The Pill is easy to take and does the job, but here are five good reasons to consider alternatives, says Joanna Evans
Some 300 million women worldwide have used it at some time in their lives, and more than 100 million are currently taking it. And it's easy to see why. The Pill-hailed as one of the greatest inventions of the 20th century-is among the most effective and convenient forms of contraception, with added benefits for many women such as improved acne, and lighter and less-painful periods.
But there could be a high price to pay, as mounting evidence shows that women on the Pill are risking all kinds of serious side-effects-from blood clots and strokes to eye problems and cancer-not to mention the myriad of 'minor' drawbacks they commonly have to contend with, including mood swings, headaches and loss of libido.
Doctors and drug regulators continue to insist that the benefits of the Pill outweigh the risks, but studies are stacking up to suggest otherwise, particularly as there are many other far safer ways to prevent pregnancy.
Here are five things you need to know about the Pill from the latest evidence-and five good reasons to ditch it.
1- It can cause potentially fatal blood clots
The Pill hit the headlines recently when it was reported that an estimated 20 women die each year in France from blood clots connected to oral contraceptive use.
Blood clots can block the flow of blood to the heart or brain, triggering a heart attack or stroke. They can also travel around the body and lodge in an organ, causing an embolism.
A study by France's health and drug safety agency comparing the risks of first- and second-generation contraceptive pills with third- and fourth-generation pills revealed that, between 2000 and 2011, oral contraceptives were linked to an average of 2,529 annual cases of venous thromboembolism (blood clots)-and the newer-generation pills, like Bayer Pharmaceuticals' Yaz, Beyaz and Yasmin, caused more than twice as many deaths as the earlier ones.1
The link between the Pill and blood clots is not a new finding. A case of venous thrombosis associated with contraceptive use was first reported back in 1961-not long after the Pill was first introduced2-and a stack of worrying evidence has accumulated since then.
According to one up-to-date review in the British Medical Journal, overall, oral contraceptive use increases the risk of a blood clot fourfold.3
Another review points out that the risk is even higher during the first three months of use: Pill users have a roughly 12-fold increased risk compared with non-users in those early days.4
2- It could cause cancer
Doctors like to point out that the Pill reduces your risk of certain cancers like ovarian and endometrial cancer-but should that be a selling point considering that it could also increase your risk of other cancers?
One of the latest studies of the Pill and cancer revealed that both long-term (more than five years) and recent users have twice the risk of cervical cancer compared with non-users. After stopping the Pill, this increased risk takes about 10 years to return to normal.5
Taking the Pill also seems to boost your risk of breast cancer, although the evidence has been conflicting. According to one recent review, women who had ever used contraceptives had a slightly higher risk of breast cancer, but the risk increased for recent users.
The worrying conclusion from the researchers was that, although the elevated breast cancer risk was small, the "relatively high incidence of breast cancers means that oral contraceptives may contribute to a substantial number of cases".6
3- It may affect your eyesight
Taking the Pill for three years or more can double your risk of glaucoma-a leading cause of blindness-according to evidence presented at the American Academy of Ophthalmology annual meeting in November last year.
The study, involving more than 3,000 women aged 40 and older, found that long-term use of oral contraceptives appeared to raise the lifetime risk of glaucoma to around 5 per cent, up from 2.5 per cent in the general population-a finding that held true even when the researchers took other risk factors for glaucoma into account.
Although the absolute risk is still small, Dr Shan Lin, an ophthalmologist at the University of California at San Francisco, believes it's something women should be aware of.
"If you are taking the pill, and particularly if you have a family risk of glaucoma, you may want to have regular screening," he said.
He also speculated that the Pill might cause damage to cells in the eye's retina by flattening out levels of oestrogen in the woman's blood circulation.7
4- It's been linked to MS
Another recent study, which will be presented at the American Academy of Neurology's annual meeting at the end of the month, suggests that the Pill can boost the risk of multiple sclerosis (MS), a disabling condition that affects the brain and spinal cord.
Researchers compared 305 women diagnosed with MS with over 3,000 women without MS, and discovered that those who'd used the Pill-usually a combination of oestrogen and progestin-were 35 per cent more likely to develop the disease than those not using it. And women who had used contraceptives but had stopped at least one month before symptoms started were 50 per cent more likely to develop MS.
According to study lead author Dr Kerstin Hellwig,"These findings suggest that using hormonal contraceptives may be contributing at least in part to the rise in the rate of MS among women."8
5- There are safer, effective alternatives
Apart from condoms, IUDs, diaphragms and caps, which don't use hormones to prevent pregnancy, fertility awareness-based methods-or FABMs-are worth considering as an alternative to the Pill.
These involve learning to recognize the signs of ovulation (when an egg is released from the ovaries) and either abstaining or using a barrier method during fertile times.
Ovulation signs include changes in body temperature, quality of cervical mucus and position of the cervix. There are also secondary signs like ovulation pain and breast tenderness.
Each of these signs can be used on its own-the Billings ovulation method, for example, relies on mucus changes alone-or all together as a cross-checking system, known as the symptothermal method.
If used correctly, FABMs are surprisingly effective and offer benefits beyond the lack of side-effects-from better partner communication and sexual interactions to lower divorce rates.9 They're also immediately reversible and can be used to boost the chances of conceiving as well as to prevent pregnancy.
As for drawbacks, other than the fact that they don't protect against sexually transmitted infections, they clearly demand a lot of organization and commitment, and there's a high risk of failure if a woman's fertility signs are not correctly calculated.
A good idea is to visit a healthcare professional trained to teach FABMs to find out if the method is right for you and, if so, learn how to practise it successfully (see www.fertilityuk.org/ukpractitionersearch.htm to find a practitioner near you).
Try these instead
Considering the risks, is the Pill really your best option?
Conventional alternatives to the Pill
The following methods don't use hormones to prevent pregnancy and so may be safer.
Male and female condomsare 98 per cent and 95 per cent effective, respectively, as barrier methods.
RISKS: The latex in condoms can cause allergic reactions in some people, and talc has been linked to an increased risk of ovarian cancer.1 However, latex- and talc-free condoms are available.
Diaphragms and capsare 91 to 94 per cent effective and more eco-friendly as barrier methods. They are used with natural or chemical spermicides. Natural spermicides include lactic acid, aloe and lemon juice, and honey.
RISKS:They don't protect against sexually transmitted infections (STIs) and, as with condoms, some people may be allergic to latex diaphragms and caps or to spermicide.
Intrauterine devices, or IUDs, are more than 99 per cent effective. An IUD, formerly known as the coil, is a plastic and copper device that's inserted into the womb by a specially trained health professional. Depending on the type of device, it can last for three to 10 years.
RISKS:Expulsion (when the device comes out), perforation (when it punctures the wall of the womb) and infection are potential problems. IUDs can also cause painful periods, and about one in 20 unwanted pregnancies that occur in users is ectopic (when the egg implants outside the womb).2 Plus IUDs don't protect against STIs and some people may be allergic to copper.
Fertility awareness-based methods (FABMs)
Few women know about them, but FABMs (see reason number 5) can be just as effective as oral contraceptives.
The Billings ovulation method
What is it?Developed over 50 years ago by Australian physicians Evelyn and John Billings, this natural method relies on the changes in vaginal mucus that occur regularly throughout the menstrual cycle to identify when a woman has released an egg and is therefore fertile.
Fertile mucus is generally clear, wet, slippery, stretchy and changeable in quality-rather like raw egg whites-while infertile mucus is unchanging and usually dry, sticky, cloudy and non-stretchy. Studies carried out by the World Health Organization (WHO) show that 93 per cent of women can identify and distinguish fertile from infertile mucus.
How effective is it?Used correctly, this method has a 98 to 99 per cent rate of effectiveness. Typically, though, around 10-20 per cent of women will have an unintended pregnancy within a year of following it. This is mostly due to a conscious departure from the rules.1
A variation of the Billings method known as the Creighton model, or NaProEducation Technology, is more standardized in the way it characterizes cervical mucus, using pictures and precise words to describe the changes. In a study of more than 1,800 couples, efficacy rates for avoiding pregnancy were between 96 and 99.5 per cent.2
Find out more:www.boma-usa.org (The Billings Ovulation Method Association); www.aafcp.org (American Academy of FertilityCare Professionals)
The symptothermal method
What is it?This also relies on observations of cervical mucus, but includes body temperature readings (which rise after ovulation) and historical cycle data to help determine fertility. It's based on the idea that, by using more than one sign of ovulation, women will be more accurate in predicting their 'safe' days.
How effective is it?A German study of 900 women found this method to be a "highly effective" form of family planning comparable to oral contraceptives. Using the symptothermal method correctly and abstaining from intercourse during the fertile time led to a rate of 0.4 unintended pregnancies per 100 women-years (99.6 per cent effective).
When barrier methods like condoms were used during the fertile time rather than abstinence, there were 0.6 unintended pregnancies per 100 women per year, which works out to an effectiveness rate of 99.4 per cent.
The overall pregnancy rate-in other words, the calculated rate when all women were included, even those who didn't always follow the rules (typical use)-was just 1.8 per cent (98.2 per cent effective) per year.3 This figure is considerably lower than the typical-use rate for the Pill, which is around 8 per cent (or 92 per cent effective).
Still, previous studies have reported unplanned pregnancy rates as high as 13-20 per cent for typical users of the symptothermal method.1
Find out more:www.ccli.org (The Couple to Couple League International)
The Standard Days Method
What is it?Based on monitoring the days of a woman's menstrual cycle, this is a modern, user-friendly version of the so-called 'rhythm method', introduced in the 1920s before the availability of hormonal methods of contraception.
Only appropriate for women who have menstrual cycles generally lasting for 26 to 32 days, the method teaches women to avoid unprotected intercourse on potentially fertile days-days 8 through 19 of their cycles. CycleBeads, a colour-coded string of beads that represents the menstrual cycle, can help keep track of fertile and infertile days.
How effective is it?Studies show that the Standard Days Method is more than 95 per cent effective when correctly used, and 88 per cent effective with typical use.1, 4
Find out more:www.irh.org (Georgetown University's Institute for Reproductive Health)
What is it?This short-term technique is based on the natural effect of breastfeeding on fertility. Breastfeeding-especially exclusive breastfeeding-suppresses the release of hormones necessary for ovulation.
How effective is it?Provided that certain conditions are met-the baby is exclusively breastfed and is fed often, day and night; the mother's menses have not returned; and the baby is less than six months old-this method is 98 per cent effective at preventing pregnancy.
For working women, however, the effectiveness rate drops to 95 per cent even when they express their milk every four hours, suggesting that it's the suckling of the infant that contributes significantly to the contraceptive effect of lactation.1
Find out more:www.irh.org (Georgetown University's Institute for Reproductive Health)
main text References
Lancet, 1961; 278: 1146-7
BMJ, 2013; 347: f5298
Pol Arch Med Wewn, 2014 Feb 20; pii: AOP_14_016; Epub ahead of print
Eur J Cancer Prev, 2014; 23: 110-2
Cancer Epidemiol Biomarkers Prev, 2013; 22: 1931-43
J Am Board Fam Med, 2009; 22: 147-57
Conventional alternatives References
Eur J Cancer Prev, 2008; 17: 139-46
Prescrire Int, 2009; 18: 125-30
Fertility awareness References
J Am Board Fam Med, 2009; 22: 147-57
J Reprod Med, 1998; 43: 495-502
Hum Reprod, 2007; 22: 1310-9
J Midwifery Womens Health, 2006; 51: 471-7