The health effects of taking the oral contraceptive pill

Looking at factors that can affect a woman's health when she's on the combined oral contraceptive pill.

A woman should be aware of conditions that have a bearing on her health and wellbeing when she's taking the Pill. These include acne, smoking, breastfeeding and migraine.

Acne

The combined oral contraceptive pill (COC) can stabilise some of the fluctuating hormones responsible for the extra oil on the skin that leads to acne.

Women who have acne will find an improvement with the use of any of the COCs, irrespective of the progestogen content in the COC.

Sometimes, acne is due to an excess of male hormones (androgens). Contrary to popular perception, androgens are produced by every woman! This is indicated by irregular menstrual cycles, premenstrual worsening of acne, excessive hair on the face or body (hirsutism) and increased blood levels of certain androgens.

Ethinyl oestradiol is combined with cyproterone acetate, a progestogen that suppresses the androgens produced by the body, to treat acne and provide contraception at the same time. It is used to treat all types of acne, or when there is increased body hair.

Smokers

Cardiovascular disease (CVD) is rare in women in the reproductive age group. However, smoking is a risk factor in CVD, with a strong relationship between mortality and smoking. Excess mortality has been well documented in women aged 35 years and above.

The risk of heart attacks increases with the number of cigarettes smoked daily and decreases when smoking ceases. This risk of CVD in COC users who are smokers is minimal in those under 35 years of age.

It is not advisable for any woman who smokes to take COCs because of the increased risk of CVD. Smoking significantly increases the incidence of heart attack, haemorrhagic stroke and ischaemic stroke by 10, 3 and 1.5-2 times respectively.

As such, COCs are not recommended for any woman who smokes and is more than 35 years old. COC users who smoke more than 15 cigarettes daily have the greatest increase in the risk of heart attacks.

Suitable contraception for women smokers above 35 years includes progestogen only contraception, intra-uterine contraceptive devices, barrier contraceptives or fertility awareness methods.

Breastfeeding

Ovarian function is suppressed during breastfeeding (lactation). The duration of an absence of periods (amenorrhoea) during lactation is variable. Women who are fully or almost fully breastfeeding are amenorrhoeic and can depend on lactational amenorrhoea (less than six months after childbirth) as a contraceptive method unless the periods return or there is a reduction in breastfeeding.

Fully breastfeeding means no other liquids or solids are given to the baby. Almost fully breastfeeding means water or juices are given infrequently.

Full breastfeeding is effective in preventing pregnancy in the first six months after childbirth. When used correctly and consistently, ie feeding at regular intervals on demand day and night with no substitutes, the failure rate is 0.5 per cent.

The COCs are not suitable for breastfeeding women because it has an adverse effect on lactation.

The effectiveness of other contraceptive methods is increased during breastfeeding because of the suppression of ovarian function.

Progestogen-only contraceptives do not affect breastfeeding. The progestogen-only pills can be started six weeks after childbirth and the implants inserted three weeks after childbirth.

The depot progestogen injections are not given until five to six weeks after childbirth because of the risk of heavy and prolonged bleeding if given earlier.

Intra-uterine contraceptive devices or systems do not affect breastfeeding. They are usually fitted after six weeks in women who have had a vaginal delivery and eight weeks in women who have had a Caesarean section. They are not inserted soon after childbirth, as there is an increased risk of perforation.

The cap or diaphragm can be used six weeks after childbirth when vaginal tone is restored. The size will have to be checked.

Condoms do not affect breastfeeding and can be used immediately after childbirth. Spermicides may pass into the breast milk in very small amounts, but no adverse effects on the baby have been reported.

Migraine

Headache is a common condition in women in the reproductive age group. There are many causes of headache, and one of the common ones is migraine. As such, it is important to make a correct diagnosis of migraine, which can occur with or without an aura.

About 20 per cent to 30 per cent of migraine sufferers have aura that comprises focal neurological symptoms, eg flashing lights, shimmering zig-zag lines, areas of lost visual field, focal numbness, or focal altered sensation. The aura precedes and resolves before the headache.

The association between migraine, COC use and stroke is complex. A World Health Organisation study looked at the association of migraine with stroke in young women. Migraine with or without aura was found to be associated with an increased risk of ischaemic stroke, but not haemorrhagic stroke. The current use of COCs with either hypertension or smoking in migraine sufferers had a multiplier effect on the risk of ischaemic stroke.

Migraine sufferers who smoked and used COCs concurrently had an increased risk for ischaemic stroke compared with non-migraine sufferers who did not smoke or use COCs.

It is pertinent to note that the ischaemic stroke risk is very low in young women and is estimated at 5.5 cases per 100,000 woman-years. The risk was found to be increased about three times in young women with migraines.

Doctors should counsel women with migraine about their increased risk of stroke and advise them not to smoke. If COCs are prescribed, the blood pressure should be monitored closely because of the multiplier effect of hypertension on the risk of ischaemic stroke.

In general, because of the increased risk of stroke in migraine sufferers who smoke, doctors would avoid prescribing COCs in such women.

Menstrual migraines have been reported to be successfully treated with monophasic low dose COCs, which may be prescribed continuously without pill-free intervals.

There are also studies which reported that there was no evidence that COCs increases the frequency or severity of migraine. If COCs are prescribed for migraine suffers, the lowest oestrogen dose would be preferred.

There are no studies of the use of progestogen-only contraception (POC) in migraine. Studies of oral contraception in relation to stroke reported no increase in thrombo-embolic stroke with POC, which do not affect blood pressure or smoking risks. As such, POC is considered suitable for migraine sufferers.

The impact of hormonal contraception on the frequency of migraine is unpredictable. If the headaches worsen after use, the POC and levonorgestrel intra-uterine system can be discontinued. However, the effects of depot medroxyprogesterone acetate (DMPA) will persist because it has already been injected and there are no antidotes to DMPA.

There is no reason why the copper intrauterine contraceptive device (IUCD) cannot be used in migraine. Because it does not affect the body's metabolism, there is no drug interaction and it is very effective. Hence, the IUCD is considered by many doctors as a first-line contraceptive method in migraine. The other alternative is barrier contraception.

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