Today's birth control pill is the silver bullet in a woman's health-care arsenal. The new generation of low-dose oral contraceptives that came on the market during the early 1990s has fewer side-effects than its predecessors and is endowed with almost mythical powers in fighting diseases of all stripes.
The benefits sound almost too good to be true. Among other things, the pill is credited with a 50 per cent reduction in ovarian cancer among its users and a 60 per cent reduction in endometrial cancer. (A woman with no other risk factors normally has a one in 43.5 chance of getting endometrial cancer and a one in 64.5 chance of getting ovarian cancer.) The pill also prevents ectopic (tubal) pregnancy and its associated problems. It reduces the incidence of benign breast disease, ovarian cysts, migraines, anemia caused by excessive monthly blood loss, acne and osteoporosis. Most recently, the pill got the nod for potentially lowering colon cancer risk, too.
Healthy, active, nonsmoking women at any point in the reproductive cycle stand to gain a lot by taking the new pill. Many doctors believe most women should strongly consider taking it for its astounding risk-reduction properties against ovarian and endometrial cancer. "We have gone beyond the idea of just taking the birth control pill for birth control until menopause, which is still a justifiable and appropriate thing to do," says Dr. Christine Derzko, a reproductive endocrinologist at the Women's Health Centre of St. Michael's Hospital in Toronto. "But there are a whole host of medical benefits that we have sort of glossed over, and we're increasingly aware that there are strong reasons for women to take the pill."
Not that Derzko or any other pill proponent would advocate its use by just anyone. Women with a history of thrombosis, cardiovascular disease, heart attack, stroke, liver disease or estrogen-dependent cancer are not good candidates for the pill. "There are a few people who shouldn't take it," she says. "But women in general should consider using oral contraceptives because of the medical benefits."
However, hormone fear exploded in 2002 after researchers cancelled the Women's Health Initiative - a large study in the United States that was evaluating hormone replacement therapy (HRT) use in postmenopausal women - because of an apparent increased risk of heart disease and breast cancer among those who had been on HRT for more than four years. And that means pro-pill doctors are fighting an uphill battle to dispel the pill's negative image. "All this hoopla about hormones and how bad they are has so permeated society that we would take almost anything that didn't have hormones associated with it," says Derzko. "I think being careful is good, but to miss the benefits because you didn't look carefully at what the data show is very sad."
Derzko sees the hormone hysteria as clouding over the enormous potential of the new pill. "At the North American Menopause Society conference in Miami last fall, one of the speakers - a male one - got up and said, â€˜You know, if I were standing up here and telling men that I had a prevention for prostate cancer, they'd raise me up on their shoulders and I'd get the Nobel Prize,'" recalls Derzko. "I chuckled and thought, this man's a good gynecologist. Nobody seems to be hearing that there are benefits."
About oral contraceptives
At some point in their lives, 84 per cent of Canadian women will take the pill. More than 100 million women worldwide are currently using oral contraceptives. By now, because it is more than 40 years old, most of us know what the pill's combination of synthetic estrogen and progesterone hormones does for us: it stops ovulation, making it extremely effective birth control, and it regulates and alleviates many unpleasant symptoms of our menstrual cycles.
Though oral contraceptives have a long history and are widely used, many women still have a surprising number of misconceptions about the pill. Many think it may compromise fertility and that it can't be used by women over a certain age. The concept of a woman taking birth control pills during the latter half of her reproductive years strikes many women - particularly those who remember the pill's early years - as outrageous.
Some of the misconceptions stem from the results of three large studies. Early in the 1980s, research that had been underway since the 1960s concluded that there was an age-related risk of heart attack in pill users - but it was highest among smokers. At that point, women over the age of 35 who smoked were advised to get off and stay off the pill or to stop smoking. But, somehow, the message got mixed up or oversimplified, and many healthy nonsmoking women over 35 - and their doctors - no longer considered the pill
a reasonable option.
But women going through perimenopause, or the transition years leading up to menopause, can often safely take the pill. "Generally, I think women in the perimenopausal age group should certainly be looking at the use of oral contraceptives," says Derzko. They not only offer health benefits but also have a strong ability to reduce or eliminate most of the cyclic and perimenopausal symptoms that drive women to distraction.
There's no question that when the pill became available in 1961 it dramatically changed women's lives. For the first time women had some control over their menstrual cycles and over when and how often they got pregnant. And relieved of the fear of pregnancy, women gained more sexual freedom. The pill also dramatically changed how doctors could manage common menstrual and reproductive problems. Before the pill, says Dr. Timothy Rowe, head of reproductive endocrinology and infertility at the University of British Columbia in Vancouver and a principal author of the most recent Canadian Contraceptive Guidelines, women routinely died from botched backstreet abortions or from ectopic pregnancies. "After the pill was introduced, this all changed," he says. "With the pill, doctors were also able to provide women with a simple method to control abnormal menstrual bleeding, which previously often meant surgery or hysterectomy."
The evolution of the pill
Still, doctors and their patients had to grapple with the side-effects of early oral contraceptives. First-generation pills contained 150 micrograms of estrogen - more than seven times the amount used in the lowest-dose pills today. Over the years, as researchers continued to search for the balance of hormones that was enough to prevent pregnancy, the amount of estrogen dropped to 100, then 50 micrograms per pill.
Now many of the pills on the market contain between 20 and 35 micrograms of estrogen. In Europe researchers are experimenting with a 15-microgram pill. Side-effects that plagued early pill users - such as spotting, weight gain and breast tenderness - tend to be minimal.
Newer pills also contain progestins that cause fewer side-effects than their predecessors. And one addition to the pill family, Yasmin, which was introduced in May 2001, uses a kind of progestin (a synthetic progesterone-like compound) that even helps reduce bloating and water retention and may actually lead to some weight loss. Not surprisingly, the maker, Berlex Laboratories, can't keep up with the demand. "It's a nice pill," says Derzko, "and people really like it."
Among pill proponents, there is a growing consensus that women might be even better served by suppressing menstruation for months at a time. Late last year the U.S. Food and Drug Administration approved the use of Seasonale, the first birth control pill that is meant to be used continuously for 84 days (so you only get a period once a season) followed by a seven-day course of placebos. (Seasonale is not approved by Health Canada, and the manufacturer, Barr Laboratories, currently has no plans to apply for approval in Canada.)
Typical menstrual symptoms, such as breast tenderness, weight gain, PMS and breakthrough bleeding, are reportedly reduced on the longer cycle. "We've all done it for donkey's years," says Rowe. "We've been prescribing pills for three continuous cycles since the late 1980s with the assumption that it's not dangerous. We routinely recommend it for so many conditions - menstruation-associated migraine, pain, endometriosis, heavy bleeding and uterine function problems - that we're all quite comfortable with it."
As many experts are quick to point out, having fewer periods is closer to what nature intended. Women once spent the majority of their reproductive years pregnant or breast-feeding, therefore having about a quarter of the number of menstrual cycles women typically experience today.
How long is too long?
But how long is too long on the pill? According to Derzko, the current thought is that many women can easily stay on the pill until about age 55 - in most cases completely bypassing the uncomfortable transition into menopause. The pill doesn't change the timing of the process; it only helps keep symptoms to a minimum and cycles predictable.
To determine when the transition is complete, doctors can check estrogen levels in the blood during the week off the active pills. Some women may even start to feel symptoms such as hot flashes on those days off. What happens next is between doctor and patient: some women are fine simply coming off the pill, others may go onto a low dose of HRT temporarily to wean themselves off and still others may move directly into regular HRT. "We're really moving into different areas now," says Derzko. "It's the boomers again, pushing the envelope, saying, â€˜I'm healthy and I don't like these symptoms I'm having.'" And the new pill may be just the cure they're looking for.
The pill vs. HRT
Oral contraceptives and hormone replacement therapy (HRT) both relieve symptoms caused by hormonal imbalance, including hot flashes, moodiness and vaginal dryness. But the two are not exactly the same, even though, points out Dr. Timothy Rowe, head of reproductive endocrinology and infertility at the University of British Columbia in Vancouver, "The line between the two is blurring so much that essentially they're two sides of the same coin."
Still, there is a difference, and it lies in the type of estrogen used. The pill and HRT both contain some form of estrogen and some form of progesterone. The pill contains a synthetic estrogen called ethinyl estradiol, which is used because of its strong ability to prevent ovulation. In theory, Rowe explains, you could use natural estrogen but you would need so much to inhibit ovulation that side-effects, such as nausea, breast tenderness and headaches, would be intolerable. The same is true of progestin. Natural progesterone itself could be used, but so much would be needed that the cost and the side-effects would be too great.
In HRT, on the other hand, the aim is to eliminate menopausal symptoms and recreate premenopausal hormone levels. Because pregnancy is no longer a possibility, virtually any estrogen and progesterone can be used. In North America, doctors tend to prescribe "natural" hormones - Premarin, an often-used brand of HRT, is derived from the estrogens in pregnant mares' urine - after menopause rather than synthetics because they are cheaper and doctors have decades of experience using them. The question nobody can really answer yet except by conjecture, according to Rowe, is why women should switch (though not all do) from the pill to HRT. "The reason we prefer to use what we use for HRT is mostly instinct," he says. "If you have ovarian failure - the ovaries have stopped producing estrogen and progesterone - the best thing to reduce symptoms is to replace the hormones the ovaries have stopped producing."
But that trend, he added, may be starting to change as both physicians and consumers express an increasing desire to use the same hormones postmenopausally as they did during the reproductive years. In addition, Rowe says there has been no evidence to show that natural estrogen is safer or more effective than synthetic estrogen. The latest HRT preparation to be introduced in Canada contains both a low dose of synthetic ethinyl estradiol and synthetic progestin, adds Rowe.
For the moment, doctors such as Dr. Christine Derzko, a reproductive endocrinologist at the Women's Health Centre of St. Michael's Hospital in Toronto, are encouraging women to stay on the pill until age 55 if they want to.
At that point they can either go off the pill or, if symptoms are still present and troublesome, onto a low dose of HRT. Derzko is noticing more women "quietly going back on hormones" following a big drop-off after the results of the Women's Health Initiative, a large study in the United States that was evaluating HRT use in postmenopausal women. "I think we all needed a good kick in the pants," she says. "We needed to stop and think what we were doing; we needed to look at lower doses." But, she adds, for a postmenopausal woman who exercises regularly and watches her weight, the benefits of hormone replacement can be excellent. "Healthy lifestyle is extremely important; you don't replace that by taking hormones," says Derzko. "But come on: all those good things over all those years could not be figments of people's imaginations."