In Our Control (9 page)

High Blood Pressure

Hormonal contraceptives can sometimes cause a slight (often clinically insignificant) increase in blood pressure. The risk has gone down significantly since first generation Pills, which were six times more likely to cause women to develop high blood pressure.
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Again, age, smoking, obesity, preexisting blood pressure issues, and family history impact the odds that hormonal contraception will raise your blood pressure. Antihypertensive medications and the Pill don’t play well together: if you have preexisting blood pressure issues that you are controlling with medicine, you may want to consider a nonhormonal birth control.

Before starting the Pill, women should be screened for high blood pressure.
If they have it, a serious conversation about risks and benefits is necessary, although some doctors argue that if high blood pressure is managed and the patient is young (under thirty-five), low-dose pill use may be possible.
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Women with elevated risk should be encouraged to explore safer options, such as barriers, instead of OCs.

Heart Attacks

Very few young women have heart attacks whether or not they are on the Pill, but early studies found that using the drug increased this risk by two to four times.
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Studies on whether the Pill increases the risk of heart attack for women with no cardiovascular risk factors have had mixed results, but it is known that
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if you have other risk factors, such as high blood pressure or smoking, Pill use can increase your risk for myocardial infarction. Smoking makes it ten times more likely that a woman under thirty-five will suffer this outcome.
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Keep in mind, of course, that we are talking about a very small risk.

A joint study between Virginia Commonwealth University and the Universite de Sherbrooke in Quebec found that women taking low dose pills had twice the risk for heart attacks when compared with non-users.
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Some women were more at risk than others: women with diabetes and polycystic ovary syndrome (PCOS), for example, may be more likely to have this problem. John E. Nestler, one of the researchers conducting the study, noted that the Pill is often used as a treatment for PCOS (which, among other problems, causes irregular periods) despite the fact that the drugs may pose more health risks for this group
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—a great example of how a medical problem may be masked, ignored, and even exacerbated by turning prematurely to hormonal contraceptives to manage it.

Stroke

The relationship between oral contraceptives and stroke (an interruption of blood flow to the brain) has been hotly debated since the 1960s, but most data confirms that Pill users have a twofold increase in risk when
compared with non-users. Young women very rarely have strokes, though, so even this elevated risk is very small—perhaps 8 in 100,000 women.
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Smoking cigarettes raises the risk of having a stroke on OCs from twofold to eightfold, and being over thirty-five compounds this risk.
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Women know that they shouldn’t smoke, and many choose to lie about this lifestyle choice to doctors because they are embarrassed. In this way, though, doctors are often prevented from discouraging a group of people from Pill use who very obviously should choose another method.

Migraine headaches, particularly those that come with visual symptoms called auras, can indicate a significant increase in risk for stroke with the Pill.
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A World Health Organization study found that women who had migraines and used OCs were eight times more likely to have a stroke than either women who had the headaches and didn’t use oral contraception, or women who took the pill and didn’t have headaches. They were sixteen times more likely to have a stroke than women who had neither migraines nor used the Pill.
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For every rule there is an exception: Ann, a thirty-year-old lawyer in Boston, tells me that the only thing that reduces and manages her migraines is combined Pill use.
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She swears she will never stop taking it, despite other annoying side effects, because it helps her get through the work day: “It used to be that anything would set off my headaches. If I got on an elevator and someone was wearing too much cologne, I knew I was in trouble. Now they’re better. Not perfect, but better.” These sorts of examples aside, if you are a woman with certain types of migraine headaches, you should think seriously about nonhormonal contraceptive methods.

Certain genetic mutations that cause blood clotting have been associated with increased stroke risk, including Factor V Leiden and MTHFR 677TT.
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When women and their doctors fail to identify clotting problems, the results can be tragic. Deanne Stein was thirty-one, a non-smoker, and physically fit when her dermatologist put her on the Pill to help with skin trouble. The reporter for a local West Virginia television station had only been taking the pills for a short time when she had a stroke. It turned out that she had an undiagnosed clotting problem. Stein
survived, but she now warns women to take the risks of oral contraceptives seriously: “I would never suggest a ban on the Pill. It is very beneficial for those women who can take them. But if you have any of the warning signs, it’s just not worth the risk.”
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Being seriously overweight, a problem that has been growing for many years in the United States, also puts women at risk for more strokes.
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Studies estimate that women in this group are two to four times more likely to have a stroke while using hormonal contraception.

Some say that women should use the Pill despite cardiovascular risks because the risk of stroke during pregnancy is even greater—about 11 per 100,000,
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compared with 8 per 100,000 who use the Pill. But, of course, this is a false comparison; it is not an either/or situation. A decision not to use the Pill does not necessarily mean a decision to undergo a pregnancy or forgo contraception.

Growing Confusion: Cancer and the Pill

The relationship between hormonal contraception and cancer is deeply confusing. The Pill seems to reduce the risk of certain cancers and raise the risk of others. While some associations are controversial, and in some cases the mechanism through which the Pill positively or negatively impacts cancer risk is still theoretical, it is worth trying to look generally at the more studied strains of the disease and OC use.

Uterine and Ovarian Cancer

Studies in recent years have shown that Pill use seems to provide protection against ovarian and endometrial cancers. Endometrial cancer is the most common reproductive cancer in American women, accounting for 6 percent of the total female cancers in the United States each year,
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and ovarian cancer is the ninth most common. Just how much the Pill reduces the risk of these cancers is still up for debate,
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but one meta-analysis estimated that women who don’t take the Pill have a 2.4 percent risk of
developing the disease through age seventy-four, and those who use OCs for twelve years have a 1.4 percent risk.
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Another study thought the benefit would be greater, positing that eight years of use could prevent nearly 1,900 cases of the disease in the United States alone.
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Still other studies insist that the benefit would be smaller: an estimate published in the British medical journal the
Lancet
reckoned that if 100,000 women between the ages of sixteen and thirty-five used the Pill, only ten lives would be saved. In any case, it is clear that the risk of cancer goes down somewhat with use, that longer use provides more protection, and that effects last beyond use, so even if you stop taking Pills you will have reduced risk.

An important point to make about disease statistics is that benefits and risks are often expressed relatively, not absolutely. That means they are expressed as percentages instead of real numbers. Relative risks are more interesting than absolute risks because they look dramatic. For example, let’s say we are testing a drug on 200 women, 100 of whom are actually taking the drug, and 100 of whom are taking a placebo (sugar) pill. If two women in the placebo group get breast cancer and one woman taking the drug gets the same illness, I could write up my report and announce to the world that my pill cut the risk of breast cancer by 50 percent. Meta-analysis, another way of looking at data, has become popular in recent years. A meta-analysis pools data from many places over the course of many years to try and spot new health patterns or confirm older suspect ones. This way of analyzing data is important but flawed: it gives us valuable information, but often pulls together very different pieces of research to do so—studies that may or may not be relevant together. Always be willing to ask tough questions about a trial, even if you aren’t a science person.

Ovarian cancer, while deadly, is relatively rare. It accounts for only 3 percent of cancers in the United States in women.
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The Pill seems to offer the greatest protection in this type of cancer in women under twenty-five. The frequency of ovarian cancer is 14 percent less after a year of use and 50 to 60 percent less after five years. Meta-analysis has suggested that out of 100,000 women, pill use for five to eight years may prevent between 192
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and 215 cancer deaths.
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A 2008 meta-analysis published in the
Lancet
sparked a cry for over-the-counter Pill access as a public health measure.
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That reaction was certainly reductionary of the diverse health and economic concerns that must inform a decision about giving a drug “over-the-counter” status, but the results of the analysis were encouraging for pill users. It found that benefits from four to five years of use persisted (although lessened) up to thirty years after suspending hormones.
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For women who used the Pill longer, greater benefits were seen: in the developed world, women who had used the drugs for ten years cut their risk from 1.2 cases per 100 people to 0.8 cases, and deaths declined from 0.7 per 100 to 0.5.
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Since most ovarian cancers in women occur after age sixty, and most people stop taking the Pill by age fifty, it is important to establish that the theorized benefit lasts for decades.
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Many early users of the Pill have only recently reached their sixties and seventies, so much remains to be seen about the long-term benefits for ovarian cancer prevention.

In addition to ovarian cancer, OC use helps to reduce the likelihood that a woman will develop benign ovarian cysts. The reason for both cancer and cyst reduction is the same: since the Pill prevents ovulation, it creates far fewer opportunities for the problems that can happen when you ripen and release an egg.

Because low-dose pills and progestin-only pills are less likely to stop ovulation, they are also less effective in preventing cysts—in fact, POPs may actually increase the risk of developing function cysts—so if this is the problem you are trying to prevent, you are better off sticking with a slightly higher-dose, combined Pill.
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But even if you have cysts, if they aren’t causing pain and interfering with your life in any way, treatment with hormones, which come with their own risks, may not be the best option.

Colon Cancer

Colon cancer is the third most frequent variety of the disease among American women, and accounts for 536,662 new cases of cancer in women worldwide each year. It is possible that hormonal contraception
curtails the production of bile acid, reducing the risk of this type of cancer.
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A 2009 meta-analysis found that OC users reduced their risk of developing colon cancer by around 20 percent over never-users.
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While the length of time which women took birth control pills for didn’t seem to impact benefit, recent use did.

It is too soon to declare this meta-anlysis conclusive,
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and improved screening, in combination with enhanced efforts to raise public awareness of this illness, remains the most important tool we can use to prevent colon cancer, which has declined 2.2 percent each year for over a decade.
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Though it is rare, even young women can be afflicted with colon cancer: during the writing of this book my dear friend lost her partner (thirty-nine years of age) to the disease, and another family friend (age twenty-seven), continues to undergo chemotherapy and radiation. The effectiveness of the Pill as a preventative measure for colon cancer certainly deserves further study but isn’t a reason to start OCs.

Cervical Cancer and STIs

Cervical cancer is a very different disease depending on who you are and where you live. For women in the developed world it has become a rare event, and deaths from the illness are relatively rare. This is due in part to advances in screening, such as Pap smears and human papilloma virus (HPV) tests, which allow the detection of the disease—which takes years to develop—in pre-cancerous and early stages. In the developing world, the story is different, and many women suffer and die from what is increasingly a preventable illness. As we will see when we look at Gardasil and advances in treating and preventing HPV, this is a disease that has been in the spotlight in the last decade as a series of truly new preventative methods have emerged.