Women's health issues and clinical perspectives

Women's Health

The history of oral contraceptives in the United States and the world is one of many controversies the fight by forward minded women and men, attempting to create a society where every child was a planned and welcomed member to a loving family, has been long and arduous and certainly is not over yet.

Reed, 1978, p. ix) Development and proliferation of birth control methods and especially oral contraceptive, is even today controversial in some circumstances. The issues surrounding oral contraceptives are varied but include perspectives of ethical/moral grounds, sometimes linked to the various manners in which oral contraceptives work from a pharmacological perspective, issues regarding the science of development, regarding pharmaceutical economics, general economics such as access in underserved populations as well as the more common economic arguments about benefits vs. cost with regard to who will pay for prescription oral contraceptives.

Oral contraceptives for women, have been available since the early 1960s and have been used internationally by more than 100 million women since their introduction, as one of the most effective and the most widely prescribed form of medication in the world. Since its introduction to the market its medical efficacy has remained the same but the dosages of the various active ingredients that compose it have gone down significantly to therapeutic levels that still elicit 99% effectiveness but are not associated with as many side effects. It active ingredients are various forms of, usually synthetic estrogens and progesterones as they are easier to obtain in bulk.

Over the years, the pill's makeup and range of side effects have changed "dramatically," Dr. Im says. The modern birth-control pill, on average, contains about 20 micrograms of estrogen, down from about 50 micrograms in its earliest incarnation. That means fewer hormones, fewer side effects. (Toto, 2001, p. 1)

The draw to the pill as an effective form of contraception is often related of the ability to take the pill at any time, (providing that you take it around the same time every day) but that it can be separated from the act of sex, a common complaint by barrier contraceptive method users. Proper use of "the pill" as it is often called will create a situation of failure in only 1% of cases, though clinicians and manufacturers are careful to warn that if a pill is skipped ovulation can occur and that there are other medications that if taken in conjunction with the pill make it less effective, such as antibiotics. Another benefit of the pill is that it is relatively quick to take effect once the cycle of pills has been started, though this varies between different pill forms, with combined contraceptives, (estrogen and progesterone) the most common form taking about a week to take full effect and progesterone only pills (mini pills) taking only a few days. Lastly, the relatively quick manner in which the oral contraceptives leave the body, and therefore allow fertility again is another serious draw for use. (Phillips, 1999, p. 93)

Social/Political/Economic Issues Surrounding OCs:

On a social/political level there are many people in the world today that believe that population control is one of the most important of human issues to date. Some are even so outspoken that they openly declare that rights of individuals need to be taken away with regard to this issue, in a system of forced population control. The oral contraceptive, and the its effectiveness is an agent that can further this cause, though there are other contraceptive forms, such as IUDs, implants and infrequent shots that would be more effective in this cause, this is still an issues closely tied to oral contraceptives as they made the first appearance as a viable option for systematic or even mandated birth control. (Hartmann, 1995, p. 170) Another social/political discussion associated with oral contraceptives has to do with another divergent controversy. On the proponent side most advocates of widely available oral contraceptives sight that the only way that society can progress is through having the power over family planning.

On an international level the access to oral contraceptives can be much more limited though this has improved significantly over the last few decades. Though OCs are still very widely used and rather universally accepted as a progressive social step toward self sufficiency of families, as well as reduces social and economic dependence of women and families upon the infrastructure of the society. (Lubin & Winslow, 1990, p. 235) in most circles it is widely accepted that access to effective and relatively inexpensive forms of birth control, such as barrier methods and OCs improve longevity and reduce undue physical and social burdens on women and economic providers in a family. Though there are also international groups and individuals who appose contraception as in their eyes the only reasonable form of contraception is abstinence. ("Clerics' Objections Erode U.N.," 2002, p. A15) Opponents of oral contraceptives often sight the belief that limiting reproduction is contrary to religious/moral codes. Some even go so far as to claim that oral contraceptives, through their pharmacology are a form of abortifcient (arguable) and should not be used. While still others believe that the wide use and availability of oral contraceptives simply leads to amoral behaviors. (Mcwilliams, 1991, p. 10) brief glance at the statistics from the United States in the period from 1960 to the present, when contraception and abortion have been heavily promoted, shows skyrocketing rates of out-of-wedlock pregnancies and abortions, though both rates have declined slightly in recent years. One indication that the "safe-sex" message is failing is that in the years 1988 to 1995, the nonmarital birthrate among sexually experienced teenage girls 15 -- 19 years old (those who have ever had sex) rose almost 30%, even while the total birthrate in this group was dropping. The birthrate among sexually active girls (those who had sex in the past three months) rose 31% during this same period. So the 9% drop in birthrates cannot be explained by better use of contraceptives among teens. Nor can it be explained by the 33% increase in condom use during this period, since this is more than offset by a 45% decrease in the use of (far more effective) oral contraceptives. Further, while 80% of the teens surveyed said they had learned about STDs in school, most believed that condoms would protect them against any risk of STDs. They were completely unaware that condoms offer no protection against many of the most common STDs. (Garcia, 2000, p. 259)

Amoral activity or not statistics show that increased sexual activity, can be physically and emotionally dangerous to young women as risks taking in this regard can lead to lifelong medical and social issues. Opponents often argue that offering oral contraceptives to young women without the involvement of one or both parents can give the young woman the sense of a free pass to have sex which can put them at risk for having to deal with serious emotional and physical consequences without the maturity to do so and without the guidance of someone who is mature enough to help.

Though by far the biggest debate surrounding oral contraceptives is the fact that many, if not most, insurances companies do not pay for oral contraceptives, even when those companies have otherwise extensive drug inclusive benefits. People who argue for full inclusion of oral contraceptives in drug plans argue that if insurance companies intend to pay for so many other, not always necessary drugs that oral contraceptives should be paid for as they have been proven through continued use to improve the health of the individuals who take them. While still others argue that the inclusion of OCs in drug payment plans is impractical, because of cost, as they are so widely used and because there are other methods of contraception that can be used, making them elective rather than necessary treatment. (Scully, 1998, p. 6) the manner in which this economic question came the public eye was comical to some when many early supporters of drugs used to treat erectile dysfunction in men were at least initially successful in lobbying many drug coverage plans to cover these very expensive medications and clearly elective forms of treatment for a disorder that by most standards is unfortunate but certainly not life threatening.. The birth control lobby answered these early successes by stating that this was just another example of the patriarchal manner in which modern medicine is dictated. Though in truth the reason why so many companies have refused to pay for oral contraceptives for so long, no matter what reasons they are currently sighting is that it would be phenomenally expensive because so many women take them, and for long periods of time. The common denominator is that the insurance companies found it much easier to stomach an occasional prescription for Viagra as apposed to a constant overarching prescription for oral contraceptives. In many ways the insurance companies won the argument as most just simply stopped paying for ED drugs rather than face the questions of the OC lobbyists, and the public in an obvious contradiction.

Baer, 2002, p. xx)

Medical issues surrounding OCs:

Medical complications associated with the utilization of oral contraceptives are varied but in general stem from both known and unknown complexities associated with the ingredients that make up OCs, as all hormones are steroids and in many cases have multi-variant biochemical effects, some known and some unknown. The complexities of steroids, of which all hormones are, demonstrate the need for a great deal of further research with regards to their use. Some more common side effects of oral contraceptives, though they can vary slightly according to brand and dosage of active ingredients are:

nausea, vomiting, stomach cramps, bloating, weight change and water retention. Water retention may cause swelling of fingers or ankles. Other side effects of oral contraceptives may include nervousness, depression, dizziness, change in appetite, loss of scalp hair, rash, vaginal infections, migraine headaches, missed menstrual periods and bleeding between periods. Contact lens wearers may notice a change in vision or more discomfort in wearing their lenses. (Willis, 1985, p.28)

More dangerous side effects also occur, rarely and there is a particular warning against smoking while taking oral contraceptives as this can significantly increase the risk of serious side effects like blood clots, strokes and heart attack, and this is especially true in women who take the pill and are over 30. There is also increased risk of cervical cancer, and some other more rare cancers as well as gallbladder disease. (Klitsch, 2002, p. 176) (Lane, 2002, p. 127) (Remez, 2003, p. 150) (Mccoy & Matyas, 1996, p. 73) Side effect, both minor and serious are often noted by women as the greatest reason why they report a discontinuation of use of oral contraceptives but it should be noted that many side effects can be reduced or eliminated by changing brands or reducing therapeutic dosages to the lowest possible therapeutic level for the individual. (Willis, 1985, p. 28) Two other common but less serious side effect was shown in a recent clinical study of OCs;

More than 40% discontinued the OC within the first year, nearly 30% within the first 3 months. Discontinuation within the first three months was associated significantly with decline in sexual interest and an increase in negative mood since starting the OC, associations more marked than for any other possible side effect we measured. It is staggering how little research attention has been paid to these two effects of OCs on sexuality and mood. These results not only replicate the findings in the Scottish women in our first study, they also raise the important question of whether adverse effects on sexuality are relevant to acceptance and continuation with such methods in other cultures. (Bancroft, 1999, p. 226)

There are also other therapeutic medical uses for oral contraceptives, as doctors often prescribe them to women who have extremely painful menstrual cycles, or as the supplementation of hormones produced by the body and suppression of ovulation decreases menstrual symptoms in most women.