ORAL CONTRACEPTIVES

Birth control pills (BCPs) were hailed as women’s liberators when first approved in 1960. They are currently used by over 100 million women all over the world and 10 million women in the United States as an effective method for avoiding pregnancy. When used properly without missing any pills, they prevent pregnancy over 98% of the time, though typical failure rates are about 5% per year. However, they do not protect against sexually transmitted diseases such as HIV/AIDS, and they are not safe for every woman.[2]

All birth control pills work by giving your body hormones so that it is fooled into thinking it is pregnant. There are two kinds of hormones in the pill: estrogen and progestin. Combination pills contain both estrogen and progestin. Some pills, known as minipills, have only progestin in them. They are not used as much as combination pills because they are more difficult to take properly and do not work as well. If you are breast-feeding or have had problems with the estrogen in combination pills, though, talk to your doctor about minipills.

The different combinations and strengths in combination pills all have the same efficacy, but they can have different adverse effects. There are three kinds of combination pills: monophasic, biphasic, and triphasic. Monophasic pills have one strength and color of pill, biphasic pills have two, and triphasics have three strengths and colors of pills. Almost all combinations then have one week of pills that do not have any hormone in them, called inert pills. You take the inert pills at the end of the pill pack, and that is when you get your period.

The pill can cause many adverse effects. Some of them are merely a nuisance, while others can be life-threatening. The pill can cause headaches, bloating, nausea, irregular bleeding and spotting, breast tenderness, weight gain, or vision changes. Other more serious adverse effects that can occur from a few months to a few years after starting oral contraceptives include high blood pressure, gallbladder disease, liver tumors, depression, and metabolic disorders, such as diabetes. Temporary infertility has been associated with the period of time right after pill use is stopped. But the two most dangerous risks associated with taking birth control pills are blood clots and cancer.

Blood clots most commonly form in the veins in your legs. They can then travel to the lungs, where they can cause severe breathing problems and even death. Blood clots can also cause a heart attack or stroke. People with high blood pressure are already at higher risk for heart attacks and strokes, so the pill is probably not right for you if you have high blood pressure. Not moving for long periods of time can increase your likelihood of forming clots, so if you are going to have surgery that requires bed rest, you should talk to your doctor about stopping the pill. Clotting can also cause problems during surgery, so ask your doctor if you need to stop the pill at least four weeks before having surgery.

The estrogen in the pill was formerly the main culprit in causing blood clots, which is why the amount of estrogen in the pill has decreased so dramatically since the pill was first introduced.[3] Make sure your pill has less than 0.05 milligrams of estradiol, and preferably less than 0.035 milligrams.

The progestin in the newer third-generation pills can also increase your risk of blood clots (see DESOGEN, MIRCETTE, and ORTHO-CEPT). Combination pills all have the same kind of estrogen, called estradiol, but there are two main kinds of progestins. The third-generation progestins are desogestrel, gestodene, and norgestimate. Of these, only desogestrel is available in the United States.

The progestin drospirenone, available in YASMIN, presents the unacceptable risk of dangerously increasing potassium blood levels.

Smoking greatly increases your risk of developing blood clots, especially if you smoke 15 or more cigarettes a day. If you take the pill, you should not smoke. The risk is especially high for smokers over age 35. For most women, the risks associated with pregnancy are higher than the risk of blood clots, but for smokers over age 35 and even nonsmokers over age 40 the risks are higher from the pill. In fact, if you are over 40 and a smoker, you are four times more likely to die from taking the pill than from getting pregnant.[4]

There has been some controversy about the link between the pill and both breast and cervical cancer. Whereas the link with cervical cancer is now strong, for breast cancer some studies show increased risks, while others do not. Until we know more, your best bet is to examine your breasts every month (ask your doctor to show you how), have your doctor check your breasts at least once a year, get a Pap smear once a year, and use a condom to prevent sexually transmitted diseases (cervical cancer is primarily caused by a sexually transmitted virus). You should not take the pill if you have or have had a history of cancer of the breast, cervix, vagina, or endometrium (lining of the uterus).

There are also health benefits associated with oral contraceptives. The pill probably helps to prevent ectopic pregnancies (pregnancies outside of the uterus) and cancers of the ovary and the endometrium (lining of the uterus), and it can decrease cramping associated with your period.[5]

One reason women like the pill is because it is good at controlling when you get your menstrual period. For years gynecologists have recommended skipping that last week of inert pills and starting the next pack right away to change when your period comes. This is easiest and safest to do with monophasic pills, since their hormone levels do not change from week to week. A new pill, SEASONALE, was approved by the FDA in September of 2003. It is an extended-cycle monophasic pill that you take for 12 weeks before getting your period during the 13th week. Since it was approved recently, there is no long-term safety data yet, but keep in mind that if you take SEASONALE you are getting an extra nine weeks of estrogen and progestin and their adverse effects. Also, since you only get your period four times a year on SEASONALE if you become pregnant while on the pill it may take you longer to realize it, and no birth control pill should be taken while you are pregnant. SEASONALE contains estrogen and levonorgestrel, a second-generation progestin.

Is the pill right for you? Only you and your doctor can decide that. However, the pill is not right for you if you smoke, have high blood pressure, diabetes, high cholesterol, liver or gallbladder problems, clotting disorders, or have ever had a heart attack, stroke, or cancer of the breast, endometrium, cervix, or vagina. If you do decide to take the pill, choose one containing a low dose of estrogen and a second-generation progestin, and remember also to use condoms to prevent sexually transmitted infections.