Benefits of hormonal contraception.
a. Menstruation becomes more regular, there is a 63% reduction in dysmenorrhea and a 29% reduction of premenstrual syndrome [PMS]).
b. There is decrease in the amount and duration of menstrual flow.
c. The Pill corrects iron-deficiency anemia.
a. Benign breast disease: An Oxford study showed a 30% reduction in fibrocystic breast disease (FCBD) and 60% fewer fibroadenomas. An American study showed a 30% reduction with 13 to 24 months’ use, and a 65% reduction when used for 25 months or more.
b. Hospitalization: The chance of hospitalization resulting from pelvic inflammatory disease (P1D) is decreased secondary to thicker impenetrable cervical mucus. Menstrual blood flow is reduced by 50% to 60%. Smaller cervical openings, which do not prevent cervical Chlamydia, do decrease upper tract disease.
c. Epithelial ovarian cancer: There is 40% to 50% reduction in occurrence if oral contraceptives are used for 5 years; an 80% to 90% reduction in occurrence if used for 10 years. Protection from cancer lasts up to 15 years after discontinuation. There is also a decrease in endometrial cancer (50% reduction, lasts for 15 years).
d. Ectopic pregnancy: A tenfold decrease in ectopic pregnancy is seen, compared with nonusers.
e. Acne: Decreasing serum testosterone improves acne.
f. Estrogen deficiency: Symptoms are improved.
g. Fear of pregnancy: The fear of pregnancy decreases, therefore sexual enjoyment is heightened.
h. Fibroid size: An Oxford study showed a 30% reduction in size over 10 years.
12. Possible benefits.
a. Prevention of rheumatoid arthritis: The onset may be postponed, but estrogen dose does not decrease the pain of rheumatoid arthritis.
b. Prevention of ovarian cysts: The rate of recurrent hemorrhagic cysts is decreased.
c. Increased bone density: not as beneficial as endogenous estrogen.
d. Decreased endometriosis and atherosclerosis with low-dose oral contraceptives.
13. Disadvantages or side effects that prompt discontinuation.
a. Nausea: Usually disappears after first month.
b. Breast tenderness.
c. Breakthrough bleeding (initial months).
d. Amenorrhea (prolonged use): May add estrogen or change pills.
f. Decreased libido: May result from decreased free testosterone circulation.
g. Expense (pharmacy dependent).
(1) Only classical migraine types should prompt stopping the Pill.
Progestin-only pills may be tried in this case.
(2) Often the headaches are experienced during the pill-free interval. This may be remedied through the use of continuous oral contraceptives (eliminate pill-free interval), i. Chlamydia infection: Chlamydia cervicitis (not PID) is more common in contraceptive pill users secondary to the increased ectropion caused by the pill than in nonusers (Box 1).
14. Major risks to health.
a. Cardiovascular disease.
(1) Cardiovascular disease includes thrombophlebitis, pulmonary embolus, and stroke. All of these may occur in women who are at risk for these events (i.e., women who are smokers, sedentary, overweight, over 50 years old, and who have increased low-density lipoprotein/high-density lipoprotein [LDL/HDL] cholesterol ratio). History of hypertension, history of diabetes, a family history of cardiovascular events, and diabetes in a premenopausal women also indicate a higher risk level.
(2) Estrogen and progesterone doses have decreased by fourfold and tenfold, respectively, from the original birth control pills, which were studied in the 1960s and 1970s. The use of low-dose oral contraceptives markedly decreases the risk of cardiovascular side effects. For select outpatients who are at increased risk for cardiovascular events, it is wise to suggest alternate forms of birth control.
(3) Smokers: Smoking increases dangerous cardiovascular side effects. Smoking fewer than 15 cigarettes per day increases the risk of myocardial infarction threefold. Smoking more than 15 cigarettes a day increases the risk of myocardial infarction to twenty-one-fold. After age 35, smokers should not use the Pill
b. Cancer: A major concern of women and the most common reason for women to decline use of oral contraceptives. (1) Breast cancer: The final word on the Pill’s influence on breast cancer is not in. There is no convincing evidence in the literature that birth control pill use increases the rate of breast cancer.
(2) A recent study done in Canada shows a 50% reduction in breast cancer risk for women who used combination oral contraceptives for 5 years.
(3) Cervical cancer: Five out of thirteen studies have shown a significant increase in cervical cancer in women who use oral contraceptives. Seven studies showed no significant increase. One study showed a relationship between the Pill and dysplasia and carcinomas of the cervix, especially in women who were on oral contraceptives for prolonged periods of time. However, this may be because Pill users generally have multiple sexual partners and are screened more frequently by Papanicolaou smears than non—Pill users. Human papillomavirus (HPV) plays a large role in cervical cancer, and oral contraception users are less likely to use barrier methods than non—Pill users.
(4) Ovarian and endometrial cancer: Many studies show a decreased risk of ovarian epithelial cancers and endometrial cancers for women on oral contraceptives. The longer the use, the more long term the protection.
(5) Hepatocellular carcinomas: Benign hepatic adenomas occur with oral contraceptive use. However, increased risk of hepatocellular cancer has not been proved in women using oral contraceptives.
(6) Adolescents: The Pill is not contraindicated; however, compliance and sexually transmitted disease (non—condom users) become issues.
BOX 1. Content
Relation of Side Effects to Hormone
Breast cystic changes
Hypermenorrhea, menorrhagia, and clotting
Increase in breast size
Uterine fibroid growth
Absence of withdrawal bleeding
Bleeding and spotting during pill days 1 to 9
Continuous bleeding and spotting
Flow decrease, hypomenorrhea
Pelvic relaxation symptoms
Flow length decrease Moniliasis
Breakthrough bleeding and spotting during pill days 10 to 21
Delayed withdrawal bleeding
Dysmenorrhea (also estrogen excess)
Heavy flow and clots (also estrogen excess), hypermenorrhea, menorrhagia
ESTROGEN EXCESS OR PROGESTERONE DEFICIENCY
Dizziness, syncope Edema
Headache (cyclic) Irritability Leg cramps Nausea, vomiting Visual changes (cyclic) Weight gain (cyclic)
BOX 2. Relation of Side Effects to Hormone Content (Continued)
Chronic nasal pharyngitis
Gastric influenza and varicella
Hay fever and allergic rhinitis
Urinary tract infection
Weight gain (noncyclic)
Oily skin and scalp
Rash and pruritus
Hypertension Leg vein dilation
Deep vein thrombosis hemiparesis (unilateral weakness and numbness)
BOX 3 Contraindications to Using Oral Contraceptives
Present or past history of thrombophlebitis
Coronary artery disease
Hepatic disease, benign or malignant
Smokers over 35 years old
Women who smoke more than 15 cigarettes per day
Migraine headaches that started after oral contraception use
Major surgery that involves immobiluation Lactation
Sickle cell disease (theoretical increase risk for thrombosis)
Active gallbladder disease
Undiagnosed vaginal bleeding
Gilbert’s disease (congenital hyperbilirubinemia)
Women over 50 years old
Immediate postpartum period (up to 14 days still in hypercoagulable state)
Cardiac and renal disease (severe)
Mental illness, substance abusers (less likely to take pills correctly)
Family history of hyperlipidemia
Family history of female sibling or parents who died from myocardial infarction before menopause