Coping with scares
H. P. G. Schneider
Department of Obstetrics and Gynaecology, University of Muenster, Germany
Synthetic sex steroid hormones have extensively been employed for a great
variety of indications, such as menstrual cycle disturbances, menopausal
complaints, infertility, threatened or recurrent abortion, endometriosis, acne,
adjuvant treatment of breast cancer and others. Substantial information was
obtained about sex steroids interfering with metabolic processes in the body.
Need for caution was pointed out to those patients with a history of cancer or
of thromboembolism. Within the first years following the introduction of oral
contraception (OC), the risk of venous thromboembolic disease was extended to
acute myocardial infarction, stroke, and hypertension. These early studies were
probably substantially biased by the tendency to overdiagnose thrombotic disease
among pill users.
In addition to vascular phenomena, a variety of disorders such as neoplasms,
diseases of the liver and biliary system, diseases of the reproductive, central
nervous and immune system, skin conditions and others have extensively been
studied in OC users with regard to pharmacodynamics, pharmacokinetics and their
influence on biochemical parameters indicative of metabolic function. Almost all
of the available data originate from studies performed in developed countries.
It can be questioned whether the findings also apply to developing countries.
Today, many women still believe there are substantial risks involved using
OCs. While some fears appear justified, many involve outright misconceptions. As
a result of increasing knowledge, with time our views about the health
applications of OC use have changed dramatically.
Current low-dose pills have been associated with a decreased risk of
circulatory disorders, minimal influence on metabolic function and minimal, if
any, and clinically insignificant impact in healthy women. In addition, OCs have
been proven to provide several powerful health benefits which fully outweigh the
risks involved. In particular, these concern diminished risks for ovarian and
endometrial cancer. Other beneficial impacts include reduction of the risk of
benign breast disease, functional ovarian cysts, pelvic inflammatory disease and
various effects on or related to the menstrual cycle.
There were many lessons to be learned during the process of public acceptance
of long-term OC use. The oral contraceptive scares of 1977 (thromboembolism),
1983 (breast or cervical cancer) and 1987 (breast cancer) and 1995 (differential
risks for venous thromboembolism between desogestrel- and gestodene-based
combined OCs) have documented the necessity of knowledgeable interpretation of
epidemiologic data. Optimally, valid causal research in population studies
should incorporate the complimentary roles of clinical medicine, biology, and
statistics, with the latter serving as the servant rather than the master.