When introduced in the 1960s, the birth control pill became a symbol of female liberation

The contraceptive pill made its appearance more than 50 years ago. Emerging during a period of social and political upheaval, it  gave women the possibility to choose how and when to have a family, and to enjoy their sexual life. Thus, it is regarded as one of the greatest scientific inventions of the 20th century and one of the utmost symbols of female liberation.

From the very beginning though, this revolutionary method of contraception has been a source of controversy: some people thought it would create “a society with unbridled sexuality likely to undermine the foundations of the family”; others feared harmful effects and the birth abnormal children.

Fifty years later, the pill remains even more controversial than before and -paradoxically enough- more and more women are “liberating” from their “liberator”: the pill’s popularity is on the decline, a trend observed in many countries. The reasons behind this shift are many, but fear of side effects seems to the most recurrent. Arguably the web and social media, with the spread of countless personal stories with dramatic headlines and numerous pill scares have influenced women’s perception on the pill’s risks. But are these fears legitimate? How dangerous is the contraceptive pill? What is true and what is false?

Let’s see what science answers to the pill’s most common assumptions…

1) The pill harms your future fertility

FALSE. All scientific evidence agrees that hormonal contraceptives do not make women sterile in the long run. Sometimes it may take three to six cycles for fertility to fully return, but within a year after going off the pill, women trying to conceive are as likely to get pregnant (80%) as those who were never on the pill. In certain cases of long-term use, there may be even increased likelihood of pregnancy within 6-12 months after discontinuing it.

Moreover, hormonal birth control may preserve fertility by offering protection against pelvic inflammatory disease, endometriosis, ectopic pregnancy, ovarian cysts, ovarian and uterine cancer (see below).

2) The pill reduces sexual desire

MOSTLY FALSE. In most cases, birth control pills don’t affect libido (sexual desire): out of 10 women taking the pill, 7  experience no change in their sex drive, 2 observe increased libido, and 1 will feel less desire.

Recently, a study provided evidence that the pill does not kill desire: contextual factors, such as the relationship with the partner, stress, fatigue, family problems, recent childbirth, have a more considerable impact on sexual drive than the type of contraception used.

3) The pill makes you fat

MOSTLY FALSE. A recent extensive review study showed no evidence that birth control pills cause weight gain in most women. Although some persons may gain some weight when they start taking it, it’s often a temporary side effect due to fluid retention, not extra fat. And, like most side effects, it usually goes away within 2 to 3 months.

A woman’s weight may fluctuate naturally due to changes in age or life circumstances. Because changes in weight are common, many times they will wrongly attribute their weight gain or loss to the use of the pill.

4) The pill increases the risk of blood clots

TRUE. From the 1960s it is known that combined contraceptives pills may increase the risk of venous thrombosis, that is, a blood clot obstructing a vein, a serious and potentially life-threatening complication. Combined contraceptives contain synthetic versions of the hormones estrogen and progesterone. It is the estrogen that is mostly associated with the formation of blood clots, but the latest years it became evident that the type of progesterone also influences the risk. Indeed, the most “modern” formulations of the combined pill – the so-called third and fourth generation – containing the synthetic progesterones gestodene, desogestrel and drospirenone are associated with higher risk of thrombosis.

The European Medicines Agency (EMA) provides the following values ​​for the incidence (frequency) of deep vein thrombosis in 100,000 women of childbearing age:

• 5 to 10 in non-pregnant women who do not use oral contraceptives,
• 20 for women using a second generation combination pill (containing levonorgestrel),
• 40 among women taking third and fourth generation pill.

Factors that may increase the risk of thrombosis are smoking, high blood pressure, obesity, age over 35 years, and a family or personal history of vascular accidents.

Although these figures may look scary, they should be analyzed in perspective:

• In absence of risk factors, the absolute risk of thrombosis is very low.
• The mortality rate of clotting events is about 1%. Thus, the odds of dying as a result of having a clot attributable to the use of the pill would be about 2 to 4 per million women.
• The risk remains considerably lower than that related to pregnancy and birth (estimated  1 in 1000- 2000 deliveries).
• Indicative of this is the 1995 pill scare in the UK, when a warning was issued on the increased risk of thrombosis related to third generation pills. This led many women coming off the pill, resulting in 12,400 additional births and a 9% abortions rise in 1996.

Overall, the odds of having a thrombotic episode related to the pill are very low, in particular with combined pills containing low dose of estrogen (30 or less micrograms) and old-generation progesterone (such as levonorgestrel).

The minipill, also known as the progestin-only birth control pill, is a form of oral contraception that does not contain estrogen, and its progestin dose is lower than that in the combined formulation. Although its efficacy is slightly reduced as compared to the combined pill, the minipill does not increase the risk of venous thromboembolism or arterial thrombotic accidents (see below).

5) The pill increases the risk of heart attack and stroke

TRUE. An extensive review study looking at arterial vascular accidents attributed to the pill (myocardial infarction and ischemic stroke) showed that the overall risk of arterial thrombosis was 60% increased in women using oral contraceptive pills compared to non-users. Unlike venous thrombosis, the risk did not vary according to the type of synthetic progesterone. However, it was twice as high in women taking pills with higher doses of estrogen (the older formulations of contraceptive pills).

Therefore, the combined pill containing levonorgestrel and low dose estrogen (no more than 30 µg) is the safest oral form of hormonal contraception. The minipill may also be considered in high risk women (see above).

6) A woman should not take the pill if she smokes

TRUE.  There is some evidence that smoking may decrease the effectiveness of hormonal birth control. When taking the pill, smokers experience more frequently irregular bleeding than non-smokers; this could signal that the efficacy of the pill is lowered, but more research needs to be conducted to better understand the effect of smoking on the pill’s action.

But what we do know for sure is that smokers who take combined oral contraceptives have increased risk of venous thrombosis and heart disease (see above). This risk is higher for women that smoke more than 15 cigarettes/day, are older than 35 years old or take formulations with high estrogen levels.

If you are under 35 years old and smoke, you should be extremely careful about using the pill, and the decision to take it should be individualized considering other risk factors such as personal and familiar history of high blood pressure, high cholesterol or heart disease. Smokers aged 35 or over should not take the combined contraceptive pill.

If you smoke you may opt for the mini pill, which does not seem to increase the risk of venous thromboembolism or arterial thrombotic accidents; otherwise you should discuss with your doctor about another contraceptive method, such as the intra-uterine device (IUD).

7) The pill causes mood changes and depression

DEBATABLE. Most studies have shown no effect of the pill on depression and mood changes; some studies have even found a protective effect. In 2016, an extensive review on hormonal contraception and mood changes confirmed the existing evidence, and concluded that “… negative mood changes are infrequent and combined hormonal contraception may be prescribed with confidence”.

However, a recent publication came to challenge this assertion. Danish researchers went through the health records of more than a million women using hormonal contraception. They found that those on the combined pill were 23% more likely to be prescribed an antidepressant than those not on hormonal contraception. For those on the minipill (and on other progesterone-only methods, including the hormonal IUD), the figure rose to 34%. It increased even further, to 80% more likely, for girls 15 to 19 years old on the combined pill.

There are a few important points to consider about these results:

• Depression is a complex condition whose cause is still poorly understood. Several factors seem to play a role: genetic, environmental, psychological and social. Therefore, it is very difficult to evaluate the link between depression and hormonal contraception.
• The Danish study does not prove that hormones are responsible for the depression – “association” does not necessarily translate into “causation”.
• The risk of being diagnosed with depression peaks at two to three months of contraceptive use, but then begins to fall.
•  Even if these findings are confirmed, the number of affected women remains small: 2.2 out of 100 women who use hormonal birth control develop depression, compared to 1.7 out of 100 non-users.

In conclusion, the pill may have impact on some women’s emotions, but further research is needed to establish whether hormonal contraceptives are indeed the cause of depression and mood changes.

8) The pill is 100% reliable

FALSE. Theoretically, with perfect use, the pill is 99.7% effective at preventing unwanted pregnancy. However, there are many factors that may interfere with the pill’s level of effectiveness: forgetting to take it, not taking it as directed, certain medications or medical problems…Therefore, when it comes to real life, the pill is about 92% effective: about 8 in 100 women using the combined pill will get pregnant in a year.

In any case, the birth control pill remains one of the most reliable contraceptive methods.

9) If you take the pill you don’t need the condom

FALSE. A survey conducted in France showed that “…one in ten young women 15 to 20 years old is not aware that the pill does not protect against HIV and sexually transmitted infections (STI)”. As stated before, the pill is a very good at preventing unwanted pregnancy but it offers no STI protection at all. In fact, the only contraceptive method that protects against sexually transmitted infections is the condom. Read more here.

10) The pill causes cancer

TRUE AND FALSE. The pill seems to increase the risk of certain cancers, but it protects again others. Overall, with the use of oral contraceptives the risk of endometrial and ovarian cancer is reduced, whereas the risk of breast and cervical cancer appears to be increased.

The protective effect on ovarian and endometrial cancer (the lining of the uterus) has been consistently demonstrated in many studies. This effect increases with the length of time oral contraceptives are used and continues for many years after a woman stops using the pill.

Long-term use of oral contraceptives is associated with an increased risk of cervical cancer. This correlation is not completely understood, as virtually all cervical cancers are caused by certain types of human papillomavirus (HPV). It has been suggested that women who use the pill may be less likely to use condoms, therefore increasing their risk of being exposed to HPV.

An extensive analysis of more than 70 studies suggested an increased risk of breast cancer among current and recent users of hormonal contraception. The risk was highest for women who started using oral contraceptives as teenagers. However, by 10 years after cessation of use, their risk was similar to that in women who had never used it.

Since most studies so far have evaluated birth control pill older formulations with higher doses of hormones, until recently it was assumed that the newer-generation pills available now would be safer regarding breast cancer risk. Yet a new study from Denmark found that even with the current pills, hormonal contraception users experienced a 20% increase in the risk of breast cancer compared to non-users; the odds rose among women who used hormones for more than 10 years. The risk was similar in magnitude to that of older pill types.

Whether oral contraceptive use increases the risk of liver cancer is not clear: while some studies found more cases of hepatocellular carcinoma ( a type of liver cancer) in women who took the pill for more than 5 years, others did not confirm this correlation.

Hormonal contraception seems to have a protective effect on colo-rectal (bowel) cancer, but this has not been yet consistently proven.

11) The pill has many bothersome side effects

TRUE AND FALSE. Some women refuse to take the pill because they fear certain annoying symptoms. Indeed, the birth control pill is a medication, and as such, it has possible side effects.

The most common adverse reactions associated with use of combined contraceptives include changes in bleeding patterns, nausea, breast tenderness, headaches, missed periods, vaginal discharge and visual changes with contact lenses; few women may also experience changes in sexual desire and mood changes, or temporary weight gain related to fluid retention (see above). In general, these side effects are not a sign of illness, and usually stop within the first few months of using the pill.

While some women may experience bothersome symptoms, the pill provides important non-contraceptive health benefits:

• Decreased risk of certain cancers (see above)
• Improved bone mineral density (in older women)
• Protection against pelvic inflammatory disease
• Prevention of ovarian cysts
• Reduction of menstrual bleeding problems
• Prevention of menstrual migraines (with non-stop formulations)
• Protection against iron-deficiency anemia
• Reduction of ovulation pain
• Treatment of acne
• Treatment of bleeding from fibroids
• Treatment of dysmenorrhea (painful periods)
• Treatment of excess hair on face or body
• Treatment of premenstrual syndrome (PMS)
• Reduction of endometriosis symptoms
• Reduction of polycystic ovarian syndrome symptoms
• Induction of amenorrhea for lifestyle considerations (when you need to stop your period for a while; you can also advance or delay your period with the pill)

So, how dangerous is the pill?

There is no perfect contraception method. I wish there were. And it is true that hormonal contraception, like any other medication, may have annoying side effects and serious health risks. Does it mean that no one should take the pill? Of course not!

We should keep in mind that severe risks are very rare and most bothersome symptoms are short-lived; in addition, the pill offers many non-contraceptive health benefits. But when discussing about the pill’s pros and cons, sometimes we forget a very important issue: the birth control pill is one of the most effective contraceptive methods. And effective birth control prevents from unwanted pregnancy, which may have not only devastating psychological consequences, but may also lead to severe physical harm.

Therefore, the potential problems of the birth control pill should be analyzed in perspective: we shouldn’t just pay attention to downsides, forgetting to place them in context with the upsides. Every woman considering taking the pill should thoroughly discuss with her healthcare provider not only the possible risks, but also its significant benefits, which for many women will be greater than the harms.

Photo credits

Heading: vintag.es; 1: thebump.com; 2: breakingmuscle.com; 3: thejewel.com; 4: health.harvard.edu; 5: newhealthadvisor.com; 6: pinterest.com; 7: pinterest.com; 8: pinterest.com; 9: blog.path.org; 10: purelyb.com; 11: buzzfeed.com; Conclusion: bigthink.com