Preventive Health?

Preventive health: the interventions designed to prevent serious disease and promote health for the population. Classic examples are interventions intended to limit devastating cancers, heart attacks and strokes. We do mammograms, check cholesterol panels and measure blood pressures to screen for factors that may contribute to early death. But contraception? Is that preventive health?

Before 2002, most women in America were strongly encouraged to be on hormone replacement therapy. We had observational studies, like the Nurses Health Study, with robust numbers that convinced the medical field that replacing a woman’s reproductive hormones after menopause would decrease her risk of heart disease by an impressive 50%, strengthen her bones, decrease her risk of colon cancer and help her think better. Initially, studies did not reveal a link between hormone replacement and increased risk for breast cancer. In 2002, the Women’s Health Initiative, a randomized controlled study where generally healthy post-menopausal women received either the most common hormone replacement or a placebo, was actually halted prematurely because of very significant findings: Instead of decreasing heart disease, we were increasing it by 22%. We were increasing strokes by 41%. And, we actually were contributing to an increased risk of breast cancer, by 26% when compared to the rates of the women who were given the placebo. It’s important to put the numbers in perspective. For every 10,000 women on the hormone replacement for one year, there would be seven more cardiac events, eight more strokes, and eight more breast cancers than in a group of 10,000 women not on hormone replacement. One woman’s individual risk may not seem high, but when looking at the entire American population, our goal of preventing serious disease was certainly not being met – we were causing disease. Within months of the release of this study, physicians around the world changed their practices to give better health care to women.

Now, oral contraceptives are considered safe, even necessary by many. What studies are there for this confidence? It is considered unethical to perform a randomized controlled placebo study with the Pill. So, we use large observational studies, like the Nurse’s Health Study, which show that the long term mortality of women who have been on the oral contraceptives is about the same as women who have not used the Pill. Hmm, so if a synthetic progestin/estrogen hormone replacement pill that we thought decreased the risk of heart disease actually increased it, how is it that something that doesn’t even show benefit with the weaker designed study is something we could still think is safe? But there is one additional factor that makes this presumption even more ludicrous. The Pill is about ten times more potent than the medication used in the Women’s Health Study. If these chemicals cause breast cancer at the level of hormone replacement, where is the logic to even presume it would be safe at ten times the dose?

Case control studies have also suggested a doubling of the risk of heart attack, stroke and autoimmune disease in women on the pill, and a five fold increase in the risk for blood clots.

We must learn from history. We must speak up for the health of women and not let women be used as pawns in a political battle which is based on the false premise that the Pill is preventing disease. Fertility is not a disease, and oral contraceptives increase the leading causes of death in women.

Oral contraceptives are not Preventive Health, they are preventing health.

JAMA 2002;228(3):321-333