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The state of hormonal contraception today: established and emerging noncontraceptive health benefits

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In the 50 years since the advent of combined oral contraceptives the amount of estrogen in oral contraceptives dropped from over 100 mcg to less than 30 mcg. Many noncontraceptive health benefits have emerged that decrease mortality and improve quality of life. Some of the immediate benefits include improvement of menorrhagia and dysmenorrhea, reduction in premenstrual dysphoric disorder symptoms, and decreased acne. As an effective birth control method oral contraceptives also decrease pregnancy-related deaths by preventing pregnancy. After the reproductive years, previous use of oral contraceptives continues to be beneficial, reducing the risk of death from ovarian and endometrial cancer. All these benefits have held up over time whereas cardiovascular risks have lessened because of the decrease in oral contraceptive pill dosage. Decreased ovarian cyst formation is an example of benefit with higher-dose oral contraceptive formulations that no longer holds true with low-dose pills.

Section snippets

What we have learned since 1960

The time line of noncontraceptive health benefits shows that some health benefits, such as reduced incidence of dysmenorrhea and menorrhagia, were identified during the early years of OC use, whereas other benefits, such as improvements in acne and premenstrual dysphoric disorder, have more recently been found to be associated with COC use (Figure 2).

Menorrhagia/anemia

In 1960, Bishop et al6 reported that norethisterone administered at the end of a woman's monthly cycle could induce withdrawal bleeding in women with amenorrhea, provide normal bleeding patterns to women with menorrhagia, and produce painless periods in some women with dysmenorrhea. A subsequent trial tested these observations in 45 women with a history of ovulatory menorrhagia.7 The women were randomized to several nonsteroidal antiinflammatory drugs, danazol, or COCs, and menstrual blood loss

Dysmenorrhea

Recent studies have reported that women using COCs experience a reduction of dysmenorrhea.8, 9 Adolescent girls with dysmenorrhea treated with COCs at an inner-city family-planning clinic were interviewed about changes in their dysmenorrhea over time. Adolescents who reported the most severe dysmenorrhea (18.2%) and experienced a reduction of dysmenorrhea as a result of taking COCs were 8 times more likely to be consistent COC users.8 Overall, 66% of subjects reported reduced menstrual cramping

Bleeding patterns

Improving menstrual cycle control has been a topic of considerable interest as hormonal contraceptives have evolved from high-dose estrogen/progestin formulations to lower-dose pills and other delivery systems. A Cochrane Review comparing pills with 20 mcg of estrogen or less to those with more than 20 mcg found that lower-dose pills had an increased risk of bleeding disturbances.10 Bleeding patterns of a vaginal ring, which releases ethinyl estradiol 15 mcg/day and etonogestrel 120 mcg/day, a

Ovarian cysts and benign ovarian tumors

Initial reports of benefits on ovarian cysts have not stood the test of time. In 1974, data from the Boston Collaborative Drug Surveillance Program found that functional ovarian cysts were far less common in those women who used COCs than in those who did not (1.7% vs 20%, respectively).14 This finding captured medical practice attention and was incorporated into class labeling for all COCs. In 1987, a case series reported functional ovarian cysts in 7 women taking triphasic COCs.15 Subsequent

Bone

The potential benefit of COCs on bone was first reported in 1975 when a cross-sectional study found that COC users had higher bone mineral density (BMD) than did nonusers.23 A case-control study reported in 1999 that use of COCs by women in their 40s was associated with a 25% reduction in fracture risk later in life (odds ratio, 0.75; 95% CI, 0.59–0.96).24 Most studies have evaluated BMD as a surrogate marker for fracture risk. In 2005, the World Health Organization (WHO) stated that the use of

Fibroids

Regardless of dose, COCs do not cause fibroid growth. In fact, 1 study found a 31% reduced risk in development of fibroids among British women who used COCs, with risk decreasing consistently with increasing use,27 but more recent information finds no clear association between COC use and fibroids.26 A prospective study reported in 2004 included a cohort of black women in the United States with intact uteri and no prior self-reported diagnosis of uterine leiomyomata and evaluated them for 4

Acne

Based on COC effects on decreasing androgens and increasing sex hormone-binding globulin, COCs should benefit women with acne. In 1997, a randomized, double-blind, placebo-controlled trial by Redmond et al28 evaluated a triphasic COC vs placebo in the treatment of acne and found that the COC reduced inflammatory lesions by about 50% in women with moderate acne (mean reduction, 51.4% vs 34.6% with placebo, P = .01). A 2009 Cochrane systematic review of 25 trials of various types of COCs

Premenstrual dysphoric disorder

Many women experience physical and emotional changes related to their menstrual cycle. In a study of 82 women with severe premenstrual dysphoric disorder, a COC-containing drospirenone was associated with improvements in some of the 22 items of a self-reported premenstrual symptom score.30 Another study on COCs containing drospirenone found that extended regimens (168 days) vs a 21/7 regimen has been found to decrease premenstrual symptoms.31 A 2009 Cochrane systematic review of 5 trials

Cancer

Among reproductive-age women, the risk of developing cancer is low. Regardless of contraception use, the probability of developing any cancer increases with increasing age. Some women who have a family history or genetic mutation that predisposes them to cancer will be especially concerned about any adverse impact of COCs on their cancer risk.

Ovarian cancer

The pill had been in use for almost 20 years when studies of cancer outcomes and COC use began to appear in the literature. A 1979 case-control study conducted in California found that ovarian cancer risk decreases as length of time of COC use increases.33 The investigators hypothesized that ovulation suppression was responsible for the protective effect of COCs. This was rapidly confirmed by other studies, the largest of which was the Cancer and Steroid Hormone Study, which found that COC use,

Endometrial cancer

By 1980, the protective effect of COCs had been identified. Weiss and Sayvetz37 found that endometrial cancer risk was about 50% less in COC users. This study also found that endometrial cancer was associated with use of sequential OCs with unopposed estrogen, and this led to the removal of the sequential pill from the US market.4, 5, 38 This protective effect is also evident in the mortality data from the 2 British cohort studies. The RCGP Oral Contraception Study reported an RR of endometrial

Benign breast disease

Benign breast disease with atypia can potentially progress to breast cancer.39 In 1981, the Oxford-FPA study reported that current users of COCs had a significantly lower risk of fibroadenoma, cystic breast disease, and nonbiopsied breast lumps (P < .001), and these risks decreased with increasing years of COC use.40 A recent Canadian cohort study showed that women who used COCs for up to a year had only slightly decreased risk.39 Women who reported having used COCs for more than 7 years had a

Colorectal cancer

The protective effect of COCs on colorectal cancer was first reported in 1983 in a case-control study that found a 50% reduction (95% CI, 0.3–1.2) in colorectal cancer incidence among women who used COCs.43 Since then, a metaanalysis of 11 case-control studies and 7 cohort studies found an RR of 0.81 (95% CI, 0.72–0.92) in users of COCs compared with never users.44 The decreased risk was noted to be stronger among recent users (OR, 0.70; 95% CI, 0.53–0.90).

Summary

All hormonal birth control methods effectively prevent pregnancy and using these methods reduces pregnancy-related deaths. Even after the reproductive years, previous COC use decreases mortality by substantially lowering the risk of ovarian and endometrial cancer and, to a lesser extent, colon cancer. COCs also improve women's lives by reducing dysmenorrhea, menorrhagia, premenstrual dysphoric disorder, and acne. Initially, higher-dose COCs were shown to benefit women by decreasing ovarian

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      Citation Excerpt :

      Combined hormonal contraceptives have been used by 82% of sexually active American women. However, studies show that most women are concerned about the safety of oral contraceptives despite the fact that, for women in every reproductive age group, the risk of death with pregnancy is greater than it is with use of hormonal contraception [1–5]. Over the last several years, we have conducted surveys from convenience samples of women and men investigating beliefs about a variety of reproductive health issues [1,6–8].

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    Publication of this article was supported by an educational grant from Bayer Healthcare Pharmaceuticals.

    The authors report no conflict of interest.

    Reprints will not be available.

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