Hormonal contraceptives: Do patients understand the real benefits and risks?

Felicia Rodriquez, single and 24 years old, has been sexually active since she was 17. At age 16, her mother told her sex and contraception were "too dangerous for a young girl" and that the Pill would keep her from being able to get pregnant when she "grew up." With that fear in mind, it's not surprising to find that Felicia became pregnant and had an abortion at 17. She then decided to use condoms, which apparently didn't work out too well because she subsequently had several pregnancy scares and used emergency contraception once; she has had no live births.

At a community health center, she was prescribed a combined OC, but "forgot them all the time," so she switched to the transdermal contraceptive patch at age 22. Last year, she started smoking cigarettes, which prompted her new primary care physician (PCP) to take her off the patch based on concerns that it was too dangerous for smokers. Unfortunately, the PCP would not consider intrauterine contraception because she also considered it too dangerous for a nulliparous patient, or depot medroxyprogesterone acetate, because it might cause bone loss, especially in a patient like Felicia, who didn't like milk. Similarly, her physician did not suggest a contraceptive implant, stating that it was "too dangerous until we know more about it." Felicia doubted she could remember to take OCs, and left the PCP's office saying she was "pretty sure" her boyfriend "will start using condoms."

As this case study so aptly demonstrates, a clinician, a parent, and a young woman were lacking critical information. The true danger to this woman was not contraception but misinformation regarding the benefits and risks of contraception. All medical interventions, including preventive health interventions, carry benefits and risks. Often, rare risks are perceived as common solely because they are rare enough to warrant a news story. Women trust their health-care providers to give them accurate medical information that they then can use to make informed choices. With that in mind, our review of combined hormonal contraceptive risks and benefits is intended to provide clinicians with the kind of information needed to dispel misperceptions about the magnitude of risks associated with hormonal contraception. Our goals are to:

Combined OCs, the transdermal contraceptive patch, and the vaginal ring have few serious health risks, yet these methods continue to receive press coverage almost every time a rare adverse event occurs. This kind of press generates unwarranted fear, causing some clinicians to hesitate to prescribe these contraceptives^1-4 and women to discontinue a method they previously liked.⁵

In 1995, the British Committee on Safety of Medicines issued a warning regarding a possible increased risk of venous thromboembolism (VTE) among users of third-generation OCs, which contain the newer progestins desogestrel and gestodene. Gestodene-containing pills are available in Europe but not in the United States.³ Studies conducted during the 1960s through the 1990s had been reporting a three- to sixfold increased risk of VTE in OC users compared with non-users.⁶ With reductions in estrogen dose in the 1980s and 1990s, the expected incidence of VTE is considered acceptable at about 20 events per 100,000 woman-years (or about 2–4 times the incidence of VTE in a non-pregnant woman who is not using a hormonal contraceptive).⁷ Although the risk of VTE associated with the newer progestins was consistent with the already known risk, media reporting in 1995 convinced the public and many clinicians that OC users were suddenly exposed to a new, unexpected, and unacceptable health risk.⁸

As a result of this perceived threat, many women stopped using OCs, and pregnancy and abortion rates increased.^8-10 In England and Wales, an additional 26,000 conceptions and 13,601 abortions were reported in 1996 compared with 1995.¹⁰ In fact, the studies that spurred the 1995 scare could be interpreted as demonstrating a lower than expected risk of VTE with OCs containing levonorgestrel compared with the third-generation progestins.¹¹ Media reporting of the findings in this positive way may have resulted in a very different public reaction.

Over time, an expected risk generates news for all products in the class of combined hormonal contraception. So it's not surprising to find that recent media reports have focused on the contraceptive patch and vaginal ring.^1,2 As before, none of these reports have indicated a higher than expected adverse event rate.

Combined hormonal contraceptives are measurably safer than pregnancy, and the absolute risk of contraceptive-related death is extremely low for most women.⁴ Overall, approximately 1 in 8,500 pregnancies (including delivery) result in death; in women ages 35 to 39 years, the risk of pregnancy-related death is approximately 1 in 4,600, and in women ages 40 years or older, this risk increases to 1 in 2,200.¹² The risk of cardiovascular death from combined OCs is 1 in 1,667,000 in non-smoking women between the ages of 15 and 34. Only in women ages 35 to 44 years who smoke is the risk of OC-related cardiovascular death (1 in 5,200) greater than the overall risk of death associated with pregnancy.¹³ This 1 in 5,200 risk of death is unacceptable, which is why OCs are contraindicated in women 35 years or older who smoke. The risk of death from pregnancy is also much higher than the risk of death resulting from legal, first-trimester surgical or medical abortion.⁴