Does the pill kill?

Press, 28 October 1977, Page 13

Does the pill kill?

Women over 35 years old are now being steered gently away from the pill. Where is the research on its ever more popular alternative, this report in the London “Economist” asks.

Nobody took chances this time. Eight years ago, when Britian’s committee on safety of drugs announced a Sink between oral contraceptives and thromboembolism, both the public and general practitioners were unprepared. Lots of people panicked and, it is said, many unwanted pregnancies resulted.

Last week, when “The Lancet” published two papers that showed the risks of the pill to be greater than had been realised, the news was released with a care that would have done credit to an advertising agency. It went out accompanied by simple, explicit interpretations of what the statistical findings meant for the dailv routine of the 3.2 M women in Britain on the pill. The medical profession, was, for once, patient with inquiries from the press.

No pill packets, all the experts emphasise, need to be thrown into the dustbin. Women under 30 can continue taking the pill as

safely as before — unless they smoke. Women from 30 to 35 can keep on, too, but if they smoke, and if they have been taking the pill for more than five years, they should seriously consider switching to something else.

Women over 35 would, in general, be wise to consider an alternative contraceptive strategy for the rest of their reproductive life. If they smoke or are long-term pill users, they have extra reason to make a change in the method. But no-one, of whatever age, should stop the pill until she has truly latched on to a substitute — unless she wants a baby.

So, then, does the pill kill? Yes. Rarely, but definitely. A study by the Royal' College of General Practitioners of 46,000 women over a period of eight years showed that the chances of pill-takers dying from circulatory disorders was five times greater than for those in the group who did not take the pill. The numbers of deaths were small: 56

among the pill-takers, 45 among the others. But risk of death suggested by this study is higher than previous estimates.

One particular figure jumped out: among those who took the pill, there were nine deaths from subarachnoid haemorrhage (bleeding on the surface of the brain); among the others, there was none.

The over-all risk clearly increased with age (for women over 45, the excess mortality rate was one in 700) and was strongly associated with smoking and long use of the pill. The college’s results were supported by a second study, of 17,000 women, done by Oxford University and the Family Planning Association. There are a few buts to be set against the college’s study. The statistics were collected among women who began taking the pill when it contained a high dose of oestrogen. In recent years low to medium doses have come to be preferred. and today’s women with only a few years’ usage may not be running the same risk.

And, as with all studies, there is the possibility of a sampling error. The women who agreed to participate may not be representative of the female fertile population in general.

But the report will be widely noticed, abroad as well as in Britain, and with justice. It was singularly thorough and lengthy, and it was prospective (i.e., it began with women before they went on the pill and followed them — and others — over the years). American researchers are hampered in conducting comparable research on people not in hospital, because Americans (women, in this case) do not have such durable relationships with general practitioners. And though the numbers of deaths reported in the study were small in absolute terms, several of the differences between the pill-users and non-users were striking. Among the users, the 24 deaths from cirulatory disease were significantly greater than the deaths from cancer (14) or from

accidents (nine). Among the 45 non-users who died, 20 died of cancer, seven from accidents, five from circulatory disease — and only two from pregnancy or childbirth. Those modem old wives' tales may be wrong: to take the contraceptive pill if you smoke and are getting on in years may indeed be more dangerous than having a baby or crossing the road (although it may possibly protect your from cancer).

At any age, the risk from oral contraception is small and requires balancing one unlikely possibility against another. Even older women may still prefer the convenience of the pill to other forms of contraceptive clobber that lie in the cupboard, to be stumbled upon by children and au pair girls. But rubber, foam, and plastic are no longer the most popular alternatives. The method of contraception that is climbing to the top of the charts is sterilisation. It is a new phenomenon, amounting to

a revolution over the last five years: the preference for female sterilisation or male vasectomy as a way of limiting a family. Seven years ago, only one British couple in 20 chose sterilisation for contraceptive reasons. Now the proportion may be as high as one in five. In the United States, surgical sterilisation appears to have passed the pill in popularity among married couples, and in 1975 nearly half of American couples married from 10 to 24 years had chosen it. Are they wise? Sterilisation is by and large irreversible. It is worrying that this dramatic surge in sterilisation figures goes along with a rise in the divorce and remarriage rates. Many of the couples who present themselves to a doctor as being in total agreement about sterilisation (“To-

gether, we chose a vasectomy”) will in a few years be splitting up and starting a new marriage. Are today’s couples getting adequate advice of the consequences of surrendering their fertility prematurely — in the case of a man, very prematurely? Not enough research has been done on the psychological effects of sterilisation. In the United States, again, the organisation and economics of American medicine work against such research. In Britian, activity is stirring. The Oxford University psychiatry department and the Medical Research Council’s reproductive unit at Edinburgh have begun a retrospective study of 300 women who were sterilised for contraceptive reasons. The study will try to assess the psychological effects

and regrets, if any, after sterilisation, and may in future extend to a group of women whose husbands have been vasectomised, and to women before sterilisation. Other work on the emotional effects of sterilisation is being done at Nottingham University, and a study on vasectomy has been done in Teesside. Amid the uncertainties, the message for all sexes and all ages is clear. The contraceptive pill is not the simple answer that many had thought. Women, menstruating earlier and later in life than ever before, want a final solution to unwanted pregnancy. But sterilisation may be unnecessarily final, and immunisation not ready yet. The world is still waiting for the tidy, easily reversible contraceptive