How Safe is the Pill?
Posted On Aug 31, 2016
From unwanted pregnancy prevention to easing everything from endometriosis to hormones gone awry, the pill remains a modern-day woman’s miracle. But is its effect on your overall health a bitter pill to swallow? New You uncovers the truth within the tablet.
By Catherine Winters
It’s tough to find a woman of reproductive age who hasn’t taken the birth control pill, or thought about trying it. Of the estimated 61 million American women ages 15 to 44 who use contraception, 16 percent take the pill, according to the 2011-2013 National Survey of Family Growth.
Avoiding pregnancy is the main reason that many women employ the use an oral contraceptive, but it’s not the only one. More than 58 percent rely on the pill to ease menstrual cramps, keep their periods on track, and tame acne or endometriosis. Other benefits: “Women who take birth control pills tend to have fewer episodes of ovarian cysts or pelvic pain that lands them in the ER,” says reproductive endocrinologist Nanette Santoro, M.D., chair of the department of obstetrics and gynecology at the University of Colorado School of Medicine.
During perimenopause, the pill has been used effectively to ease symptoms triggered by wildly fluctuating hormonal levels, including hot flashes, night sweats, and irregular bleeding. “However, if contraception is not a concern, bioidentical hormones may offer a safer and more natural option,” says Sahar Swidan, Pharm. D., president of Pharmacy Solutions.
Getting older doesn’t mean women should set aside their former worries about unplanned pregnancy, however. “The second highest incidence of unwanted pregnancy occurs in women in their forties ” says Owen Montgomery, M.D., obstetrics and gynecology department chair at Drexel University College of Medicine in Philadelphia, Pennsylvania.
Pregnancy prevention and symptom relief aren’t the only reasons for prescribing the pill. Research has shown that the pill lowers the risk for ovarian and endometrial cancers. And the longer you take the pill, the greater your protection against these cancers, according to the National Cancer Institute (NCI).
But while the pill, which recently turned 55, has been heralded as one of the most studied medications on the planet, some doctors and researchers have raised concerns, ranging from increased risk of blood clots in women who take it to an increase in breast cancer risk. One researcher has even suggested that pill use is associated with autism spectrum disorder (ASD).
Additional health concerns associated with birth control pills include decreased libido, an increased risk of gallbladder disease, benign liver tumors, mood changes, and weight gain.
Another concern: Are the risks increased in women who started taking the pill as teens? Here’s what you need to know.
THE PILL 101
The birth control pill contains a combination of estrogen, such as ethinyl estradiol, and progestin, the synthetic form of progesterone. There’s also a progestin-only pill, the so-called mini pill, designed for women who can’t take estrogen.
And while the birth control pill is the most widely prescribed hormonal form of contraception, it isn’t the only one. Others include a hormonal injection, an implant, a patch, a vaginal ring, and an intrauterine device (IUD).
The pill comes in all sorts of formulations. For example, you can take the combination pill for 21 days and either go pill-less or take a placebo pill for seven days, when you’ll experience bleeding. Another option is to take the combination pill daily for 12 weeks and switch to an inactive pill for seven days, so you get just four periods a year. Or you can take one particular brand of pill for 24 days and a placebo for four. If you opt for the mini pill, you follow a 28-day cycle with no inactive pills.
Regardless of the formulation prescribed or preferred, hormonal contraception works by preventing ovulation, keeping the embryo from implanting in the uterus, and thickening cervical mucus so sperm can’t gain a foothold. When used correctly—taking it at the same time every day—the pill’s failure rate is a super low 0.1 percent. But during the first year of use that rate is more like 9 percent. The reason: Human error. Some women may miss a dose or forget to start the new cycle on the appointed day.
UNDERSTANDING THE RISKS
The pill circa 2015 is way different from the one women took when oral contraception was approved in 1960. Older formulations contained as much as 150 micrograms (mcg) of estrogen; today’s contain 20 to 35 mcg of estrogen and some may have as little as 10 mcg. There have been similar dips in the dosage of progestin. Older oral contraceptives contained up to 10 times the dose of progestin found in today’s formulations. Still, even low doses of hormones may pose some health risks. Here, a look at some:
According to the NCI, women who take the pill for five to nine years up their risk of cervical cancer threefold; those who take it for 10 years or more raise their risk fourfold. One theory as to why this is the case: The pill may make cervical cells more susceptible to the human papilloma virus (HPV), which causes cervical cancer. Once women stop the pill, the risk drops over time.
Earlier higher-dose oral contraceptives raised the risk of heart attack in women, especially if they smoked. But observational research suggests that the new low-dose pills may not raise risk. Still, more research is needed. If you’re over 35, your doctor should assess your risk for heart disease before you start the pill. Women over 35 may want to consider a non-hormonal form of contraception if they have high blood pressure; their LDL cholesterol— the so-called bad cholesterol—exceeds 160 mg?dl; they smoke; they’re obese; or they have diabetes, kidney or vascular disease, or migraine with aura.
Women who take the pill are at higher risk for ischemic stroke. That’s the kind that occurs when you develop a blood clot in the brain. While that sounds alarming, the actual risk in healthy women is tiny–about 8.5 strokes for every 100,000 women, according to a recent study published in the journal MedLink Neurology. However, a Danish study of 1.6 million women, showed that using combined oral contraceptives with ultra-low doses of estrogen (20 mcg) was associated with a 50 percent increase in risk, while use of traditional low-dose pills (30 to 40 mcg) was associated with an 80 percent increase in risk.
Overall, the study concluded that heart attacks and strokes caused by blood clots were about twice as likely in women using combination oral contraceptives. But the risk is still very low for most women, especially those younger than 35. Still, if you smoke or have high blood pressure or a history of migraine headaches with aura, your risk is higher.
When a 2014 study in the journal Cancer Research reported an increased risk of breast cancer among women ages 20 to 49 who had recently taken oral contraceptives, it made headlines. Read between the lines, and you’ll learn that the risk depended upon the estrogen dosage and the formulation. And the risk dropped once women stopped taking the pill.
In the study, women who took higher-dose estrogen pills—50 mcg of ethinyl estradiol or 80 mcg of mestranol—were nearly three times more likely to develop breast cancer. Women who took pills containing 30 to 35 mcg of ethinyl estradiol or 50 mcg of mestranol—considered a moderate dose— were about 1.6 times more likely to be diagnosed with breast cancer. Women who took low-dose pills containing 20 mcg of estrogen did not have an increased risk. The so-called triphasic pill, in which the dosage of estrogen changes three times during a woman’s monthly cycle and contains 0.75 mg of norethindrone, a type of progestin, also raised the risk.
While the estrogen in oral contraception ups the likelihood of blood clots, the risk is miniscule. “It’s comparable to the risk that affects women who become pregnant,” says Dr. Santoro. Still, the risk rises as you grow older. “If you’re 16, the risk of having a blood clot is so low you don’t have to worry about it so much,” says Dr. Santoro. “In your forties, you may have a more substantial risk. That needs to factor into your decision making.” And the type of progestin in your pill may also be a concern. A 2012 study published in the journal Contraception found that women who take birth control pills containing a progestin called drospirenone might have a greater risk for blood clots and blockage of the arteries.
According to the American Congress of Obstetricians and Gynecologists, your risk for a blood clot increases if you are obese; are over 35; or have several risk factors for heart disease, including high cholesterol or diabetes; have migraine with aura; or have a history of stroke, heart attack, or blood clot. Smoking also increases the risk of stroke among pill users. In these instances, you’re better off considering a non-hormonal form of contraception.
As women approach menopause, our estrogen levels wane and we lose bone. A 2014 report in the journal Best Practice & Research Clinical Obstetrics and Gynaecology suggested that the pill may help women preserve bone density and even gain some. On the flip side, adolescent girls who take combined oral contraceptives may lose bone density. A 2012 report in Best Practice & Research Endocrinology & Metabolism suggested that the risk may be greater if a teenage girl goes on the pill within the first three years of starting her period. It’s not yet known if the estrogen dosage makes a difference or if taking the pill as a teen is associated with a higher risk of fracture later in life. A recent analysis of 14 studies failed to show that the pill had an effect on fracture risk.
According to a 2014 article in the journal Medical Hypotheses one possible reason for the increase in cases of ASD over the past six decades is the parallel rise in the use of combined oral contraceptives. The ethinyl estradiol in the pill is considered an endocrine disruptor so could “modify or degenerate” the eggs of women who take the pill or use another type of hormonal contraception, according to the author, who concludes that more research is needed to tease out a possible association.
THE TOLL OF CONTROL
What to do? If you’re trying to decide whether you or your teen should take the pill, discuss the risks and benefits with your healthcare provider. “Concerns about whether or not taking a medication for a long time is good for your health is a great question to ask your provider,” says Dr. Montgomery.
If you have a personal or family history of breast or cervical cancer or blood clot, for instance, ask your health-care provider about contraception options that don’t involve hormones. And put the risks in perspective.
As you get older, your comfort zone may change since the risk for disease climbs as you age. If you opt for oral contraceptives, or another form of hormonal contraception, take the lowest effective dose possible to minimize hormone exposure.
But, if you choose to take the pill regardless of your age, protect your health by taking a good B vitamin supplement because hormones can cause a deficiency in B vitamins. Try to avoid using personal-care products that include plastics, parabens, or preservatives that can function like estrogen in your body, and stick to a diet that is high in green leafy vegetables, which help your body metabolize estrogen.