Considering the Options: The Risks and Benefits of Modern Contraceptives

In 1914, Margaret Sanger coined the term “birth control” to describe her vision of an accessible, effective method of preventing unwanted pregnancies [1]. Today, 62% of women of reproductive age use some form of birth control—and there are certainly more options now than there were a century ago. The most common method, providing for 28% of all contraceptive users, is the oral contraceptive or birth control pill [2]. But with recent research suggesting that it is by no means the safest or most effective method around, it may be time for more women to learn about finding the right method for themselves [3].

2480078234_45c677498fBirth control pills deliver either a combination of synthetic estrogens and progestins—“combination pills”—or progestin only, both with the aim of blocking ovulation. Side effects of the pill are varied: decreased risk of some cancers, increased risk of others, weight gain, lighter periods, etc. [3]. At least two of these effects, however, are increasingly raising doubts about these oral contraceptives’ safety for all. Recent research has demonstrated an association between a specific type of pill—combination pills containing drospirenone, like Yaz—and blood clots. Reporting “…as high as a three-fold increase in the risk of blood clots…” among users of these pills as opposed to other pills, the FDA explicitly cautions, “Women should talk to their healthcare professional about their risk for blood clots before deciding which birth control method to use.” [4]

Though less extensively investigated, additional evidence has been found to suggest a link between combination birth control pills and reduced libido. In fact, the same mechanism that tends to reduce acne in women on the pill may not be so helpful in other areas. All combination birth control pills are antiandrogenic, elevating levels of a protein called sex hormone binding globulin (SHBG) and, as the name suggests, binding up and reducing free testosterone. Given this sex steroid’s implication in sexual desire and physical arousal, it comes as no surprise that altering testosterone concentrations leaves many women without the desire to have sex—or worse, results in painful sex, thanks to the thinning of vulvovaginal tissue or decreased lubrication. Whether combination pills truly cause lasting sexual dysfunction in some women is still unclear. What is clear is that persistently high levels of SHBG have been observed in women six months after going off of the contraceptive that elevated them in the first place—a definite cause for concern [1].

These side effects are rare, and the vast majority of women who use oral contraceptives have few problems with them. But when the symptoms are vague and can be life-changing—blood clots, for example, can present as simply as shortness of breath—oral contraceptives necessitate careful attention to risks by both the patients seeking them and the physicians writing the prescriptions. Luckily, there are other forms of birth control to consider—like the increasingly publicized implant and intrauterine device (IUD). These long-acting reversible contraceptives (LARCs) are the most effective methods available, have not been associated with blood clots or major sexual problems, and can stay in the body for years [3]. Yet IUD and implant use remains at between 1-8% of all women using contraception [2].

A recent study of New York City physicians painted an interesting picture of the conflicting forces behind LARCs’ low prescription rates. Coding in-depth interviews with a handful of family physicians, pediatricians, and obstetrician-gynecologists, the researchers identified a few major obstacles to LARC prescription. For one, many physicians’ training was outdated, preventing them from correctly counseling about and inserting these devices. Knowledge gaps surrounding modern LARCs’ safety and authorization for younger women without children were also common. Lastly, many physicians neglected to promote LARCs due to worries of empirically unsupported risks, including the belief that such effective pregnancy prevention may lead women to neglect using condoms for STI protection. However, in contrast to the researchers’ analysis, the doctors themselves cited parental resistance, high costs, and lack of interest among many adolescents as primary reasons for not prescribing LARCs to more, and especially younger, women. Taken together, it seems that doctors believe their patients to be ineligible or unwilling to receive these contraceptive devices; their interviewers, on the other hand, suspect that the misinformation stems from the physicians advising these patients in the first place [5].

8528725328_ffe4ba4283LARCs’ high upfront costs—up to $900 for a device—are often more cost-effective than a $10–90 monthly pill over the long term.3 With the Affordable Care Act now in effect, financial concerns surrounding birth control may be alleviated for some [2]. Moreover, another recent study in which women received three years of free birth control—any kind they liked, after individual information sessions with a physician—certainly attested to women’s overwhelming interest in these long-acting, low-maintenance, highly effective devices: LARCs were around six times as popular as oral contraceptives [5]. However, LARCs’ own batch of adverse side effects, such as uterine perforations and irregular bleeding, suggest that they be selected with the same caution as any other drug that influences the body so directly [3].

Bedsider.org, a popular new resource for exploring contraceptive options, often proclaims across its advertisements, “You didn’t give up on sex. Don’t give up on birth control.” [3] It’s true that birth control’s whole purpose, the prevention of pregnancy, is a hefty benefit in the face of its so many potential costs. Regardless, the answer to which method is right for each individual woman doesn’t come from a magazine article that doesn’t know her body, her hormones, her risk factors for adverse side effects, and her preferences. That’s for the patient and her doctor to figure out—and for many, a single visit to obtain the first option suggested just doesn’t cut it. Follow-up appointments, thoughtful reviews of medical and sexual history, and the determination to recognize and address problems over time are the best ways to ensure that each woman finds the best method for herself. Now, a century after Margaret Sanger’s vision that started it all, nothing should stop women from educating themselves about contraceptive options and taking control of their birth control.

References

1. Burrows, L. J., Basha, M., & Goldstein, A. T. (2012). The Effects of Hormonal Contraceptives on Female Sexuality: A Review. Journal of Sexual Medicine, 9(9), 2213-2223.
2. “Contraceptive Use in the United States,” Guttmacher Institute. http://www.guttmacher.org/pubs/fb_contr_use.html#2
3. Bedsider.org
4. (2012). FDA Drug Safety Communication: Updated information about the risk of blood clots in women taking birth control pills containing drospirenone. The U.S. Food and Drug Administration. http://www.fda.gov/Drugs/DrugSafety/ucm299305.htm?source=govdelivery
5. Rubin, S. E., Davis, K., & McKee, M. D. (2013). New York City Physicians’ Views of Providing Long-Acting Reversible Contraception to Adolescents. The Annals of Family Medicine11(2), 130-136
6. Peipert, J. F., Zhao, Q., Allsworth, J. E., Petrosky, E., Madden, T., Eisenberg, D., & Secura, G. (2011). Continuation and Satisfaction of Reversible Contraception. Obstetrics & Gynecology117(5), 1105-1113.

Claire Wilson is a fourth-year student at the University of Chicago double-majoring in English and psychology. Follow The Triple Helix Online on Twitter and join us on Facebook

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