Pill: benefits and damage

1989/06/01 Bardino von, K. Iturria: Elhuyar aldizkaria

• Osasuna

Different types of pills.

The two large female hormones, estradiol and progesterone, were known in the 1950s that ovulation could be paralyzed. From there to think that they can be used as contraceptives.

American researcher Gregory Pinais was the first to test with animals. After these tests, in 1956 it was used with women from Puerto Rico and Haiti. The trials were increasing in the following years: Women from India, Mexico, the United States and the United Kingdom took the onion in this phase. Thus, after several sessions, it was possible to reach the most commonly used products currently, the stroprogestants. These are formed by estrogens and a progesterone by synthesis, being able to vary the proportions between both of one brand to another. They will be extroprogestational, the topics to be discussed in this article, since, as already mentioned above, they are the participants themselves in the composition of the majority of the pills.

The contraceptives of these compositions began to be used in the 1960s and since then numerous studies have been carried out in their surroundings. The goal of the pill is not to cure a disease, so a very high sustainability must be required. Special attention has been paid to long-term effects, as their goal is for women to take it for years (and sometimes for decades). Hence, epidemiological studies have been conducted based on long follow-up of users. Clinical pharmacology and animal toxicology methodologies have also been used.

However, the conclusions of all these investigations are not very safe, and what we will analyze in this article is not what is known on this subject, but the validity of these knowledge.

Little studied effects

The study of the side effects of oral contraceptives has focused on serious diseases such as cardiovascular complications or cancer. The favorable side effects of the pill, or other effects of greater frequency and nothing favorable without being serious, are diminished in the literature of the area.

Among the latter are, for example, those that occur at skin level and mucous: skin pigmentation, hair reproduction, etc. Acne resistance is not as systematic as it has been said, but it largely depends on the progestive compound used. Many times the presence of vaginal yeast has been attributed to the pills, between 5-29% according to the authors. Not much has been worked out on these conclusions that have been considered of little importance, but it should be taken into account that, because they are not acute or serious, they affect the lives of a large number of women.

As a result of classic tracking users have described other effects such as urinary infections, headaches, depression and libido reduction. However, these effects are frequent in clinical tests of any other drug and it is difficult to verify that they have a yatrogenic origin, that is, medicinal.

Another little worked aspect is the drug interactions. On the one hand, the pill can alter the metabolism of other drugs, for example, increase the toxicity of some antidepressants and reduce anticoagulant activity. On the other hand, the use of other medications along with the pill can alter the effect of the pill and become pregnant. This is the case of tuberculous and barbituric. For the little we know about this topic, the fact that the woman gets pregnant while taking the pills and has forgotten her or that it is her responsibility does not seem correct.

Cardiovascular risks: what we know and what we do not know

Carbiovascular risks are one of the most worrying of those produced by oral contraceptives. The carbiovascular complications derived from stroprogestins are grouped in four groups: hypertension, thrombosis, stroke and myocardial infarction. The blood pressure of almost all women who take the pill increases, although to a very small extent, but this increase between 1% and 5% of users exceeds the measures that define arterial hypertension. It usually does not become very high and by abandoning the low treatment again to its normal values.

The tendency to hypertension increases with the duration of treatment. Although this data is unanimous, the interpretation is difficult and uncomfortable. Is there a risk population? What are the effects of this moderate hypertension on complications usually attributable to hypertension?

In the sixties, thrombosis was detected among the women who took the pill. In most cases it was venous thrombus, most of them of inferior limbs and whose main risk was pulmonary embolism by migration of the clot, which often involved death. It can also touch other organs such as the liver, retina, or ear. In the latter case, bapate deafness may appear.

It is also thought to affect myocardial infarction. The most important risk factor for infarction is undoubtedly smoking, but it seems that when the pill matches the age that is a risk factor, the risks of both do not add up, but multiply. Therefore, it behaves synergistically with age and it seems that the risk may persist even after having stopped taking the pills.

The problem worsened earlier this decade with the publication of articles in which the pill did not pose danger in some medical journals.

On the other hand, it has been considered for a long time that the risk of cardiovascular disease was related to the proportion of compound estrogens. More recent data indicate that progestures also have influence. Therefore, according to this data, we will disrupt the optimal balance between estrogenic and progestational compounds.

The permanent concern regarding oral contraceptives has been and is the composition of the pill. In the search for maximum safety, it has been sought to reduce the dose of hormones, since effectiveness as a lower contraceptive limit. Thus, the dose of estrogen has dropped from 100 m of the initial pill to the current 50 or 30.

To fatten the menstruations and others

The opinion of those who fat the pills is very widespread. But not many in-depth studies have been conducted on this point. Moderate fat, gaining about two kilos, is usually very common during the first six months of treatment and it is usually the kilos that are lost immediately if the treatment is abandoned.

And what do we know about gynecological effects? Amenorrhea, that is, if the absence of menstruation is very rare, when it occurs it becomes a source of anxiety for the fear of a fortuitous pregnancy. However, the most frequent amenorras are those that appear after the abandonment of the pills and occur in 2% of the female users. Sometimes it takes to return to your normal hormonal cycles. But the pill does not generate sterility: the fertility of users is the same as that of women who have never used the pill.

Then, we will take as object of study the liver, which is the path towards the elimination of the stroprogestives. The risk of hepatic diseases produced by drugs is high, so numerous studies on hepatic reactions in clinical pharmacology are carried out. Hepatitis has been described, although in most women, ancient composition pills have been used.

Two other complications in the liver are thrombosis of the suprahepatic vein (very rare but very severe) and the appearance of hepatocellular adenoma. This incidence among users of the pills is very high, at least 30 times higher than normal. The risk of this benign tumor is an intraperitoneal fracture, but it seems that the tumor slowly recedes after leaving treatment. However, taking into account the low incidence of this disease on the population as a whole, the absolute frequency remains very low: an annual case between one hundred thousand users.

Cancer at the center of the debate

If we want to analyze the relationship between oral contraceptives and the risk of cancer, we will soon find methodological problems. How to obtain reliable data if there is no animal model that allows to properly reproduce the female cycle, if the frequency of some diseases that are intended to be measured is very low, if the time interval between the two facts that are wanted to be analyzed is so large, etc. ? Different methods are used to overcome all these and other barriers. It is not the same to study cases of hepatocyte adenoma as breast cancer. In the first, as seen above, the relationship between disease and pill can be narrow, but the frequency of the disease is so low that it would still have a very rare disease.

The case of breast cancer is different. In some Western countries it affects one in fourteen women, which would cause the lowest frequency increase per pill to increase disease cases considerably.

What are other risk factors for breast cancer? age greater than 40 years, genetic predisposition (can be known through family cases), certain benign mastopathies, absence of children, first pregnancy from 34 years or late menopause.

Despite the fact that all these factors have been analyzed to a greater or lesser extent, the debate in recent years has focused on the well-known influence of estrogen in the appearance of breast tumors, especially in very young women or who have used the pill more than 4 years in years before the first pregnancy. While some research claims that women in these two groups are at higher risk, others have denied it.

The second concern about cancer would be cervical cancer. The studies carried out in this case also present methodological problems and in this case a new variable should be added: users of the pill perform more medical explorations. This can distort reality, as they are most often detected and before cervical cancer, moving away from the actual frequency of the disease.

Contrary to what happens with breast cancer, the different researchers seem to agree that the prolonged use of the pill (more than five or eight years, according to researchers) increases the risk of cervical cancer. And it seems that stroprogestins also accelerate the development of these malignant tumors.

It should not be forgotten that in the case of endometrial and ovarian cancers, the pill has a protective function, since most of the investigations in this field confirm it. The risk of users in these cancers would be half of the others.

Risk/benefit ratio

Oral contraceptives do not aim to cure or prevent the disease. The pill is undoubtedly the only drug with this feature. The measure of benefit is the probability of healing or improvement of a pathology to evaluate the risk/benefit with drugs. Therefore, how is this evaluation done? First of all, it is one of the few drugs that fulfills its goal almost 100%. And the second thing is to compare it with comparable things. In no case can it be compared with pregnancy or abortion as in some scientific articles.

This, without the help of medicine, means recognizing that the consequence of all the little ones is pregnancy. And that's not so. It seems more logical to compare it with other methods in the same area, taking into account risk, safety and quality of life. It seems human, including all methods for that comparison, even without sexual medicine.

But the demand for the pill has been and remains strong. What does this mean? That the user (and no one) decides to take it? And is it true what has been repeated so many times, that is, that users know what they are doing and have valued the risks and benefits? A study conducted in France a few years ago indicated that gynecologist women and the wives of gynecologist men used the pill in a lower percentage than the French average. What does that mean?

Returning to the pernicious effects of the pill, the real problem is whether the doubts about the pill are more abundant and deep than those admitted in similar fields. Some consider that this question has an affirmative answer. If the doubt about the use of the pill persists, the consequences are because they are of great magnitude: millions of healthy women (and over many years) are taking this medication every day.

On the other hand, scientific practice is not alien to other effects. The study of contraceptive methods has focused mainly on women, being that of very limited men. This means that the risks that are considered acceptable to women are up to what is not acceptable to men. If by contraceptives there was a decrease in libido, what it means in men is known, but in women it is not so obvious.

After all this, we can say that from a scientific point of view the problem is not so worrying. But from a moral point of view there is a clear point: even if the pill has no danger, this does not exclude the risk of not being so certain when it was marketed. The morality of a company cannot be based on conclusions affirmed “a posteriori”. The most serious problems we have mentioned can be due to a dosage of the first pills and a lower dangerousness derived from subsequent improvements. But does that not deserve the name of “experimentation in human species”?