The Cardiovascular Costs of Contraceptive “Freedom”

The advertising campaign that introduced the first oral contraceptive in 1960 featured a rendition of the Greek goddess Andromeda “freed from her chains.”  The adjoining caption, promoting the drug Enovid, read as follows: “From the beginning, woman has been a vassal to the temporal demands of the cyclic mechanism of her reproductive system.Now, to a degree heretofore unknown, she is permitted normalization, enhancement, or suspension of cyclic function and procreative potential.” 

Women would soon find out that the touted freedom came at a cost.

The first report of a blood clot in the lungs related to the use of Enovid was published in 1961. By 1963, many doctors had witnessed enough cases of grave or even fatal cardiovascular complications to be convinced the pill posed a serious risk to their patients. They petitioned the FDA for action but the committee set up by the agency to analyze the problem declared the evidence “insufficient” to establish a causal link between the pill and the reported complications. Ignoring criticism that the statistical methods used by the committee were flawed, the FDA elected not to intervene and even removed an initial warning about the potential risks associated with the drug.

By the late 1960’s, when subsequent studies confirmed beyond any doubt that hormonal combination contraceptives were hazardous, the sexual revolution was essentially completed and the pill had become an indispensable commodity of the modern age. Any curtailing of its use—even if called for by prominent feminists—seemed unlikely. Nevertheless, the ultimate recognition of serious adverse effects may have limited more widespread adoption of these drugs. The list of complications that can result from the use of combination contraceptives reads like a textbook of pathology. Chief among these are cardiovascular problems: deep vein thrombosis, pulmonary embolism, stroke, or heart attack. Clots can form literally anywhere in the body. There have been reports of clots forming in the retina causing permanent loss of eye sight, clots forming in the intestine causing necrosis of bowel, clots forming in the kidneys, etc. And most of the time, the catastrophe afflicts a previously healthy woman not known to have any predisposition to clotting.

The drugs “thicken” the blood by increasing the concentration or activity of blood clotting proteins. A study has shown that small asymptomatic clots can be detected by sensitive techniques in the bodies of up to 27% of otherwise healthy women who are given the pill compared to 6% of women given a placebo. This finding is in keeping with other studies indicating that pill users have a rate of serious venous clots that is 4-5 times greater than in the general population.

The risk of clot formation is higher in older women compared with younger ones and is greatly magnified by smoking. The FDA mandates a “black box warning” for all combination contraceptives alerting prescribers and users that these drugs are absolutely contraindicated for women older than 35 who smoke. But this warning does not keep zealous proponents of the pill from aggressively pushing for its dissemination in developing countries, where smoking is on the increase and where illiteracy will likely cause the dangers of hormonal contraception to be overlooked.

Newer contraceptives containing low doses of estrogen have a rate of cardiovascular complications that is significantly reduced compared to the first generation drugs used in the 1960’s and 1970’s. But even with the 2nd and 3rd generation pills, rates of clots, hearts attacks, and stroke are still substantially above what would be expected for the general population. And the problem is not going away: the “4th generation” contraceptives Yaz, Yasmin, and Beyaz (Bayer) have been found to impart risks of venous clots that are even greater than with older generation drugs. These products are now mired in expensive litigation.

Combination contraceptives also increase the blood pressure by a few points (millimeters of mercury) in most women who take it, and can cause overt hypertension in up to 5% of users. When it comes to the management of blood pressure in other settings, hypertension experts are quick to point out that even a one point increase in the blood pressure in the general population can lead to a great increase in the rate of stroke and cardiovascular complications. But when it comes to the increase in blood pressure induced by the pill, we hear again the familiar refrain that the statistical data are “insufficient” to warrant a change in practice and that the benefits of contraception far outweigh the risks.    It is precisely this judgment about benefits versus risks that sets the tone for any discussion about the adverse effects of contraceptives. Proponents of the pill invariably point out that the risk of complications must not be judged in isolation: blood clots, eclampsia, strokes, hemorrhages, ectopic pregnancies, obstetric complications, and a myriad other problems can affect fertile women. On the balance, the argument goes, the risks of pregnancy are far greater than the risks of the pill.

But this assessment is untenable. The realities of motherhood cannot be crudely contrasted to a particular method to avoid pregnancy. One cannot compare a means with an end result. If one wishes for a more apt comparison, it is indeed the totality of the choice and its consequences that need examination. The potential consequences of the contraceptive mentality unleashed by the pill must be part of the equation: debasement of sexuality, objectification of women and men, weakening of marriage and relationships, increased promiscuity, sexually transmitted diseases, psychological distress, to name but a few.

In fact, many women instinctively understand the falsity of the forced comparison between contraceptive versus pregnancy risks. In survey after survey, contraceptive proponents puzzle that women’s misgivings about the pill seem “out of proportion” to the actual “small” risks of cardiovascular and other complications. They term such misgivings “cognitive dissonance.” With more education, they hope, women will see the light and embrace the pill and the freedoms it purportedly offers.

But the real cognitive dissonance is not with the women to whom the pill is promoted so relentlessly. Rather, it is with the pill pushers themselves and their academic, regulatory, and industrial allies who promote the harshest manipulation of a woman’s hormonal system as a boon for “quality of life,” as a “freedom from the chains” of fertility, or, most bizarrely, as a “fundamental right” to a “preventive service,” when in actuality, using the pill is nothing more than playing Russian roulette in the casino of the sexual revolution.

The only worthwhile comparison, of course, must be between the pill and natural family planning. For not only is NFP equally effective in helping couples plan for or postpone pregnancy, but only NFP fosters love, only NFP is open to life, only NFP supports the family, and only NFP protects the health of the woman and encourages her to cherish her God-given natural fertility. Only NFP can truly be called liberating.

References and Further Reading :

1.  Jordan WM. Pulmonary embolism. Lancet 1961;2:1146-7

2.  Langer E.  Enovid: contraceptive pill and recent FDA report clearing it stir continued medical dispute. Science, 1963; 141(3584):892-4

3.  Shufelt CL, Bairey Merz CN. Contraceptive hormone use and cardiovascular disease. J Am Coll Cardiol.  2009;53(3):221-31

4.  Alkjaersig N, Fletcher A, Burstein R.  Association between oral contraceptive use and thromboembolism: a new approach to its investigation based on plasma fibrinogen chromatography. Am J Obstet Gynecol. 1975;122(2):199-211.

5.  Lenzer J. US panel rules that warnings on two birth control pills be strengthened. BMJ. 2011 Dec 13;343

6.  Eberstadt M. Adam and Eve after the Pill: Paradoxes of the Sexual Revolution. San Francisco:Ignatius Press, 2012