Lecture 5: Adverse Effects of Hormonal Contraception and Hormone

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Heath Effects of Fertility Control
OUTLINE
1.
Beneficial effects of oral contraceptives
2. Contraception and risks of STDs, PID, HIV,
and infertility
3. Sterilization
4. Abortion
5. Maternal mortality and risks/benefits of
contraception
Beneficial effects of contraception
Well-established major protective effects of oral contraceptives by problem or condition (UK or US)
Relative Risk
Influenced by Duration of Influenced by OC
Condition
Use Formulation
Current Use Past Use
Yes - protection
Menstrual problems 0.75 1.0 No decreases with "low-
dose" pills
Iron-deficiency anemia 0.75 1.0 No Unknown
Yes - protection Yes - protection
Benign breast cysts 0.5 1.0 increases as duration increases as progestin
increases increases
Pelvic inflammatory disease 0.5 1.0 Unknown Unknown
Functional ovarian cysts 0.25 1.0 No Probably not
Yes - protection
Epithelial ovarian cancer 0.5 0.5 increases as duration Probably not
increases
Yes - protection
Endometrial cancer 0.5 0.5 increases as duration Probably not
increases
Adapted from Vessey MP. The Jephcott Lecture, 1989: An Overview of the Benefits and Risks of Combined Oral
Contraceptives.” In: Oral Contraceptives and Breast Cancer. Mann RD, ed. Park Ridge, NJ: The Parthenon
Publishing Group, 1990
Effects of Contraception on STDs
Barrier Methods
• 1.
– Mechanical and chemical barriers protect against
cervical and upper genital tract infections
2. Oral and injectable contraceptives
– Protect against ascending infections due to ↑
cervical mucus viscosity (e.g., gonorrhea RR~0.5).

– Oral contraceptives may increase the risk of
chlamydia, due to increase in ectopy. (Possible
detection bias)
Effects of Contraception on
STDs, PID, and Tubal Infertility
3. IUD
– Increased risk of PID within first 3 months after
insertion. Due to introduction of infection at time
of IUD insertion, increased menstrual bleeding,
IUD tail and possible foreign body reaction.
4. Female Sterilization
– Partially protective against PID in distal tube and
peritoneal cavity.
Primary Tubal Infertility and
Contraceptive Use
Adj RR 95% CI
No History of PID
IUD 1.7 1.2, 2.3
OC 1.1 0.8, 1.5
Barrier 0.7 0.5, 0.9
PID History
IUD 3.9 2.0, 7.5
OC 1.8 0.7, 4.5
Barrier 0.5 0.2, 0.9
Contraception and HIV
1. Barrier Methods
• Male Condoms protect, dependent on
consistency of use.
• Female condom, no data
• No clear evidence for effects of diaphragm or
cervical cap (vaginal mucosa exposed).
• Microbicides:
– Nonoxynol 9, no effect or increased risk. Increased
ulceration
– Cellulose sulphate, trial stopped for harm 2007
HIV Seroconversion and
Condom Use in HIV Discordant Couples
Cumulative HIV
Number Seroconversion
of over Two Years
Condom use Couples (95% CI)
Consistent 121 0
Inconsistent use 124 12.7 (5.9-19.5)
Inconsistent Users
Use in <50% 60 15.0 (9.7-20.3)
sex contacts
Use in ≥50% 60 10.3 (5.9-14.7)
of contacts

Source: Vincenzi et al. NEJM 331: 341-6, 1984
Condom Use and Relative Risk of STD
HIV, Rakai
Inconsistent Consistent
Use RR Use RR
HIV 0.96 (0.5-1.7) 0.37 (0.2-0.9)
Syphilis 1.06 (0.9-1.2) 0.71 (0.5-0.9)
Gonorrhea/ 1.44 (1.1-2.0) 0.50 (0.3-1.0)
Chlamydia
BV 1.11 (1.0-1.30 0.89 (0.7-1.1)
Ahmed et al AIDS2001;15:2171
Studies of Condom Breakage
Study Year Population Location Recall Period Breakage Rage (%)
Cross-sectional
vanGriensven et al 1988 Gay men Amsterdam 6 mos 2 to 4
Tindall et al. 1989 Gay and bisexual men Sydney 6 mos 5 to 7 (anal)
Golombok et al 1989 Gay men England 12 mos 3 to 5 (anal)
Consumers Union 1989 Men and women US 12 mos 1 (anal), 0.6 (vaginal)
Albert et al 1991 Women US Lifetime 1
Family planning clients US 12 mos 0.8
Cohort
Richters et al 1988 Male prostitutes Sydney 4 mos 0.5 (anal), 0.8 (vaginal)
Trussell et al 1992 Family planning clients US 16 days 1.5 to 2.0
Trussell et al 1992 Family planning clients US 21 days 1.2 to 1.3