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Population Reports Population Reports Series A Number 6 May-June 1982 ORAL CONTRACEPTIVES Population Information Program , The Johns Hopkins University, Hampton House, 624 North Broadway, Baltimore, Maryland 21205, USA Oral Contraceptives in the 19805 Editors' Summary. More than so million women around the can be a life-threatening emergency that requires im­ world are using oral contraceptives (OCs) as of 1980-81. Over mediate surgery. half of these women buy supplies from pharmacies or other • Protection against endometrial cancer. Women who have commercial sources, with or without a medical prescription. used OCs for a year or more have about one-third the risk The rest, including about 7 million Chinese women, are sup­ of never users of developing this form of uterine cancer. plied by government or private sector programs. • Protection against cancer of the ovaries. Women who have used OCs face about two-thirds the risk of never In developed countries, where almost all users buy their OCs, users of developing ovarian cancer. sales fell from a peak of about 287 million cycles in 1975 to 253 • Protection against benign breast disease . Current OC million in 1979 and have remained stable at that level. The ma­ users have breast lumps or cysts about half as often as jor drop in sales took place in the US . By contrast. sales in a nonusers. Benign breast disease is very common in devel­ number of Latin American countries have increased by about oped countries and may require repeated biopsy to rule so percent since 1975. In other developing areas public and out cancer. private family planning programs supply all but a small per­ • Relief from a wide range of common menstrual disorders, centage of users. The US Agency for International Develop­ including irregular menses, premenstrual tension, excess ment (USAID) provides family planning programs, mostly in blood loss (which may lead to anemia), and cramps. Asia , with about 100 million cycles annually. Other donors and Recognizing the importance of these benefits, the United international agencies altogether provide about 20 million cy­ States Food and Drug Administration's Committee on Fertility cles annually. and Maternal Health recommended in February 1982 that in­ structions in each pill package include information on the Knowledge of the benefits and risks of th e pill has grown con­ benefits of OC use. siderably in recent years. Important health benefits of OC use have been identified in addition to prevention of unwanted Risks limited pregnancy. At the same time it has become clear that the risks In the last half decade three major cohort studies and a number associated with OC use are largely confined to women over of other analyses have found that the greatest danger asso­ age 35 and especially to women over 35 who smoke. The risk ciated with pill use is increased risk of circulatory system dis­ for younger women is very small. ease among women over 35 , especially women who smoke. In the largest study, conducted by the Royal College of General Beneficial Effects Noted Practitioners in Britain and involving nearly 50,000 white The benefits of OC use cover a wide range of health concerns, women, a pattern emerged. Among all women under age 35 beginning, of course, with effective contraception. US surveys and among nonsmokers under 45, there were no statistically show that the pill is the most effective reversible means of pre­ significant differences between OC users and nonusers in the venting unwanted pregnancy. By comparison, IUDs have a rates of death from circulatory system disease. Among older 12-month failure rate two times greater than the pill , condoms women risk was lowest for those who neither smoked nor used three times, diaphragms four times, and other methods more OCs, somewhat higher and roughly equal for those who either than five times greater. Of course, the effectiveness of OCs smoked or used OCs, and much higher for those who both depends on regular use. smoked and used OCs. Risks are reduced with lower doses. Among the other beneficial effects that some women obtain CONTENTS from OC use are: • Protection against pelvic inflammatory disease WID). Cur­ Usage . .. .... ... .. .. ... A-191 rent OC users face about half the risk of noncontraceptors Reproductive Function ... .. .. ... A-l96 or one-fourth the risk of IUD users. PID can lead to later Neoplasia . .. .. .. ... ..... .. .. A-200 infertility or ectopic pregnancy, as a result of blocked Circulatory System Disease, Age, and Smoking . A-204 tubes. Other Conditions .. .. .. .. .. .... A-209 • Protection against ectopic pregnancy. Current OC users Risks, Benefits, and Program Issues . ... .. A-21O have one-tenth the risk of noncontraceptors of developing Bibliography ...... .. .... .. ... A-214 ectopic, or extrauterine, pregnancy. Ectopic pregnancy Vo lume X, Number 3 but to d .e, after more than 20 years of experienc . , no increast This issue of Population Reports was prepared by Ad­ with O( use has been demonstrated. While the vidence is in­ rienne Kols, M.A., Ward Rinehart, Phyllis T. Piotrow, conclus 4e, OCs have not been proved to influence rates of Ph.D., louise Doucette, M.H.S., and Wayne F. Quillin cancer )f the cervix, melanoma (skin cancer), or pituitary on the ba sis of published and unpublished materials, cor­ tumors. OCs are associated with the occurrenc of nonmalig­ respondence, and interviews. Comments and additional nant liv r tumors in one or two per 100,000 wo en per yea r. material are welcome. These t mors may rupture, causing internal ble ding and po ­ sibly dt tth . The assistance of the following reviewers is appreciated: Mark Belsey, An selmo E. Bern al, Ronald Burkman, L. P. OCs h. -Ie no adverse effects on later childbearing. Return ( li Chow, Larry L. Ewing, Ronald Gray, Robert Hatcher, fecund y is delayed by several months in some OC users, b t Louis Hellman, Douglas Huber, Clifford R. Kay, Theo­ fecund y does not appear to be permanently impaired. RaLS dore M . King, Peter M. Layde, Malcolm Potts, R. T. of mis! trriages and birth defects are not affected by OC u-e Ravenholt, Judith Rooks, Allan Rosenfield, Pramilla before pregnancy, although some questions remain about Senanayake, James Shelton, J. Joseph Speidel, Bruce birth ( ~ fects and inadvertent OC use during pregnancy. In Stadel, and Martin Vessey. breast- 'eding mothers, OC use may reduce th e volume f milk 0 duration of breast-feeding, but use of OCs with 50 m g Poputation Reports (USPS 063·150) is published bimonthly (j anuary, or less )f estrogen has not been shown to affect infant growlh. March, M ay. July, Sept ember, November) at 624 North Broadway, Balti· more, M aryland 21205, USA , by the Population Information Program of The Johns Hopkins Universi ty and is supported by the United States Benefits of Regular Use Outweigh Risks Agency for Intern ational Development. Second class post age paid at Baltim ore , Maryland. Postmaster to send address changes to Population An ob xtive assessment of the risks and benefi ts of using OCs Reports, Population Information Program , The Johns Hopkins Uni ver· must t ke into account the risk s of pregnancy if contraception sit y, 624 North Broadway, Baltimore, Maryland 21205, USA. is not sed and the availability and risks of oth r contracept 'e Population Reports is designed to provide an accurate and authoritative methe Is. In both developed and developing countries Ihe overv ie w of important development s in the population field. It does not risks ssociated with pregnancy and childbirth are mll h represent official statements of policy by The Johns Hopkins University or th e US Agency for Interna tional Development. highe than those associated with using OCs. For most women in de eloping countries using OCs for a year is much less Phyllis T. Piotrow, Ph.D ., Dired or; Walter Stender, Associate Director; Ward Rinehart, Edito r. dangE ous than using no contraception for a ear and risk ing pregr ncy. Even for the few developing-country women over age 3 who smoke, the hazards of OC use do not approach he It is generally agreed that OC use increases the risk of four spe­ hazar s of pregnancy if contraceptives are nOI used . For his cific conditions among the US and British women who have grour especially, however, other methods of fertility control been studied: woul be safer than OCs. • venous thromboembolism , or blood clots in the veins, • ischemic heart disease, including heart attack, UndE existing conditions in developing cou tries, th " preg­ • cerebrovascular disease, or stroke, nanc ~ s that occur because of irregular use the pill-o of • hypertension, or high blood pressure. othet ethods of family planning-cause mor deaths th an the The most serious risks are heart attack and stroke. met~ Ids themselves. The implications for fam ily planning pro­ grarr are clear: Older women who smok should be n­ The Royal College study found that, overall, OC users were cour ged to use a method other than the pill o r to stop sn ok­ four times more likely to die of circulatory system disease than ing. or younger women and nonsmokers, encouraging r 'gu­ nonusers, but it is debatable how overall figures apply to other lar u _of OCs will yield greater health benefjl ~ than restric ting populations or individual women. Deaths in all of the cohort the ;, ailability and use of OCs. Greater effort is needed not only studies are concentrated among older women who smoke. to rr ke reversible means of contraception su h as OC ~ wirlely The number of deaths in younger wom.en is so few that no con­ avai ble, but also to be sure that they are u d regul.u ly and clusions can be drawn from them .
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