In Our Control (10 page)

Most cervical cancers are caused by HPV, which is transmitted primarily through sexual contact. HPV causes cellular changes that can lead, after years of unchecked development, to cancer.

There seems to be a small increase in the likelihood of developing cervical cancer with OC use. A 1995 meta-analysis estimated that 425 women
between the ages of twenty and fifty-four who didn’t use the Pill in every 100,000 got this cancer. For users of hormonal contraception, particularly those who took the drugs for eight years or more, an additional 125 women might be diagnosed with cervical cancer.
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Considering how many women suffer from the illness each year, this is a very small number. Another large analysis reckoned that among women who used the Pill for five years, there would be an additional 67 cases per 100,000 women in the United States,
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and still another trial put that number at 76 additional deaths per 100,000 women.
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It is difficult to theorize why cervical cancer and Pill use might be connected, but one possibility has nothing to do with how the drug works in the body. Pill users, as a group, may simply have more sexual partners than non-users, and it is even more possible that they neglect to use condoms, which, though not foolproof, indeed decrease transmission of HPV. Hormonal contraception may increase the chance of contracting HPV by causing something called cervical ectopy, which increases the surface of vulnerable cells on the cervix. Finally, it is possible that lower folic acid in the body—a potential result of taking the Pill—decreases the immune system’s response to HPV and changes the cervical mucus in a way that makes women more vulnerable to infection.

The relationship between sexually transmitted infections and the Pill is a confusing one. Studies suggest that users have fewer cases of pelvic inflammatory disease (PID), but more incidence of chlamydia, an illness that can lead to PID. Pill users are more likely to engage in sexual activity that could lead to contracting chlamydia, but fewer Pill users’ infections advance to PID at least in part because they are required to undergo yearly exams, which often include testing for STIs, in order to get prescriptions. It is also possible that the Pill somehow controls and tames chlamydia.

Whatever the effect of the Pill, it is important to use condoms if you have multiple partners. They should be the first line of defense against HPV, chlamydia, HIV, and all other STIs. Every woman who is sexually active should make sure to have regular Pap smears or some other variety of screening for HPV and pre-cancerous growths as well as for STIs.

Breast Cancer and Benign Breast Disease

There are few illnesses that inspire as much fear and emotion in women as breast cancer. It is the most frequent cancer in women in the United States, and most of us know someone who has dealt with the illness.

Since hormones were synthesized, scientists have been aware that they have the potential to cause breast cancers.
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Charles Dodd, the British scientist who helped make diethylstilbestrol (DES), noticed that in the months after his male scientists started making and working with the compound, they began developing breasts. By 1940, the
Journal of the National Cancer Institute
was reporting that DES caused breast cancer in both male and female mice.
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Exactly what the risks of taking OCs are in terms of developing breast cancer remains controversial. What is certain is that very few
young
women get the disease: indeed, fewer than ten in every ren thousand under age thirty-five.
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A re-analysis of data from fifty-four trials found a small increase in breast cancer risk with Pill use in those under age thirty-five.
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This risk was greatest while using the drugs, and persisted for about ten years after use, eventually disappearing. Older formulations of the Pill were more risky, and recent trials of lower dose pills suggest that risks are now minimal.
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Some studies have suggested that while Pill users may be slightly more likely to get breast cancer, they are also more likely to be diagnosed at early stages when treatment is more possible (in particular, before the cancer has spread beyond the breast). As with PID, it seems possible this is due in part to more frequent visits to health care professionals, which are a required part of OC access.

The Women’s Health Initiative (WHI) confirmed that menopausal women taking the hormone drug HT (a combination of estrogen and progestin similar to but less powerful than birth control pills) were at a 24 percent higher risk for breast cancer than those taking a placebo.
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Women who took estrogen alone for the trial had lower rates of breast cancer than those who took a combination of estrogen and progestin, leading researchers to wonder if perhaps progestin is responsible for increased breast cancer risk in birth control pill users as well. The particular
progestin used in the WHI—medroxyprogesterone acetate—has been implicated before in causing greater cancer risk.
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As one author writes, “The previous assumption that progestin does not promote breast cancer development needs to be reexamined since a growing body of evidence indicates the opposite.”
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The less-than-positive findings of WHI about hormone use inspired thousands to ditch their menopause drugs, and the results were fast and striking. In 2003, the year in which WHI halted its trials to much media fanfare, breast cancer dropped a stunning 7 percent.
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Christina A. Clarke, leading a team of researchers writing in the
Journal of Clinical Oncology
, noted that the “drop was sustained in 2004, which tells us that the decline wasn’t just a fluke.”
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Rates continued to decline in 2005, adding further fuel to the anti-HT fire. When I spoke to Jacques Rossouw, one of the lead scientists in the massive study, he told me, “The data for OC use and breast cancer are very mixed. I think a critical difference between OC use and HT use is that OCs substitute for the woman’s endogenous hormones, so her total hormone exposure is only increased slightly in dose or duration, while postmenopausal HT increases the dose and duration of hormone exposure compared to menopause with no HT use.”
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While HT and the Pill are different—and women take them at very different points in their lives—the increasing evidence that giving up hormones cuts breast cancer in older women poses some very important questions for younger ones. Because cancer can take so many years to develop, it can be tough to demonstrate causality. But if you have a family history of breast cancer,
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or if you have had it in the past, you should ask your doctor if a nonhormonal alternative might be safer for you.

Women on the Pill are less likely to develop benign breast diseases, including fibradenoma and fibrocystic breast disease.
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This benefit is only seen in current users. If you are among the small number of women who do develop fibrocystic breasts after starting Pill use, you may want to consider discontinuing use, as it could put you at an increased risk for breast cancer.

Many women develop swollen or painful breasts when they use the Pill, especially in the first several months of use. This problem can be addressed switching to a drug with lower estrogen potency and lower progestin content.
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You may also want to try cutting caffeine, reducing salt intake, drinking plenty of water, and drinking diuretic herbal teas, such as rosehip.

Liver Cancer

The risk of liver cancer, a rare but almost inevitably fatal disease, is slightly increased with Pill use.
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Since so few women develop this disease, it should not be a major consideration in your decision to take or avoid hormonal contraception. Taking the Pill raises your risk of developing benign liver tumors, too, but this condition is also infrequent, occurring in just 3 in every 100,000 users each year.
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Using low dose pills probably alleviates this already slight risk. If you experience any growth in the liver, benign or otherwise, taking hormones can be very dangerous.

Jane Bennett and Alexandra Pope write, “Your liver is your largest internal organ and has a wider range of functions than any other organ in your body. Among other things it processes nutrients and detoxifies your blood … taking the Pill places considerable strain on your liver.”
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In particular, drospirenone, the progestin in Yaz and Yasmin, has been shown to potentially raise potassium levels in a way that may be dangerous, so women with kidney, liver, or adrenal problems shouldn’t use these pills. Some doctors have advocated switching to an alternative distribution method—a hormonal device such as a contraceptive patch or vaginal ring—that delivers the drug directly in to the bloodstream.
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As we will see, these newer methods may prove to be good options for some, but they currently carry their own risks of increased blood clotting and other problems.

All in Our Heads? Depression, Mood, and Libido

Like me, many women go off the Pill because they believe it causes unwelcome changes in mood and mental health. Since oral contraceptives first hit the market there have been women who claim that a small dose of hormones each day can cause big emotional problems, and today it is still one of the top reasons for discontinuing hormonal contraception.
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Another
group of women argue the opposite: that taking birth control pills helps to tame their premenstrual syndrome and stabilize emotional variability. Analyzing mood is tricky, particularly when we get into classifying what is “normal” and what isn’t. Drugs that promise to end premenstrual fluctuations have been criticized by some feminists who argue that PMS is used as an excuse to dismiss women’s legitimate concerns, sorrows, and complaints, and medical management of mood changes constitutes an effort to suppress noncompliance and unpleasantness in the female population.

On this issue, doctors are as divided as patients. When I spoke to Dr. Susan Rako, a Boston-based psychiatrist who has written passionately and persuasively against menstrual suppression drugs, she told me that the relationship between the Pill and depression has been “seriously overlooked.”
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Dr. Rako frequently treats young women who don’t tell her they are taking oral contraceptives, and she sees it as an important piece of information for a doctor to have when treating mood symptoms.

The World Health Organization estimates that one in four women will become clinically depressed at some point in their lives, compared with one in six men.
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Because women are more vulnerable to depression, it is particularly important to understand whether oral contraceptives could be playing a role in the problem. Over the years, doctors have studied different hormone concoctions to try to determine how the Pill might change moods. Decades and dozens of trials later, we still don’t have good answers.

Some theorize that estrogen causes a deficiency of vitamin D, leading to other shifts in body chemistry, or that hormones pair with certain brain chemicals to suppress or alternately increase others. Other nutritional deficiencies, such as a decrease in B vitamins or increasing copper and decreasing zinc, may also play a role in making women feel blue.
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Since pills work on the adrenal gland, some have theorized that adrenal fatigue and altered levels of cortisol (a hormone that is related to the body responding to stress) may be the reason that many people feel bad on hormonal contraception.

For women who feel better on the Pill, it is possible that positive mood changes happen because other health problems—terrible PMS, irregular bleeding, or extreme cramping, for example—are curtailed.

If we accept for a moment that the Pill does cause negative changes in mood for some women, it is unclear whether that shift is short term or long term. It is important to distinguish between depression—an illness that lasts for a long period of time and often requires treatment—and a mood swing, which is shorter and more prone to change. These are two very different conditions that may require different solutions and treatments, and it is possible the Pill contributes to or cures one and not the other.

Trying to predict which women will interact badly with birth control pills is impossible at this point, but some factors that might predispose a woman to Pill-instigated negative mood changes are coming into focus. If a woman has a history of depression, postpartum depression, or severe premenstrual mood changes, she may be more likely to have problems on the Pill. As you might expect, if women close to you in your family have had emotional problems on the Pill, you may be more likely to have them too, although of course older high-dose pills produced different problems than today’s lower-dose ones. If you have trouble with vitamin B deficiency on the Pill, you may need to be careful about mood problems. Finally, women under twenty may be more likely to have negative mood or affect changes, while these problems seem to decrease in women over thirty.

There is no agreement about whether estrogen or progestin is more likely to cause mood problems, or what ratio of estrogen to progestin is best for reducing problems. Some studies have suggested that women who have a history of PMS before using the Pill do better with more progestin to estrogen, and those without a history of PMS fare better with a drug that has a lower progestin to estrogen ratio.
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If this is true, then a history of PMS could be an important consideration in choosing a specific brand for women starting on oral contraceptives. One area ripe for future research is an examination of the way that cholesterol levels, known to be impacted by Pill use, can impact mood. Other open questions include understanding the roles individual hormone levels, family history, weight, and body fat distribution play in changing the way the Pill can make you feel.