Protecting the pill

Imagine you are an expert on some medication and research comes to hand that shows the drug, used long-term by a large proportion of the population, is riskier than you thought -- or, at least, than most users thought. Would you: A) have a good think about whether you should continue to recommend this medicine; B) call your colleagues and organise a press conference to ensure people know they should have a searching interview with their doctor about whether to use it; C) take the media calls one by one and emphasise how minimal the risks really are.

Most of us, probably, see ourselves taking the cautious options (A and B), and hope that our own doctor would. But when The Lancet published a study last week confirming the link between oral contraceptives and cervical cancer it was the C option that the professionals chose. Media headlines and reports were studded with "not to worry" and "small risk" and "don't stop taking it" reassurances for the 100 million women around the world who take the pill and who could thus, on average, double their risk of invasive cancer of the cervix. 

The pill has undoubtedly changed sexual behaviour, and in the direction
of greater promiscuity. HPV infection is critically dependent on the
number of lifetime partners. One could truthfully say, therefore, that
the pill is the underlying cause of the cervical cancer epidemic -- and
of much else that ails us today.

A bit of worry, however, would have been in order. Cervical cancer is only one of the risks elevated by the pill; breast cancer and liver cancer are implicated and there is a well established link with blood clots and high blood pressure in some women. Only a few days before the Lancet article was published, researchers from Belgium at an American Heart Association conference had presented their discovery of another pill-related risk for heart attacks and strokes: a build-up of plaques in the arteries of pill users they had studied. 

Lead researcher of the Belgian study Dr Ernst Rietzschel was so carried away with the novelty of his findings that he admitted it was "incredible that a drug which has been taken by 80 per cent of women … is almost bereft of any long-term outcome data, safety data". As if to correct himself he then hastened to advise women not to abandon their birth control pills. Follow the guidelines and cut down on other risky things like smoking, being overweight and not exercising, he said.

Ah yes, smoking. Has there been a single piece of evidence about the risks of tobacco in the last 40 years that health experts have not brandished in front of the public and thrust under the noses of government officials with the purpose of dissuading people from smoking? Why? Because the habit of filling one's lungs with pollutants on a regular basis leads to millions of deaths each year -- 438,000 in the United States alone -- and a huge burden of disease. Nothing but billboards, educational programmes and bans will do when it comes to preventing the harm of smoking.

The pill is an unnecessary pollutant, too, filling women's bodies with excess hormones to prevent the natural consequences of sexual intercourse. In many ways it is a lifestyle drug, like tobacco. It cures nothing. It alleviates the psychological pain of having to say no (or yes) to oneself or a partner, or deal with difficult issues. Although it happens to reduce the risk of ovarian and endometrial cancer in women, its dangers are, so far, more numerous and, as Dr Rietzschel's comment indicates, largely unknown.

How, then, can reproductive health specialists justify their protective attitude to the contraceptive pill? Partly they are playing a numbers game: relatively few deaths can be traced to the pill compared with cigarettes or -- according to a favourite comparison -- pregnancy and birth. That is what Dr Jane Green, of Oxford University, one of the authors of the new cervical cancer study, implies in a media report where she explains that the increased risk of cervical cancer is "less than one extra case per 1000 women by the age of 50 for 10 years' use of the pill". Even so, that is 100,000-odd women a year globally, by my calculation. Are people like Dr Green saying that is a reasonable sacrifice to the god of fertility control, who pays us back, anyway, with fewer cases of other cancers?

Not quite. Teetering on the brink of crass utilitarianism they are saved by the existence of screening programmes and now the advent of vaccinations against the strains of the human papillomavirus that are the most likely cause of cervical cancer. Such programmes, dependent largely on the public purse -- and therefore beyond the reach of most women in developing countries -- can, in the words of one doctor, "circumvent" much of the danger of oral contraceptives by picking up early signs of cancer. It appears that exposure of women to the risk of a lethal disease is quite ethical if when disease does strike it can be nipped in the bud.

There is one further excuse for gambling with women's lives and health in this way and it goes like this: The pill does not cause cervical cancer, HPV infection does. We don't know exactly how the pill interacts with the infection and it may be that it has nothing to do with it. There may be a certain kind of pill user who, coincidentally, behaves in a way that makes it more likely she will get the virus and therefore cancer. The whole pill-cancer link is in question.

Actually, there is something in this line of reasoning that makes sense, although not in the way intended. The pill has undoubtedly changed sexual behaviour, and in the direction of greater promiscuity. HPV infection is critically dependent on the number of lifetime partners. One could truthfully say, therefore, that the pill is the underlying cause of the cervical cancer epidemic -- and of much else that ails us today.

That is not a diagnosis that will carry any weight with reproductive health boffins, but if they would just attend to their core business they would find reasons enough for warning women clearly about the dangers of the pill, and seriously rethinking the whole business of birth control.

Carolyn Moynihan is Deputy Editor of MercatorNet.


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