Popular pill with doubtful reputation

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Despite the fact that the contraceptive pill has been around for 60 years, there is little research on how it impacts women’s quality of life. Some women get mood swings and have lower energy levels. At the same time, many more women could benefit greatly from contraceptive pills to reduce menstrual cramps and heavy bleeding.

When the first contraceptive pill, Enovid, was launched in America in 1957 it was the first time that women got access to an effective contraceptive which they could control. For centuries men held the decisive power to control pregnancy, while women assumed the major social and financial consequences of unwanted pregnancies. But now there was a pill which would become highly significant for women’s liberation and sexual health. 

Foto: iStockWhat many considered to be a fantastic opportunity was perceived as a threat by others. The contraceptive pill gave women access to a sexuality which was not only about having children and it created a heated debate. Enovid was considered to be so controversial that during the initial years it was only approved as a drug for menstrual disorders. However, everyone knew what the contraceptive pill could really be used for and Enovid quickly became a best-seller.

60 years later the contraceptive pill is a contraceptive used by roughly 100 million women across the globe. A lot has happened during this time. The hormonal doses in contraceptive pills have declined radically, Enovid contained almost 100 times more gestagen (synthetic progesterone) than current contraceptive pills. Now there are contraceptive pills which only contain gestagen, but most comprise a combination of gestagen and oestrogen.

Even though the contraceptive pill has been essential for women’s power over their sexuality, it has always had a bad reputation. When the contraceptive pill was introduced 60 years ago, women reported side effects such as mood swings, lower sexual desire, weight gain and acne. Even now many women report that they have side effects and the media regularly reports about problems with contraceptive pills.

The risk of blood clots has been the greatest cause for concern for doctors and pharmaceutical companies have contributed to extensive research on the problem. Now we know that combined contraceptive pills have a slightly higher risk of causing blood clots. Consequently they should not be used by women who have other risk factors, such as smoking or a higher tendency of blood clots in the family. 

Inger Poromaa Sundström, photo: Joakim Poromaa Helger.In the 1960s there were reports of some women suffering from mental problems due to the contraceptive pill.

“It was taken seriously, but the research focused on the risk of suffering from depression. Studies showed that there was not any higher risk of suicide, or being admitted to a psychiatric clinic, and then we were happy with that. Researching other mental problems was not interesting”, says Inger Sundström Poromaa, Professor of Gynaecology and Obstetrics at the Department of Women’s and Children’s Health at Uppsala University.

Considering that so many women use contraceptive pills and that so many report various side effects, strangely there is little research on how contraceptive pills affect women’s quality of life.

“This is because pharmaceutical companies largely control the research. It’s not in their interest to compare a contraceptive pill with a placebo to find out more about side effects”, says Angelica Lindén Hirschberg, Professor at the Department of Women’s and Children’s Health at Karolinska Institutet.

She has managed one of the few studies conducted in the area and the results were published during the spring. 340 healthy women got three months of treatment with the most common combined contraceptive pill in Sweden or placebo pills. Neither the investigators nor human subjects knew who was given what. Women who received contraceptive pills reported a significantly lower quality of life than those who received a placebo. This applied to both quality of life in general and more specific aspects such as the energy level and self-control. However, there was no significant impact on depression.

Angelica Lindén Hirschberg“The fact that contraceptive pills can have such side effects is important knowledge. Some women are impacted, but far from everyone. In a previous study we had similar results for sexuality. Some women can be impacted negatively in terms of, for example, sexual desire and excitement. But these are small changes and you should not make too big a deal out of it”, says Angelica Lindén Hirschberg.

The side effects may be one reason for why some women use contraceptive pills irregularly and are at risk of getting pregnant.

“When it comes to medicine, we have a certain level of tolerance for them having possible side effects. But in terms of contraceptives, women impose higher demands on them not creating any problems”, says Angelica Lindén Hirschberg.

A difficulty of such blind studies is that contraceptive pills change the menstruation pattern and therefore the human subjects can conclude whether they have been given a contraceptive pill or a placebo.

“We could not rule out that some women understood that they had been given contraceptive pills, but there is not any better way of doing such a study than with randomised placebo-controlled design”, explains Angelica Lindén Hirschberg.

Last year Inger Sundström Poromaa published a study which showed similar results. 202 women received either a contraceptive or placebo pill for three months.  During this period they were required to keep a diary of how they felt. In the group which received contraceptive pills, there was a small but significant increase in anxiety, mood swings and irritability during the period between two menstruations. However, there were no differences in terms of depression, on the contrary contraceptive pills improved the mood during the week before menstruation.

“It’s a matter of very small differences. Many women feel better by eating contraceptive pills, but there are slightly more who feel worse”, says Inger Sundström Poromaa.

She explains the fact that the study only lasted for three months like this:

“It’s because we gave a placebo. Young women need contraceptives. You can protect yourself in other ways for three months, but it would be unethical to do a study for a longer period. Then we would have more pregnancies, even during this short period one woman in the placebo group got pregnant”.

By allowing the human subjects to write a diary, the researchers obtained a more nuanced view of how contraceptive pills impact women, and it clearly showed that many women feel that there is a benefit of taking them. Perhaps there is too much focus on the side effects of contraceptive pills, and we underestimate the major positive effect which they can have for women with heavy bleeding and severe menstrual cramps?

Helena Kopp Kallne, foto: Stefan Zimmerman.“Yes, that’s really what it’s like. We have performed a study which shows that 57 per cent of Swedish women cannot mention a single positive health effect of contraceptives. At the same time, we have known for long that hormonal contraceptives reduce bleeding, menstrual cramps and the risk of certain types of cancer”, says Helena Kopp Kallner, senior consultant and researcher at the Department of Clinical Sciences, Danderyd Hospital at Karolinska Institutet.

She refers to surveys which show that 75 per cent of Swedish women take painkillers in connection with menstruation, and that 9-13 per cent have heavy menstrual bleeding. Some bleed so much that they get anaemia.

“Many women live with the notion that this is the natural part, it should hurt, you should bleed. It’s a part of being a woman. But there’s nothing natural about having periods 12 times in a year for most of your life, it’s a complete misunderstanding! The normal thing is being pregnant and breastfeeding. Having your period is a sign that it’s time to become pregnant again”, she continues.

Helena Kopp Kallner is critical of many women still taking the contraceptive pill with a break of one week, as that is how the pill strips are labelled. She and many other doctors recommend what is referred to as ‘extended cycle use’, that you take the contraceptive pill continuously until you get a breakthrough bleeding. Then you have a break for four days. It puts you in a better mood and results in less bleeding.

“It’s ideal to take contraceptive pills continuously. There are not any drawbacks of doing this, on the contrary. We need to focus on what is best for the woman, how you reduce problems of bleeding, pain and restrictions in daily life in the best manner”, she says.

The weakness of contraceptive pills is that it is so easy to forget to take them, or that you refrain from taking them when you feel that they are causing side effects. Many unwanted pregnancies have occurred while the contraceptive pills have been lying in the drawer.

“Those of us who work with women and contraceptives focus on reducing the use of contraceptive pills and instead suggest hormonal contraceptives such as implants or coils. It’s not because contraceptive pills can lead to mood swings, but because contraceptives which you don’t need to remember to take are much more efficient”, says Inger Sundström Poromaa.

Figures from the National Board of Health and Welfare show a clear trend: In 2016, approximately 13,000 girls aged between 15 and 19 chose to insert a coil or implant. Compared to 2013, this is an increase of 46 per cent. During the same period, the number of girls of the same age who obtained the contraceptive pill declined by 13 per cent.

There is a great need of continued research on how contraceptive pills impact women’s quality of life. However, it is difficult to obtain funding. Researchers also have a growing problem of recruiting human subjects for clinical studies, people are increasingly busier and fewer want to take the time to participate in research projects.

“I would like to do a study on which contraceptive pills have the least impact on the mood of women who suffer from mental ill-health. It’s a very big problem for them and we need more knowledge so that we can give good advice to them”, says Inger Sundström Poromaa. 

True and false about contraceptive pills

They cause weight gain. Many studies show that contraceptive pills do not lead to any weight gain. Women who gain weight probably do this because they start taking contraceptive pills at the same time as they make other lifestyle changes.

Contraceptive pills cause blood clots. Contraceptive pills which contain oestrogen entail a higher risk of blood clots. However, the risk is very small, 6 of 10,000 women are affected. If you belong to any risk group (see main text) then you should not take contraceptive pills.

It is difficult to get pregnant after you stop using contraceptive pills. There are no studies to prove such a link. Sometimes contraceptive pills lead to irregular periods, and then you also have irregular ovulation, which makes it more difficult to get pregnant.

Contraceptive pills reduce sexual desire. Some women may experience lower sexual desire. However, for many women the problem is solved by changing to another type of contraceptive pill.

Contraceptive pills cause depression. Research shows that certain contraceptive pills can impact the mood, but they do not cause depression. If contraceptive pills impact the mood, then this happens right when you start taking them. Many women benefit from changing their contraceptive pill.

Text: Johan Sievers, first published in Swedish in Medicinsk Vetenskap no 3/2017. 

GynaecologyObstetricsPharmacology