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Weighing the Health Benefits of Birth Control

Posted by tothewire on January 13, 2009




Unveiled in 1960, the birth control pill revolutionized contraception. Yet despite an abundance of birth control options today, almost half the pregnancies in this country are unintended, according to the Centers for Disease Control and Prevention, more than in any other developed nation. What’s the reason?

The issue is not technology. But economics and human behavior are another story. Nearly a third of women who start a new type of birth control stop within a year, according to one recent study, largely because of changes in their insurance coverage. All methods have some side effects. And the current crop of intrauterine devices, or IUD’s, despite having a nearly perfect efficacy rate, have been slow to catch on, experts say, partly because more doctors need to be trained in inserting them.

“Adherence is a huge issue,” said Dr. Nancy Padian, an epidemiologist at the University of California, San Francisco, who specializes in reproductive health and H.I.V. prevention. “To have a significant effect you have to use a product very consistently.”

As a result, whether to promote their particular brand or to encourage better compliance, many birth control manufacturers and doctors are promoting the noncontraceptive benefits of contraception. Whether it’s reducing the risk of cancer, improving the health of mothers-to-be, easing cramps or enhancing complexion, it’s nice to have a medical excuse for using birth control.

Hormonal contraceptive methods use manufactured estrogen and progestin in different combinations and deliver them in a variety of ways — through pills, shots, skin patches, implants, IUDs and vaginal rings. Studies have shown that all those methods reduce the risk of ovarian and endometrial cancer. Some may also help protect against osteoporosis.

Using contraception can also give women a chance to get healthy before they conceive — to stop smoking, lose weight or lower their blood sugar.

“If a diabetic woman gets pregnant unexpectedly, there’s a risk of major anomalies — heart problems, neurological problems — in the baby,” said Dr. Anita L. Nelson, director of women’s reproductive health at the Harbor-U.C.L.A. Medical Center in Los Angeles. Very young mothers are also at greater risk for pre-eclampsia and premature births.

“Early prenatal care is not good enough anymore,” Dr. Nelson said. “We could do so much better if we got moms into really good health before they got pregnant.”

If those reasons aren’t enough, ads for pills like Yaz cite beautiful skin and relief from premenstrual bloating and mood swings. Loestrin 24 Fe includes an iron supplement. The oral contraceptives Seasonale and Seasonique reduce menstrual cycles to three and four times a year. And Lybrel is supposed to eliminate menstruation altogether, a potential boon to women who suffer from severe cramping and bleeding, anemia, mood swings and migraines that can worsen with menses.

The “no-bleed” pills aren’t exactly new, of course, but a refinement of the pill introduced 47 years ago. By suppressing ovulation, the pill — or any hormonal method — automatically stops menstruation, because if no egg has been deposited, the uterus has no reason to shed its lining.

But the pill was such a radical departure that its inventors decided to include a week of placebos in the 28-day pack to create a fake period, or withdrawal bleed. The cycle of 21 days on, 7 days off was pure marketing, designed to make the pill more acceptable to the public. Many women have been controlling their periods for years by skipping the placebos in their packs and taking the real pills continuously.

Today’s marketing of the “no-bleed” or “extended regimen” pills, all variations on the original pill, plays down the breakthrough bleeding that can occur, according to some skeptics. And while some advocates argue that these newer contraceptive techniques are likely to cause no long-term problems since, historically, women spent most of their reproductive years either pregnant or nursing so had far fewer menstrual periods than women today, the health effects of going for months or even years without a period remain unknown.

In the clinical trials that led to Lybrel’s approval by the Food and Drug Administration, for example, many women dropped out because of breakthrough bleeding, and nearly 40 percent of the participants still had breakthrough bleeding after a year of use. Lybrel’s manufacturer, Wyeth, is also recommending that users take a monthly pregnancy test because the absence of a regular menstrual period makes it harder to tell whether conception has occurred.

“Is it really worth it if you have to put up with all that?” asked Barbara Seaman, a feminist health writer, several months before her death earlier this year.

Dr. Susan Wood, a professor of public health at George Washington University, has called for long-term safety studies of these newer contraceptive techniques. Dr. Wood resigned from her post as the Food and Drug Administration’s assistant commissioner for women’s health over the delayed approval of Plan B, the emergency contraception pill that is now available over the counter for women and men 18 and older. (Those younger than 18 still need a doctor’s prescription.)

With more potent doses of hormones than daily birth control pills, Plan B is designed to prevent conception if taken within three days of unprotected intercourse. Even without a noncontraceptive benefit, sales of Plan B are booming, according to the health research company IMS Health.

While all these new products are just variations on an old theme, novel approaches like a long-awaited male pill or a method for women that would prevent both pregnancy and sexually transmitted diseases like AIDS remain elusive. Several experts said that the cost of developing an entirely new contraceptive method outweighed prospective profits, and that research financing from pharmaceutical companies had dried up.

“The holy grail is a drug that would specifically target the ovaries and testes that would have no effect on any other organ system, so they would be side-effect free,” said Dr. James Strauss, who was co-chairman of a national committee on contraception research and is now dean of the medical school at Virginia Commonwealth University. “That would be based on the discovery of genes only present in those reproductive tissues. We know a significant number of those genes today, and that’s the fruit of 20 years of research. Unfortunately, that knowledge has yet to be translated into a product.”


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