A Contraceptive Perspective

There is no doubt that the introduction of effective contraception has had an important role in empowering women: however it doesn’t necessarily feel like you are making an empowered decision when understanding the myriad options available can be a minefield. Not to mention the conflicting information portrayed in the media; if I had wanted to write an article proving that the combined pill causes cancer then I would have been able to find news sources to back it up, but equally if I had wanted to prove that it actually reduces cancer risk then there are enough sources to back that up as well. Confused? Me too. And, to add to these contraception misconceptions, we often perpetuate misinformation around our friendship groups by passing off anecdotal evidence as fact. That’s not to dismiss there can be real side-effects but it is important to understand that something that works for one person may not for another. Moreover, our understanding of the risks involved can often be clouded by these judgments. So let’s delve into some of the headlines, based on both facts and myths, and see if we can make some sense of it all.

Does the pill cause infertility/blood clots/cancer/depression?

There are a huge range of hormonal contraceptives but the combined oral contraceptive (COC) pill is the most common. It contains the synthetic hormones oestrogen and progestogen which prevent ovulation. Progestogen also creates a mucus block at the cervix to prevent sperm from being able to enter and thins the lining of the uterus to prevent any eggs that are released and fertilised from implanting. It is 99% effective if taken correctly, making it one of the most competent methods of birth control.

Hormonal contraceptives have been getting a fair bit of bad press over the years so let’s rattle through some of the most worrying claims made against them and try to clarify what is known: Infertility – There is zero evidence that the pill can make you infertile and most women will quickly become fertile again as soon as they stop taking it. Blood Clots – Yes, the pill can put you at a risk of blood clots, but this is well documented and your GP will not prescribe it if they think you could be at risk. This is why you have your blood pressure checked every 6-12 months before getting a new prescription and if you have any additional risk factors, such as migraines with aura (visual disturbances), then you will not be able to take the COC. In this case progestogen-only methods such as the implant or mini-pill might be options. Cancer – Research is still ongoing on this. Current consensus is that the pill can give you a slightly elevated risk of breast cancer but it reduces the risk of other cancers, such as ovarian or colon cancer, and 10 years after you have stopped taking the pill your cancer risk returns to normal¹. Depression – This one is slightly more complicated as there is conflicting research. Certainly as it influences your hormone levels it can contribute to mood swings when you initially begin taking it, though this should settle after a few cycles. But can it cause depression? One large study that has underpinned much of the media claims only found a link with depression when prescribing of antidepressants in the first few months of taking COC’s, but then the risk declined². It’s also important to note that correlation is not causation and the findings from this study do need further investigation. However if you do have a history of anxiety or depression then discuss this with your GP before starting any hormonal contraceptive, and if you are on the pill and you feel it is affecting you then don’t be afraid to consider trying an alternative.

Natural cycles; hormone free utopia or risky fad?

Not being an expert on this subject, I have to admit that my original reaction was not trust these apps as far as I could throw them (or as far as I could throw the phone they’re downloaded onto). I still remember in school being told that people can get pregnant even on their period, so I had a healthy cynicism when they became popular. However, last year the Natural Cycles app was approved as a certified contraceptive in the EU. The company claim that the app has an efficacy of 93% when used regularly (i.e. imperfectly but still to a typical standard) in a study of over 22,785 women³. It works by monitoring daily body temperature measurements and uses this to estimate when you are ovulating and might be at risk of becoming pregnant. It seems attractive as a cheap and side-effect free method – though note that while 93% sounds high, that’s 7 in every 100 women having an unwanted pregnancy. The NHS do not recommend the app: they state that further research should be carried out to confirm results found in the initial study as it was a retrospective data analysis, which can be an imperfect study design as it does not always give a sensitive enough level of information⁴. Notably, the study relied on app users inputting information regarding sexual intercourse. However, it is clear that some data was missing as almost half of all pregnancies recorded during the study followed a cycle with no intercourse recorded. This is compromising to the study design as efficacy studies of contraceptives are required to exclude months without sex in their analysis, as the risk of pregnancy is null by default. Other flaws with the study include conflicts of interest, as the lead authors were also the app developers and the study was funded by the company; a lack of clarity around differences in efficacy between those with regular and irregular menstrual cycles; and a high participant drop-out rate (of 34%).

More insight is needed before Natural Cycles can be said to be anywhere near as reliable as the alternatives. Recently it has also been under investigation in Sweden following a string of unwanted pregnancies⁵. Although it may have value for tracking your cycle generally or to work out when you are ovulating if you are trying to get pregnant. If you cannot use other contraceptives then it is a helpful option to have but do read up on it and be aware that you could still be at a risk of getting pregnant. Also, if you struggle with irregular periods or conditions such as Polycystic Ovarian Syndrome then the app may not be able to track your cycles effectively. ⁶

So the coil is like, kinda scary?

The coil, or intrauterine device, is implanted into the uterus via the cervix and prevents pregnancy by creating a physical block and releasing copper, a natural spermicide. The thought of getting a coil put in might be a little daunting but it is possible to have local anesthetic during the procedure so don’t let that part put you off. It’s one of the most effective birth control methods and can last 5-10 years⁷. When it is first put in, the copper coil can lead to heavier or prolonged periods but for most this does settle, and it is a hormone free method. If you have heavier periods then the Mirena coil, which releases progesterone, is a similar method – though it lasts 3 or 5 years depending on the specific brand.

What’s happening with male contraceptives?

You may have heard over the past few years that male contraceptives are on the horizon. In 2016, an injected, hormone-based contraceptive (like female contraceptives, it also uses progestogen) was trialled and found to be highly effective, with 75% of men in the trial saying it is something they would be happy to continue using were it available⁸. However side-effects including mood disorders and changes to libido, similar to other hormonal contraceptives, were found. As a result the trial was halted until formulations could be improved to reduce this. More recently a male pill, dimethandrolone undecanoate, or DMAU, has shown promise in early trials, with fewer side effects reported. However, it has several phases of testing to go through before it could come to the market. Other innovations include an injectable gel which can block the ducts which carry sperm out of the testicles which may be available as soon as 2020⁹.

And don’t forget the trusty condom!

This one is not a myth to debunk but rather a shout-out to latex (or latex-free for those with allergies). They may not be glam but they are one of the only ways to prevent sexually transmitted infections so, no matter your birth control, they are the safest way to go if you are with a new sexual partner.

So after all that, what have we learned? Some contraceptives do have real side-effects and it is important to be aware of these risks so that you know what’s right for you. Of course there are legitimate concerns starting any new medication so if you are new to contraceptives, or considering a switch, make an appointment with your family planning clinic to discuss concerns if you are in doubt. Information is empowerment and contraceptives allow us a degree of control over our fertility that not all women have access to. Be skeptical of scaremongering headlines and don’t rule something out just because it didn’t work for someone you know.

This article was specialist edited Tuuli Hietamies by and copy-edited by Kirsty Callan.

1. https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/#advantages-and-disadvantages
2. https://www.nhs.uk/news/2016/09September/Pages/Women-taking-the-contraceptive-pill-more-likely-to-be-depressed.aspx
3. https://www.naturalcycles.com/en/science
4. https://www.nhs.uk/news/pregnancy-and-child/would-you-trust-a-smartphone-app-as-a-contraceptive/#conclusion
5. https://www.theguardian.com/society/2018/jul/21/colossally-naive-backlash-birth-control-app
6. http://ask.naturalcycles.com/customer/en/portal/articles/2067116-using-natural-cycles-with-pcos
7. https://www.nhs.uk/conditions/contraception/iud-coil/
8. https://www.newscientist.com/article/2110729-male-contraceptive-injection-works-but-side-effects-halt-trial/
9. https://www.telegraph.co.uk/news/2018/03/18/male-contraceptive-pill-safe-use-does-not-harm-sex-drive-first/