Contraceptive Risk Research Articles

The Safety of Modern Contraceptives

Mortality is the greatest concern in assessing risks of modern reversible contraception. The problems identified with older oral contraceptives (OCs) have decreased with the lower doses in current OCs. These problems include cardiovascular and thrombotic effects, changes in lipid metabolism, breast cancer, liver cancer, increased risk of chlamydia cervicitis, no protection against sexually transmitted diseases (STDs) and HIV, and interferes with breast feeding. On the other hand, OCs protect against anemia, menstrual disorders, ectopic pregnancy, acute pelvic inflammatory disease (PID), and ovarian and endometrial cancer. Since the contraceptive implant, Norplant, has no estrogens, it does not have the cardiovascular risks associated with OCs. Possible risks from Norplant use include changes in carbohydrate, liver, and lipid metabolism but they tend to be clinically insignificant and no protection against STDs/HIV. Menstruation disorders are the major side effect. Apparent benefits of Norplant are protection against anemia and ectopic pregnancy and no effect on lactation. The injectable contraceptive, Depo-Provera, causes menstrual changes, may slightly increase the risk of breast cancer, may decrease bone density, and does not protect against STDs/HIV. It protects against endometrial cancer. It has no effect on metabolism. Risks associated with the IUD include PID, perforation, anemia, increased menstrual bleeding, and pregnancy. IUDs do not affect the quantity of composition of breast milk. They are best suited for women in a mutually monogamous, long-term relationship. Barrier methods provide some degree of protection against STDs/HIV and PID. Condoms provide the most protection. They do not affect lactation. Their major complications are contraceptive failure and risks associated with pregnancy. For all women, especially those in high risk categories, one must balance the risks of modern contraceptive use with the risks of childbearing and with their benefits.

Contraception for patients with psychiatric or medical disorders

The increased risk that pregnancy carries for women with medical disorders must be weighed against the risks of reversible contraception. In the absence of prospective randomized trials of various contraceptive methods and their effect on a given disease process, the clinician must use information regarding the risk of pregnancy in a woman with medical problems, the well-documented failure rates of various methods, and the probability that the patient will use the method (or any other method) effectively. The possible effects of contraceptive methods on cardiovascular, endocrinologic, neurologic, and other medical disorders are discussed as are appropriate contraceptive options and considerations for these women.

The gynecologist and cardiovascular disease: a window of opportunity for prevention.

We present current concepts and assess the quality of information available for the prevention of cardiovascular disease in women. This article reviews research bearing on the prevention of cardiovascular disease in women, with particular attention to modifiable risk factors. We describe the magnitude of the problem and assess the quality of the data with respect to the classic risk factors. The concept is emphasized that changes at menopause, states of endocrine aberration, and benefits and risks of hormone substitution and oral contraception must be understood in conjunction with all other potentially modifiable and nonmodifiable risk factors. Primary care physicians, especially obstetrician/gynecologists, have a pivotal role to play in the reduction of this disease. Behavior modification is the key to integrating prevention into the regular annual visit.

The sexual behaviour of young people

Chlamydia trachomatis is currently the major sexually transmitted disease (STD) in Sweden. In the early 1980s 20% of young clinic attenders were infected. Treatment policies, including partner tracing, instituted in 1988 reduced the prevalence to less than 5%. Pelvic inflammatory disease (PID) has also declined with the decrease of gonorrhea and chlamydia. The improvements can be associated with policy: the introduction of compulsory sex education at school in 1956 and the establishment of youth clinics in the 1970s with contraceptive counselling, screening, and treatment for STDs. a 1992 study of more than 9000 sexually active Swedish teenagers revealed that 99% considered the condom the most effective means against STDs, and 84% recognized chlamydia, HIV/AIDS, gonorrhea, and genital warts as STDs. 75% of the subjects had engaged in coitus at first intercourse and 82% at the most recent encounter. 17% had had an STD, and 9% had been or had made somebody pregnant, mostly ending in abortion. In 1975, when the new abortion law was adopted, the teenage abortion rate was high at 30/1000 teenagers aged 15-19. Counseling and free contraceptives reduced the rate by 30% in the next 10 years. However, news about the possible risks of oral contraceptives in the 1980s again boosted the rate from 18 to 25/1000. Recent concerted efforts cut the rate anew. Preventive policies need to convey a positive attitude about sexuality and deal with the basic teenage problems of multiple partners and stress the importance of condom use. Condoms are effective only in stable relationships, and those with less education or those unemployed take more risks, using condoms and contraceptives less frequently. Girls from emotionally poor environments often engage in sex for emotional satisfaction. Openness and further knowledge is needed to ensure the safe sexual behavior of young people.

Education Contraception: What pharmacists should tell their patients

Unintended pregnancies occur despite the availability of highly effective contraceptives. Patients' contraceptive choices, as well as the availability of certain methods, however, may be affected by social, religious, and political forces. It is therefore vital that health care professionals provide consumers with unbiased, factual information on contraceptive methods, in a comfortable environment. All sexually active individuals who wish to prevent unwanted pregnancy should be counseled on contraception. Pharmacists are well-placed to counsel consumers on the efficacy, safety, cost, convenience, and availability of birth control methods in an unbiased fashion. The author discusses menstrual cycle physiology, selecting a contraceptive method, oral contraceptives, combination oral contraceptives, progestin-only oral contraceptives, long-acting steroid contraceptives, and barrier methods, emphasizing information on hormonal contraceptives. Consumers need to be educated to keep pace with the development and marketing of new forms of contraception. Moreover, both health care professionals and consumers need to be reeducated on the health benefits and risks of low-dose combination oral contraceptives.

Benefits and Risks of Combined Oral Contraceptives

The use of combined oral contraceptives carries a number of well-established major non-contraceptive benefits. Of these, the most important protective effects are suppression of the risk of epithelial cancer of the ovary and cancer of the endometrium. Also of great importance is a reduction in the risk of pelvic inflammatory disease. Needless to say, there are also some established risks of combined oral contraceptives. The most important of these are the vascular ones, comprising effects on acute myocardial infarction, thrombotic stroke, haemorrhagic stroke, and venous thrombosis and embolism. Possible risks which are still under evaluation include an adverse effect on breast cancer and, likewise, on carcinoma of the cervix. More information is needed about both these conditions. A number of authors have provided analyses of varying degrees of complexity in which they have attempted to weigh the benefits and risks of combined oral contraceptives. Results from some of these studies are presented in the paper. On the whole, the findings are reasonably reassuring.

Contraception in Finland — with a focus on IUDs

We studied Finnish patterns of contraceptive use In the late 1980s, in a random sample of 1,000 women aged 18–44, of whom 84% responded. Three-quarters of the respondents used contraception: 26% used intrauterine devices (IUDs), 23% condoms and 21% oral contraceptives (OCs). Overall patterns of use were accordant with medical recommendations. However, all of the frequent IUD use detected was not ideal, for example, 9% of IUD users had a non-steady sexual relationship. Therefore, this study indicates that selection and counselling of contraceptive users is still of current clinical and public health importance — given the Impact of health benefits and risks of contraception on the health status of women of childbearing age.

The Saskatchewan oral contraceptive cohort study of oral contraceptive use and cardiovascular risks

The Saskatchewan oral contraceptive cohort study of oral contraceptive use and cardiovascular risks

A case-control study of the risk of breast cancer in relation to oral contraceptive use.

The relation of oral contraceptive use to the risk of breast cancer was evaluated in a case-control study of women under the age of 70 years, conducted in Toronto, Canada, from 1982 through 1986. A total of 607 breast cancer cases identified in a cancer hospital were compared with 1,214 controls matched to the cases on neighborhood and decade of age. Information on oral contraceptive use and risk factors for breast cancer was collected in home interviews. Conditional logistic regression was used to control multiple confounding factors. For women aged 40-69 years (527 cases, 1,054 controls), the results suggest that oral contraceptive use does not increase the risk of breast cancer. Multivariate relative risk estimates were close to or below 1.0 for long durations of use overall and in various categories of parity status and other factors. For women under the age of 40 years, the data were sparse (80 cases, 160 controls). Although there were some elevated relative risk estimates, most were not statistically significant, and there were no consistent patterns across duration of use. The present data add to the body of evidence that indicates that oral contraceptive use does not adversely affect the risk of breast cancer in older women; the data are inadequate to clarify the effect in younger women.

Oral contraceptive use and risk of cutaneous malignant melanoma.

The relation between cutaneous malignant melanoma (MM) and the use of oral contraceptives (OC) was investigated in a case-control study carried out from 1979 to 1991 among patients in hospitals and clinics in the Philadelphia (PA) and New York City (NY) metropolitan areas (United States). Cases were 615 women under age 70 who recently had been diagnosed with invasive melanoma; controls were 2,107 women of the same ages who had been treated for other conditions unrelated either to OC use or to skin diseases. The cases were categorized as severe or nonsevere based on the depth of invasion of the tumor or the presence or absence of metastases. Among the severe cases, OC use was not associated with MM: the relative risk (RR) estimate for ever-use was 1.1 (95 percent confidence interval [CI] = 0.8-1.5) and the estimate for 10 or more years of use was 1.1 (CI = 0.6-2.1). Nor was risk associated with recent use, long latency, or young age at first use. Among the nonsevere cases, ever-use of oral contraceptives was associated positively with MM (RR = 1.5, CI = 1.1-2.4) but there was no trend with increased duration of use. The findings provide evidence against the hypothesis that OC use increases the risk of malignant melanoma. The elevated estimates among the nonsevere cases most likely reflect selection bias rather than a causal relation.

Emergency Contraceptive Pills: A Simple Proposal to Reduce Unintended Pregnancies

A new form of postcoital contraceptive therapy is described as more effective because of reduced incidence of nausea, vomiting, and breast tenderness. Other forms of emergency contraceptive pills (ECPs) are the "Yuzpe" method or high-dose contraceptives. The new method calls for administration of 3 200-mg tablets of danocrine (Danazol) within 72 hours of unprotected intercourse and a second dose 12 hours later. There are mixed reviews of the efficacy of danocrine and ECPs. In one comparative study of ECP and danocrine use, efficacy of danocrine was greater but not significantly so. Another study found danocrine so ineffective that the study was halted. ECP use would not end unintended pregnancies caused by method failure unless it was condom failure. Estimates of ECP use involve 75% of the 1.7 million women with user or method failure, all 1.9 million women with unintended pregnancies from nonuse of contraceptives, and some of the 1.6 million abortion users. An obstacle to ECP use is lack of knowledge due to lack of Food and Drug Administration approval of Ovral and Danazol and physician concern for legal liability. Another obstacle consists in the logistics of obtaining ECPs and the fear of side effects. Provision of ECP kits with 3-5 regimens in clinic or physician offices is proposed for women without contraindications. Anticipated objections are reported to be encouragement of contraceptive risk taking, the health risks of repeated use, restrictions in Title X programs, and the drug effect on fertilization. Another proposal is to sell ECPs as over the counter drugs or in vending machines and changing US contraceptive prescription laws. Objections to elimination of the physician prescription requirement might be an increase in use among women with contraindications and a decrease in regular checkups and Pap tests. The objections could be overcome with proper package labeling. Paternalism is not a sufficient justification for requiring prescription of contraceptives and medical visits. ECPs, in fact, are already available as low dose contraceptives such as Lo/Ovral, Nordette, Levlen, Triphasil, and Tri-Levlen when 4 pills are used. Instructions for ECP use are given.

Anticonceptivos Orales y Cáncer de Mama: Análisis de la Potencia Estadística de la Asociación

The power of the association between oral contraceptives and breast cancer was analysed in all the papers published up to date. Seventy-seven publications (from 44 studies) were collected and graded as to quality using meta-analytical methods. Power achieved a figure of greater than or equal to 0.8 in a 10.8% of the associations studied. It showed a significant relationship with the existence of a significant relative risk of the oral contraceptives for breast cancer. The relationship with the sample size of a study was not linear. Power did not show any significant relationship to other variables related to the design of a study (apart from matching, being the power higher in unmatched studies), or to the biases detected, although studies considered as unbiased yielded a higher power. Logistic regression analysis included as predictors of a power greater than or equal to 0.80 the existence of a significant relative risk and the lack of biases in a research.

"Contraception and Ectopic Pregnancy Risk"

Studies of the association of ectopic pregnancy with contraception have generated a conflicting array of results because of methodologic differences between studies. We estimated the absolute incidence rates of ectopic pregnancy for various contraceptives by multiplying the pregnancy rate by the proportion of pregnancies with ectopic implantation for each method. Our results indicated a more than 500-fold difference in ectopic pregnancy incidence, from a low of 0.005 ectopic pregnancies per 1000 women years of oral contraception or vasectomy to a high of 2.6 per 1000 women years of no contraception. These estimated incidence rates should be useful for clinicians and patients seeking to better understand the risks and benefits of contraceptives.

"Oral Contraceptive Use and Breast Cancer Risk in Young Women: Subgroup Analyses"

"Oral Contraceptive Use and Breast Cancer Risk in Young Women: Subgroup Analyses"

Risk of Chlamydial PID and Oral Contraceptives

<h3>To the Editor.—</h3> Our colleagues Wølner-Hanssen et al¹conclude that oral contraceptive use is associated with decreased risk of pelvic inflammatory disease (PID) among women infected with<i>Chlamydia trachomatis</i>but not among those infected with<i>Neisseria gonorrhoeae</i>. We have two questions about their methods and would like to caution against overinterpretation of their principal findings. First, why were all variables showing significant differences between the case and control groups^1(Table1)not considered in the multivariate analysis? The variables "ever pregnant" (<i>P</i>&lt;.001), "unemployed" (<i>P</i>&lt;.001), "drinking" (<i>P</i>=.002), and "mean number of lifetime sexual partners" (<i>P</i>=.004) should also be included. Would inclusion of these variables affect the odds ratio and level of significance? Second, how is oralcontraceptive use measured? In particular, how is duration or intermittent use taken into account? The data on the overall relationship observed between oral contraceptive use and PID^1(Table3)do not demonstrate

Risk of chlamydial PID and oral contraceptives

Risk of chlamydial PID and oral contraceptives

Risk of Chlamydial PID and Oral Contraceptives

To the Editor.— Wolner-Hanssen et al 1 report a decreased risk of symptomatic chlamydial pelvic inflammatory disease associated with oral contraceptive use. Pelvic inflammatory disease is the principal cause of ectopic pregnancy (EP), yet our recent findings do not indicate a decreased risk of EP with use of oral contraceptives. Study. — We conducted a case-control study between January 1988 and March 1989 in seven departments of obstetrics and gynecology in the Paris area. A group of 279 patients with EP, confirmed by laparoscopy or laparotomy, were individually matched with two control women: the first woman admitted to give birth and the first woman admitted with a miscarriage to the same department. The case women and control women were interviewed with respect to prior gynecologic disease and surgical procedures, pregnancy history, contraceptive use at the time of the current conception, sexual activity, smoking habits, and constitutional and socioeconomic factors. The

RE: “BREAST CANCER BEFORE AGE 45 AND ORAL CONTRACEPTIVE USE: NEW FINDINGS”

Miller et als recent study on the relationship between oral contraceptive (OC) use and breast cancer risk found a relative risk of 2.0 in ever-users under 45 years of age. This positive finding stands in contrast which a study conducted 3 years earlier (1983) that used the same case-control technique; in the earlier study the relative risk was 1.0. To determine whether this change in findings reflected new trends in OC use among cases and/or controls the authors compared the crude rates of OC ever-use in both the 1983 and 1986 studies. To control for age cohort the analysis focused on women who were 25-39 years of age in the earlier study compared with the total number of women from the later study. Among cases the rate of ever-use of OCs was equal (69%) in both periods. In contrast among controls the OC ever-use rate was 67% in the 1st study versus 58% in the 2nd study. Thus it would appear that the difference in the odds ratios in the 2 studies reflects different patterns of OC use among controls in 1983 versus 1986. This in turn appears due to the different diagnostic distributions of controls in the 2 years. 14% of controls in the earlier study versus 31% of those in the later study had acute infection as their presenting diagnosis and it cannot be assumed that their use of OCs reflects that found in the general population.

The risks of oral contraceptives and estrogen replacement therapy.

The benefits and risks of both oral contraceptives and estrogen replacement therapy (ERT) are evaluated by summarizing briefly the results of the most evidential studies on breast, ovarian, endometrial, and hepatobiliary cancer, heart attack, stroke and venous thromboembolism. The methods used to estimate risk ratios, prospective random-allocation, double-blind trials, and retrospective case- controlled studies, are explained briefly. The ERT used today resemble sequential oral contraceptives, except that only 10-20 mcg ethinyl estradiol is taken for 25 days, and progestins are used on the last 10 days. Breast cancer risk is not different in pill users from nonusers, based on the U.K. General PRactitioner, Oxford Family Planning, Harvard nurses or U.S. SEER National Cancer Institute studies. Studies on ERT and breast cancer are mixed, but only injected estrogens raised the risks. Ovarian cancer is prevented by pill use in proportion to length of use. No studies were reported for ERT. The risk of hepatic cancer is 3.8 to 7.8 higher in pill users, but the number of cases is so rare that this should not affect prescriptions. Neither pill nor ERT raise the risk of myocardial infarction, and after premature surgical menopause, ERT lowers the risk. Based on studies done in the 1970s, oral contraceptives raise the risk of thrombotic stroke while women are taking them, from 10-13/100,000 to 41/100,000. ERT has no clear association with stroke. Similarly, orals increase the risk of venous thromboembolism, 8-fold in the Oxford Family Planning study published in 1986, although the absolute numbers are very small. ERT had no effects no risk of thromboembolism according to the lipid Research, Framingham and Nachtigall studies.

Oral Contraceptive Use and Breast Cancer Risk in Young Women

Oral Contraceptive Use and Breast Cancer Risk in Young Women