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.