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Hormonal Contraception: Another Downside
The Pill is the most studied drug in history, and a good thing too since it is taken by healthy women. Many of the benefits and detriments are well known and for the most part are disclosed on the FDA warning label. The benefit of pregnancy prevention is of course the major benefit, but there are others relating to disease and cancer prevention. Women experience different side effects, most of which are fully disclosed. One of the more serious downsides that gets less attention than it deserves is the loss of libido among some women on the Pill. This side effect is by no means universal and some women experience the opposite. It is clearly something needing further study. There has been extensive study of what the increased risks might or might not be of breast cancer and cardio-vascular events in some patients taking certain formulations of the Pill. The research and debate continues.

But now, confirmation has come out regarding another side effect that I talk about extensively in Chapter Six of Beyond Choice: the seeming increase in sexually transmitted diseases among pill users. This does not occur just because couples on the pill use fewer condoms, though they do; it occurs probably because there are physiological changes in the reproductive tract making it easier for the bacteria to penetrate and infect the body.

A new study confirms what I presented in Beyond Choice, but also makes clear that we must be careful to distinguish between different forms of hormonal contraception. This should not be surprising since there are different formulations used in various hormonal contraceptives and these could lead to different physiological changes in the woman's reproductive tract.

The new study by Charles S. Morrison and others from Family Health International is published in the September issue of the journal Sexually Transmitted Diseases. It can be accessed at www.stdjournal.com.

With the cooperation of Planned Parenthood, the study took a prospective look at almost 1000 women in their Baltimore clinics. The women could select their own method of contraception, or not. In fact 354 women selected the pill, 114 selected Depo-provera (DMPA) and 351 selected no hormonal method. The women were followed up every three months for a year and were examined and tested for chlamydia and gonorrhea.

There was an increased risk of infection in the DMPA and pill users, but the risk was far greater for the DMPA users. The authors called the DMPA risk "significant"---the hazard ratio was 3.6. The hazard ratio for the pill was 1.5. This was in line with 29 previous studies of the pill that averaged a 1.9 hazard ratio for chlamydia and a 1.7 hazard ratio for gonorrhea. The hazard ratio measures relative risk between the hormonal contraceptive users and the control group.

The study found varying sexual risks in the different groups. The control group (no pill or DMPA use) was more likely to have multiple sex partners and to have had sex with a possibly infected person. Pill and DMPA users were more likely to have sex but used condoms less frequently (this is in line with previous studies).

The mechanism by which there is an increased risk of infection is still a mystery. Cervical ectopy, also called cervical erosion, was found not to be what they called "an important mediator" of the hormonal contraception-cervical infection association---this was a surprise to the authors. Their hypotheses as to the physiological mechanism for the increased infection risk include: thinning of the vaginal walls by DMPA, the hormones enhancing the growth of the infection or the hormones depressing the immune system. Clearly more study is needed on the mechanism operating here.

The authors properly examined any biases in their study and concluded that "any residual bias might underestimate the risks for acquiring a cervical infection among hormonal contraceptive users".

The authors also correctly pose the issue of the effect on pill use and HIV acquisition. This remains unclear and studies are conflicting. There are also studies ongoing on whether hormonal contraception might increase HIV transmission to others, including to newborns, and whether it increases disease progression.

The challenge for us is to figure out a new approach to get couples using hormonal contraception to also use condoms. There has been an inverse relationship between more effective contraceptives and condom use---the more effective the method, the less likely the couple is to use condoms. Past studies have indicated that Norplant and Depo users were less likely than pill users to also use condoms.

A recent study published in the August issue of the American Journal of Public Health confirms what we already know--that condoms reduce the risk of gonorrhea, chlamydia and pelvic inflammatory disease. Women in the study always using condoms were half as likely to get a recurring case of PID, which is caused when gonorrhea or chlamydia travel into the upper genital tract. PID is a major cause of infertility. This study can be accessed at www.ajph.org. This should put to rest the fears that contraception opponents tried to raise a few years ago when they challenged the efficacy of condoms in preventing STDs.

So, what to do. First, admit there is a problem. I have seen no articles from health writers on this study. This study needs to be examined by experts, evaluated and suggestions made for further study and action. The IPPF Medical Committee is taking the lead and will be doing exactly this within a month.

Second, I think we need to come up with a new and balanced evaluation of hormonal contraception. There is now confirmation of the tradeoff between pregnancy prevention and disease acquisition. While this has been known since earlier studies, it has now been confirmed. How do we counsel patients? How do we, as providers, now feel about hormonal contraception? How do we develop new strategies to promote dual method contraception and condom use? Do we abandon trying dual method promotion? Clearly the old strategies are not as effective as we would wish.

Thirdly, how do we stay ahead of those who want to ban birth control entirely, or at least female controlled contraception? This political problem is real in the United States and elsewhere.

Fourthly, do we have a different standard for hormonal contraception depending on the health care and gender situation in each country? In some countries where childbearing is so risky, should there be a different standard for the use of hormonal contraception than in countries where there is less risk in childbearing and where abortion is readily available? What relevance is the status of women where men often control the use of contraception and women frequently surreptiously use hidden methods like Depo and the pill? Can hormonal contraception be discouraged and condoms be promoted in such a society where men won't use them?

The risks of sexually transmitted diseases are well known. In the United States 65 million people currently have one. STDs not only cause disease, but also infertility. There is a direct connection between rising infertility and STDs---infertility is not all age related. STDs can damage a woman's fallopian tubes, thus preventing conception and implantation. They also can cause birth defects in children born to an infected mother. Studies estimate that one-third to one-half of cases of female infertility are caused by pelvic inflammatory disease. In Africa, the WHO estimated that two-thirds of infertility is caused by STDs.

I believe the framework to approach analyzing this problem is through fertility. Fertility, the ability to have children, is after all the biological purpose of humanity, just like any other species. Hormonal contraception should be evaluated by its ability to promote fertility. This includes the ability to have the children one wants when one wants to have them, and no more than one wants. While men and women each have reproductive interests, women alone bear the risks of childbearing.

The reality is that a woman in order to get pregnant must have unprotected sex with her partner. This puts her at risk for the sexual behavior of her partner and everyone else he has had sex with. Thus a woman is a risk for a STD through no fault of her own but because of the decisions and actions of other members of society. And women are more likely to contract a STD than a man is because these diseases are more easily transmitted male to female than female to male.

STDs have an effect on the reproductive capacity of the entire society. Arguments in favor of hormonal contraception based on choice are now less persuasive. New thinking is needed. We owe it to our patients and to women and men everywhere.
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Margaret Sanger and the 2004 Election
This week marks the 125th anniversary of the birth of my grandmother, Margaret Sanger. On speaking engagements around the country, the question I am most frequently asked is, “What would your grandmother think about the seemingly unending struggle over reproductive freedom?”

Well, she would be appalled, because the fight for the fundamental right of women to control their childbearing still goes on, but not surprised by how little attention the issue is getting from our presidential candidates.

My grandmother was born in 1879 and died in 1966, a year after the Supreme Court’s decision in Griswold v. Connecticut, which overturned that state’s Comstock law outlawing the use of birth-control devices by married couples. With diaphragms, condoms, and pills then in wide use everywhere, the Comstock law was clearly an anachronism. But to nullify it, the court needed to find a provision in the U.S. Constitution that the law contravened. This was easier said than done.

The court could not base a decision on the obvious assertion that the law was antiquated or out of step with reality. As Justice Potter Stewart put it in his Griswold dissent, “As a practical matter, the law is obviously unenforceable… But we are not asked in this case to say whether we think this law is unwise, or even asinine. We are asked to hold that it violates the United States Constitution.” The court solved this problem by enunciating a constitutional right to privacy and then finding that the Comstock law violated it.

Justice William O. Douglas found that a key intent of the Bill of Rights was to create a zone of “personal privacy,” which was to be protected from unwarranted government intrusion. This zone of privacy was held to include decisions about marriage and childbearing. My grandmother died thinking the battle for reproductive freedom was won. And indeed, Griswold became the basis of the Roe v. Wade decision in 1973, which voided the Texas criminal abortion law.

But thirty years later, feverish efforts to reverse Roe are still going on. And it is not just Roe that is under attack; it is Griswold as well. The religious right questions the very right to decide when and how many children to have, and whether to use contraceptives. The Supreme Court reaffirmed this right to privacy last year in Lawrence v. Texas, which overturned the Texas criminal sodomy law by a 6-3 margin.

The next president is likely to appoint as many as three new justices, and could, with arch-conservative appointments, eliminate the constitutional right to privacy that the Griswold court found. Both parties understand what is at stake. Pro-choice and anti-abortion forces are running ads in swing states trying to educate voters.

But a closer look at the candidates and their national committees reveals a curious and disquieting silence on the issue. Neither candidate made any serious mention of the issue in his convention speech. although there are pointed references buried in their platforms, which no one reads, no mention of the Supreme Court, abortion or reproductive freedom is to be found in either party’s list of key agenda items, as published on their web sites.

It seems that neither party wants to risk offending swing voters by disclosing their true agenda. Polls indicate that swing voters, including moderate Republicans, do not want abortion criminalized, but neither do they want unrestricted access to abortion, especially by minors. The Republicans make an issue of parental consent, but threats to overturn Roe and recriminalize abortion get no mention by the Bush camp, nor – surprisingly – by John Kerry.

My grandmother would not be surprised to see politicians ducking this issue; after all, she saw Franklin Roosevelt do so for twelve years, despite Eleanor’s urgings that he endorse birth control. But she probably would be amazed that after thirty years of contentious debate the issue of reproductive freedom is still so politically toxic that neither party will say plainly what it wants.

Is reproductive freedom to be the dog that didn’t bark in the political night? Only if John Kerry allows it. He has everything to win by hammering the Republican Party’s hidden agenda to overturn Roe and Griswold, to eliminate the right to privacy, and to force women to bear children when it is not best for them or for their other children. If John Kerry places himself unequivocally on the side of a woman’s right to choose, then he will be seen as the true pro-family candidate and will reap the electoral benefits.
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Alexander Sanger
Alexander C. Sanger, the grandson of Margaret Sanger, who founded the birth control movement over eighty years ago, is currently Chair of the International Planned Parenthood Council.
Mr. Sanger previously served as the President of Planned Parenthood of New York City (PPNYC) and its international arm, The Margaret Sanger Center International (MSCI) for ten years from 1991 - 2000.

Mr. Sanger speaks around the country and the world and has served as a Goodwill Ambassador for the United Nations Population Fund.

Beyond Choice
Beyond Choice
The new book by Alexander Sanger published by PublicAffairs


Purchase from Amazon.com

Click here for full book information

With reproductive freedom in jeopardy, Alexander Sanger, grandson of renowned family planning advocate Margaret Sanger and a longtime leader in the reproductive rights movement, has taken an urgent, fresh look at the pro-choice position—and even the pro-life position—and finds them necessary, but insufficient. In Beyond Choice he offers the first major re-thinking of these positions in thirty years.

“Well researched and readable, Beyond Choice should be required reading for both pro-choice and pro-life supporters.”
—Governor Christine Todd Whitman

»

» Much more on Beyond Choice, including an excerpt, discussion guides, reviews
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External Links
» International Planned Parenthood Federation/Western Hemisphere Region

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» The Margaret Sanger Papers Project, NYU History Dept.

» When Sex Counts: Making Babies and Making Law, by Sherry Colb