the Global Study of Sexual Attitudes and Behaviors.Arch Sex Behav. 2006; 35: 145-161Crossref PubMed Scopus (370) Google Scholar With all due respect to Dr Nelson’s personal view on sexuality, 46% of adolescent high school females have been sexually active,10Centers for Disease Control and Prevention (CDC). 1991-2011 High School Youth Risk Behavior Survey Data. CDC website. http://apps.nccd.cdc.gov/youthonline. Accessed June 27, 2013.Google Scholar 82% of adolescent pregnancies are unplanned,11Abma J.C. Martinez G.M. Copen C.E. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, National Survey of Family Growth 2006-2008.Vital Health Stat 23. 2010; : 1-47PubMed Google Scholar and 68% of unintended pregnancies occur in women aged 20 to 34 years.12Mosher W.D. Jones J. Abma J.C. Intended and unintended births in the United States: 1982-2010.Natl Health Stat Report. 2012; 24: 1-28Google Scholar Most reproductive-aged women and their partners do not espouse the philosophy on the beginnings of human life presented by Dr Nelson. Unplanned pregnancy is one of the highest-priority public health issues in the United States today. Perhaps the increasing use of long-acting reversible contraception, as highlighted in the Contraceptive CHOICE Project13Secura G.M. Allsworth J.E. Madden T. Mullersman J.L. Peipert J.F. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception.Am J Obstet Gynecol. 2010; 203 (e1-7): 115Abstract Full Text Full Text PDF PubMed Scopus (470) Google Scholar and other studies,14Committee on Adolescent Health Care Long-Acting Reversible Contraception Working GroupAmerican College of Obstetricians and Gynecologists. Committee opinion No. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices.Obstet Gynecol. 2012; 120: 983-988Crossref PubMed Scopus (361) Google Scholar, 15Finer L.B. Jerman J. Kavanaugh M.C. Changes in use of long-acting contraceptive methods in the United States, 2007-2009.Fertil Steril. 2012; 98: 893-897Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar may be a factor in the lowest reported rates of adolescent pregnancy since the 1960s.16Hamilton B.E. Ventura S.J. Birth Rates for U.S. Teenagers Reach Historic Lows for All Age and Ethnic Groups. NCHS Data Brief, No. 89. National Center for Health Statistics, Hyattsville, MD2012www.cdc.gov/nchs/data/databriefs/db89.pdfGoogle Scholar Further, emergency contraception works by delayed or suppressed ovulation, not by interruption of reproductive physiology after the sperm and egg have united or uterine implantation has begun. Given that sperm may remain viable within the female reproductive tract for 3 or more days after intercourse, this delayed or suppressed ovulation after taking hormonal emergency contraception accounts for its selective efficacy.17American College of Obstetricians and GynecologistsACOG Practice Bulletin No. 112: Emergency contraception.Obstet Gynecol. 2010; 115: 1100-1109Crossref PubMed Scopus (59) Google Scholar The American College of Obstetricians and Gynecologists and the US Food and Drug Administration’s Center for Drug Evaluation and Research support its safety and endorse Plan B (levonorgestrel emergency contraception) availability without prescription for women of all ages.18Committee on Health Care for Underserved WomenACOG Committee Opinion Number 542: Access to emergency contraception.Obstet Gynecol. 2012; 120: 1250-1253PubMed Google Scholar, 19US Food and Drug Administration. Statement from FDA Commissioner Margaret Hamburg, M.D. on Plan B One-Step. FDA website. http://www.fda.gov/NewsEvents/Newsroom/ucm282805.htm. Published December 7, 2011. Updated January 6, 2012. Accessed May 5, 2013.Google Scholar, 20FDA approves OTC Plan B for all ages. Time website. http://healthland.time.com/2013/06/20/fda-approves-otc-plan-b-for-all-ages/. Published June 20, 2013. Accessed June 27, 2013.Google Scholar In addition to legislation confirming contraception as a part of preventive health care for women today, we as health care professionals are ethically obligated to counsel women on all options of contraception, sterilization, and abortion, independent of their baseline knowledge, knowledge gaps, or perspectives. If unable or unwilling to do so, we must refer the patient to another physician in a timely and nondiscriminatory manner.21American College of Obstetricians and GynecologistsACOG Committee Opinion No. 385: The limits of conscientious refusal in reproductive medicine.Obstet Gynecol. 2007; 110: 1203-1208Crossref PubMed Scopus (143) Google Scholar Contra ContraceptionMayo Clinic ProceedingsVol. 88Issue 8PreviewThe recent review article by Marnach et al1 asserts that contraception is a public health need because of the high rate of unintended pregnancies and the high rate of such pregnancies ending through abortion. This assertion is misleading on several fronts. First, “unintended” implies accidental, yet procreative potential is an essential element of the sexual act, not an accidental by-product. It is a disservice to the understanding and volitional capacity of most people who engage in an act inherently procreative to imply that they do not understand the nature of the act or do not exercise free choice when deciding whether or not to engage in it. Full-Text PDF