Injectable contraceptive, DMPA, serum HDL cholesterol and heart infarct

In 23 women who had used the injectable contraceptive depot medroxyprogesterone acetate (DMPA) for at least 1 year, the mean serum high-density lipoprotein cholesterol (HDL-C) level was distinctly lower than in 23 women carrying an IUD. The high serum DMPA levels during the 1st few weeks after a subsequent DMPA injection, and the low levels 12 weeks after the injection were found to be associated with the same (low) serum HDL-C level. For this reason, a fall in the serum HDL-C level in DMPA users is probably not a direct effect of the DMPA, but rather an indirect effect of the diminished production of endogenous estrogens in the ovaries of DMPA users. Though the investigation does not justify definite conclusions, it appears advisable not to prescribe DMPA to women with an increased risk of atherosclerosis and myocardial infarction. (author's)     

The pill and the breast

Discussion focused on the role of the ovarian steriods, estrogen and progesterone, in the development of breast cancer, the effects of natural and synethic hormones on breast tissue, and recent epidemiological studies concerning breast cancer and the use of oral contraceptives (OCs). Apparently, ovarian hormones play a role in the development of breast cancer. Late menarche, early menopause, and the removal of the ovaries provides some protection against breast cancer. Women who experience a full term pregnancy also have a reduced risk, and the level of protection is increased if the pregnancy occurs early in the reproductive life span. Little is known about how these protective effects operate. It is known that estrogen proliferates endometrial cells and that progesterone checks this growth. Unchecked proliferation can produce malignant cells. Perhpas during pregnancy, breast epithelium becomes more responsive to progesterone, or perhaps the increased progesterone levels which prepare the breast for lactation alter the growth of breast epithelium. Changes in breast tissue during the course of the menstrual cycle, which could be attributed to the altering levels of ovarian hormones during the cycle, appear to be minimal; however, recent investigations report that DNA synthesis and mitotic counts in breast tissue increase during the 2nd half of the menstrual cycle. These findings indicate that progesterone might stimulate breast activity. The effect is the opposite of that observed for endometrial proliferation which occurs during the 1st half of the cycle in response to estrogen. One would expect that breast activity would also be increased for women who use OCs, but preliminary studies indicate that OCs do not overstimulate breast epithelium. Perhaps breast tissue is less responsive to synthetic hormone or perhaps OCs inhibit progesterone receptor synthesis. It is difficult to assess the epidemiological evidence concerning a link between breast cancer and OC use because the studies are based on only a few cases, the effects are delayed over many years, and most of the subjects in the studies took OCs when only high dose preparations were available. These studies include 1) a California study of 163 women, which found that OC use prior to 1st pregnancy increased the risk of breast cancer; 2) an additional 151 cases analyzed at a later date in the California study, which indicated that OC use, prior to age 25, increased the risk of breast cancer; and 3) a British study in which the addition of 27 cases to a previous study of 1176 cases to the reversal of earlier findings and indicated that prolonged use of OCs prior to last pregnancy increased the risk of breast cancer.     

Facts,fallacies and fears: The public and the health professionals at odds

Risk assessment as well as risk perception and risk communication are essential skills for the occupational health professional. However, in view of the widespread failure of employed groups and the general public to reach national conclusions on risk, we are clearly failing in our duty to the wider world. This paper reviews the basis of public ignorance and disquiet as well as the essential elements needed for effective risk communication. Examples include the Brent Spar saga, electromagnetic fields, and bovine spongiform encephalopathy. The way public perceptions can effect symptomatology is discussed as well as low political and legal opinions can influence the risk debate. A way forward is proposed.     

The pill around the world

The emergence of the oral contraceptive pill as a coitally independent method of fertility regulation is discussed. Estimates show that users in the United States increased from 408,000 women in 1961 to 5,000,000 in 1965 and 12,000,000 users are forecast for 1985. In comparison, 20% of the women of reproductive age in Australasia use oral contraception, while users in the United States represent 8.2%, 3.2% in the United Kingdom, and .05% in India. Figures for world use, by region and country, are presented. Lack of governmental approval, the relatively high cost of the pill compared with IUDs and condoms, and difficulties in mass-scale distribution are cited as reasons impeding more widespread use. It is estimated that 40,000,000 of the world's women will be using the pill by 1980, and development of an effective low-dosage pill is expected to increase the number.     

The pill and cancer--IPPF response

The response of the International Medical Advisory Panel (IMAP) of the International Planned Parenthood Federation to 2 recent papers suggesting a link between cancer and oral contraceptive (OC) use is reported. The 1st paper by Pike et al. suggested an increased risk of breast cancer in women who use OCs containing high potency progestogens before age 25 for at least 4 years. It is noted that several methodological problems with the study design could have introduced a degree of selection of ascertainment bias. These issues include the procedures used for age matching between cases and controls, the 1/3 loss to follow-up among cancer cases, and the use of telephone interviews to ascertain OC use history. Moreover, data from other studies suggest that ever-users of OCs who develop breast cancer may be more likely to survive than women with breast cancer who have never used OCs, leading to the overrepresentation of women in the former group among surviving cases. The ranking of OCs by progestogen potency does not take the estrogen content into consideration. In addition, assessment of progestogen potency by use of a delay of menses test may not correlate with the degree of effect on the breast and has produced conflicting results when used by different researchers. Finally, the numbers of women using some OC brands were too small and the possibility that women may have changed OC brand over the study period was not considered. Largescale studies such as the UK Oxford-Family Planning Association contraceptive study and the Centers for Disease Control Cancer and Steroidal Hormone Study are curently being reanalyzed, controlling for type and amount of progestogen in the OCs. Until new data become available, IMAP believes there is insufficient evidence to recommend modification of existing practice. The 2nd study by Vessey et al. suggested a higher incidence of cervical cancer in OC users as compared to IUD users. However, several key modifying factors on the risk of cervical cancer, including age at 1st sexual intercourse and number of partners, could not be controlled for. Moreover, a high proportion of OC use involved preparations containing 50 mcg or more of estrogen. Although regular cervical smears are recommended for OC users, the IMAP again does not recommend any change in current practice. The IMAP noted that the possible cancer-related risks of OCs must be weighed against the protective effects of OCs against cancers of the endometrium and ovary, pelvic inflammatory disease, and unwanted pregnancies.     

The pill: Perceptions and usage among Nigerian students

The knowledge and use of oral contraception were investigated in 498 students from 5 tertiary institutions in south-eastern Nigeria. Awareness of the pill was high (92.2%) but usage was comparatively low (17.5%). Post-coital oral contraception was more often used (11.5%) than the other types.Perceptions about the risks of the pill were variable: 46.4% of the students believed that it could damage the uterus, and 41% said it could cause infertility; 31.7% believed that it caused amenorrhea, while only 14.9% of the students admitted ignorance of the risks of the pill.There was a lack of desire to use the pill in 72.3% of the respondents. Only 18.7% desired to do so, including students already using the pill.The most common source of information on contraception was peer groups (43.6%), while lectures and sex instructions constituted the least common source (11.2%). Poor information on the pill and ignorance were identified as the major factors militating against pill usage. Accordingly, the role of early and adequate sex and contraceptive education in improving pill usage in this population and developing countries in general is highlighted.

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Resumen Se realizó un estudio entre 498 estudiantes de 5 institutos de nivel terciario del sudeste de Nigeria a fin de examinar el conocimiento y uso de anticonceptivos orales. Estas estudiantes conocían en general (92,2%) la píldora pero la usaban relativamente poco (17,5%). El anticonceptivo oral poscoito era más frecuentemente utilizado (11,5%) que los otros tipos.Los riesgos de la píldora eran advertidos de modo variable: el 46,4% de las estudiantes pensaba que dañba el útero y el 41% dijo que podía provocar esterilidad; el 31,7% consideraba que causaba amenorrea y el 14,9% reconoció que desconocía los riesgos relacionados con la píldora. Se verificó que el 72,3% de las personas entrevistadas no deseaba utilizar la píldora. Sólo el 18,7% deseaba hacerlo, porcentaje que incluía a estudiantes que ya la utilizaban.La fuente más común de información acerca de los anticonceptivos eran los grupos de compañeras (43,6%), mientras que las conferencias y la educación sexual constituían la fuente menos común (11,2%). La falta de información y la ausencia de conocimientos relativos a la píldora se identificaron como las principales razones contra el uso de la misma. En consecuencia, se destaca la función de la educación sexual, temprana y adecuada, sobre anticonceptivos para mejorar la utilización de la píldora en esta población y en los países en desarrollo en general.

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Resumé Une enquête a été menée auprès de 498 étudiantes de 5 établissements du troisième niveau dans le sud-est du Nigéria en vue de faire le point sur les connaissances et l'utilisation des contraceptifs oraux. Ces étudiantes étaient généralement (soit 92,2%) au courant de la pilule mais l'utilisaient relativement peu (17,5%). La contraception orale post-coïtale était plus fréquemment employée (11,5%) que les autres méthodes.Les risques que présente la pilule étaient perçus de façon variable: 46,4% des étudiantes pensaient qu'elle endommageait l'utérus et 41% ont affirmé qu'elle compromettait la fertilité; 31,7% croyaient qu'elle provoquait une aménorrhée, alors que 14,9% ont admis qu'elles ignoraient les risques liés à la pilule.On a constaté que 72,3% des personnes interrogées ne voulaient pas utiliser la pilule. 18,7% à peine étaient disposées à la prendre, y compris celles qui l'avaient déjà adoptée. Des renseignements sur la contraception étaient le plus souvent recherchés auprès de groupes de camarades (43,6%), tandis que les cours et l'éducation sexuelle étaient la source d'information la moins courante (11,2%). Le manque d'information et l'absence de connaissances au sujet de la pilule ont été identifiés comme étant les principales raisons qui jouent contre l'utilisation de la pilule. Par conséquent, le présent exposé met l'accent sur le rôle de l'éducation sexuelle et de l'enseignement en matière de contraception, dispensés tôt et de manière satisfaisante, si l'ont veut améliorer l'utilisation de la pilule au sein de cette population et généralement dans les pays en développement.

     

The children of the missed pill

We assess the impact of exogenous variation in oral contraceptives prices—a year-long decline followed by a sharp increase due to a documented collusion case—on fertility decisions and newborns’ outcomes. Our empirical strategy follows an interrupted time-series design, which is implemented using multiple sources of administrative information. As prices skyrocketed (45% within a few weeks), the Pill’s consumption plunged, and weekly conceptions increased (3.2% after a few months). We show large effects on the number of children born to unmarried mothers, to mothers in their early twenties, and to primiparae women. The incidence of low birth weight and fetal/infant deaths increased (declined) as the cost of birth control pills rose (fell). In addition, we document a disproportional increase in the weekly miscarriage and stillbirth rates. As children reached school age, we find lower school enrollment rates and higher participation in special education programs. Our evidence suggests these “extra” conceptions were more likely to face adverse conditions during critical periods of development.