On March 21, 2024 the Washington Post came out with an article titled Women are getting off birth control amid misinformation explosion, which has sparked quite a bit of controversy since publication [15]. As a board-certified family medicine physician who does not prescribe birth control and promotes natural family planning (NFP), the article was extremely frustrating to read. It suggests that “influencers” and individuals online are spreading misinformation and fear about birth control by encouraging people to ditch the synthetic hormones and use their body’s natural signs of fertility. In a gross blanket statement they claim that all medical professionals unanimously agree that birth control is safe and effective, side effects are minimal, serious side effects are rare, and that NFP methods are an ineffective alternative. They not only discredit any woman who has had adverse side effects from birth control, but also mock any woman who dares think she can navigate her body without the help of drugs to suppress its apparently unpredictable cycle. In this article I’d like to walk through these inaccurate claims laid out by the Washington Post and discuss the facts, clinical trials, and statistics published by journals and the pharmaceutical companies themselves.
Navigate Through the Article:
Side Effects and Contraindications:
While the Washington Post article brushes off the side effects of birth control as minimal, rarely serious, and over dramatized by “influencers” and individuals online, taking a simple look at the prescribing information published by the pharmaceutical manufacturers themselves shows a plethora of side effects seen in rather high numbers.
Mirena (a progestin containing intrauterine device [IUD]) self-reports common side effects include pelvic inflammatory disease (PID), ectopic pregnancy, uterine perforation, headache, vaginal discharge, abdominal or pelvic pain, inflammation/irritation around vulva, and ovarian cysts. As listed on the Mirena’s prescribing information [8], clinical trials were performed on 5,091 women over 5 years. During the clinical trials the following adverse effects were seen:
Abdominal/pelvic pain (22.9%)
Headache/migraine (16.3%)
Vulvovaginitis (10.5%)
Weight gain (9%) – however, they were unsure if the Mirena was the underlying cause
Breast pain (8.5%)
Ovarian cysts (7.5%)
Acne (6.8%)
Depression (6.4%)
Alopecia and Pelvic Inflammatory Disease (<5%)
The prescriber information packet for Nexplanon (a progestin-containing implant placed in the arm) discusses results of their clinical trials performed on a total of 942 women [14]. The following adverse effects were documented in these trials:
Headaches (24.9%)
Weight gain (13.7%)
Breast pain (12.8%)
Abdominal pain (10.9%)
Dizziness (7.2%)
Emotional lability (6.5%)
Nausea (6.4%)
Depression (5.5%)
Next, we can look at different combined oral contraceptive (COC) pills. Since there are many different brands of birth control pills, I will just use Lo Estrin Fe and Yaz as examples.
Lo Estrin Fe conducted their clinical trials on 1,660 women over 1 year [9]. Some of the serious adverse events that were documented were blood clots such as deep vein thrombosis (DVT) and ovarian vein thrombosis, as well as cholecystitis (gallbladder inflammation). During this clinical trial, 10.7% of the subjects had to stop the trial early due to adverse reactions. The pharmaceutical manufacturer also published that their clinical trials showed an increased relative risk of breast cancer seen with use of Lo Estrin Fe. It was found that women using this birth control pill for less than 1 year had a 1.03 relative risk, and women who used this pill for over 8 years had a relative risk of 1.4. In other words, women using this brand of birth control pill for 1 year are 3% more likely to develop breast cancer, and women using this birth control pill for over 8 years are 40% more likely to develop breast cancer. Forty percent is definitely not a side effect to brush off or overlook! Some of the less serious adverse effects found in the Lo Estrin Fe trials:
Headaches (7%)
Weight fluctuation (4%)
Breast tenderness (4%)
Acne (3%)
Anxiety (2%)
Depression (2%)
The other brand of oral contraceptive pills I included in this analysis is Yaz. The prescriber information published by Yaz shows their clinical trials followed a total of 1,027 women [4]. Some of the severe adverse effects found in these trials were migraines and cervical dysplasia. The clinical trials looked at Yaz for contraception and Yaz for PMDD use (pre-menstrual dysphoric disorder) separately. The trial that looked at Yaz for contraception included 742 subjects, and these are a few of the less severe effects found:
Headaches/migraines (6.7%)
Breast tenderness (4%)
Depression (2.2%)
The trial that looked at Yaz for treatment of PMDD included 285 subjects, and these are some of the less severe effects noted:
Headaches (13%)
Breast tenderness (10.5%)
Decreased libido (2.8%)
Weight gain (2.5%)
The prescriber information publication also states some possible concerns about cervical cancer, which cervical dysplasia is already noted to be a severe adverse effect found in Yaz birth control pill trials. The Yaz publication states, “Some studies suggest that COCs are associated with an increase in the risk of cervical cancer or intraepithelial neoplasia. However, there is controversy about the extent to which these findings may be due to differences in sexual behavior and other factors.”
The National Institute of Health (NIH) writes, “Oral contraceptive pills can cause hypertension in 4-5% of healthy women and exacerbate hypertension in about 9-16% of women with pre-existing hypertension.” The NIH also discussed a meta-analysis of 28 publications, which showed that compared to those who did not use birth control, combined oral contraceptives caused a 70% increased risk of ischemic stroke (relative risk of 1.7), and a 60% increased risk of heart attack (relative risk of 1.6) [12].
Finally, all contraceptives discussed above listed several contraindications, or risk factors that suggest that these methods of birth control should be avoided and not be used. Contraindications to contraceptive use are any known increased risk of blood clots (i.e. history of stroke, deep vein thrombosis (DVT), pulmonary embolism (PE), cerebrovascular disease, inherited coagulopathies, valvular thrombotic heart disease [endocarditis], atrial fibrillation, smoking), migraine with aura, liver disease, uncontrolled hypertension, breast cancer or any progestin or estrogen sensitive cancers, diabetes with vascular disease, undiagnosed abnormal uterine bleeding, and use of certain medications for treatment of HIV or Hepatitis C. Additionally, IUDs have even more contraindications, which include having an active sexually transmitted disease (STD), or having concern for cervical or uterine cancer.
Ideally, we all would love to read that a pharmaceutical product has zero side effects found in clinical trials, but that is unrealistic. However, the frequency and numbers of side effects documented in these clinical trials is not something to take lightly. Most of the studies are showing that over 10% of women in the trials experienced headaches/migraines (1 in 4 women when looking at the Nexplanon alone), over 1 in 5 women experienced abdominal/pelvic pain with Mirena, and 1 in 20 women developed depression after use. While the Washington Post can dismiss migraines, a 40% increase in breast cancer, cervical dysplasia as “minimal side effects” or suggest that side effects will resolve on their own or improve after switching to a different birth control method, I cannot. The data from the pharmaceutical companies shows that side effects are actually fairly common, are so serious that many women had to discontinue the trial (10.7% in one case), and that the same side effects tend to be present among all forms of birth control (progestin-only and estrogen containing contraception).
Can Birth Control Cause Abortions?
The Washington Post article protests that, “Some commentators inaccurately depict hormonal contraception as causing abortions.” This is a topic that is very much based on semantics. Pharmaceutical companies claim that birth control cannot terminate an existing pregnancy. However, this is because they consider an “existing pregnancy” as a fertilized egg that has implanted in the uterus, and if the fertilized egg does not implant, it is not considered a true pregnancy by their standards. The birth control companies themselves admit different products can prevent an already fertilized egg from implanting in the uterus, and therefore kill an already fertilized egg, otherwise known as a conceived baby. The American Pregnancy Association writes, “The IUD changes the lining of the uterus, preventing implantation should fertilization occur. It is important to consider the ethical implications of this third method.” Moreover, the Cleveland Clinic describes the mechanism of birth control pills as preventing ovulation, thickening cervical mucus to prevent sperm from entering the uterus, and thinning uterine lining to prevent implantation of the fertilized egg [2]. The Cleveland Clinic also says that copper IUDs “Heighten the inflammatory response, causing your uterine lining (endometrium) to become inflamed. Even if sperm were to fertilize an egg, your uterine lining would make it difficult for a fertilized egg (embryo) to implant there and develop,” [3]. Finally, the Mirena website states, “Pregnancy while using Mirena is uncommon but can be life threatening and may result in loss of pregnancy or fertility,” [11].
It’s clear then that birth control does in fact act as an abortifacient. The attempt by the Washington Post to say other is in fact the misinformation they claim to be defending against.
Can Birth Control Affect Fertility Long Term?
The Washington Post writes, “Medical experts say there is no evidence birth control impacts fertility long term.” While studies on this subject are very limited, to claim that birth control has absolutely no effect on women’s fertility is very misleading, inaccurate, and to be honest, bold. The drug companies themselves aren’t even this bold. Mirena reports on its website that if you get pregnant while using Mirena, this could lead to “loss of pregnancy or fertility,” [11]. Many forms of contraception increase a woman’s risk of ectopic pregnancy, which can also in turn lead to fertility issues in the future. This is especially true if a salpingectomy (removal of fallopian tube) is necessary. Plus, pelvic inflammatory disease (PID) causes increased risk of infertility, and this is a listed adverse effect of contraception such as IUDs.
Additionally, while studies show that some women may resume ovulation within 2 weeks of discontinuing birth control, there are many women that do not resume ovulation and menstruation immediately after discontinuation. This could be related to long-term use of artificial hormones that shut off the ovulatory cycle for years, or it could be due to underlying reproductive disorders that were already present but masked by hormonal birth control. Being on birth control does not cure these reproductive disorders. It simply hides the symptoms, which will present and affect fertility later in life, possibly when trying to actively achieve pregnancy. Overall, this is a topic where more studies are necessary since information is so limited, especially when 1 in 5 women in the US suffer from infertility, and 1 in 4 have difficulty getting pregnant or maintaining a pregnancy. I believe it would be very beneficial to do more studies comparing the infertility rates of women who have never used hormonal birth control to women who have discontinued hormonal birth control use to show if any causation is linked to contraception.
Actual Effectiveness of Natural Family Planning (NFP):
Back to the Washington Post article–-it says, “’natural’ alternatives, such as timing sex to menstrual cycles — a less effective birth-control method” and an additional article they posted reported NFP to have a failure rate of up to 23%. This means that 23 out of 100 women who use NFP to avoid pregnancy, will end up with an unintended pregnancy. This misleading failure rate statistic is due to a flawed study the CDC originally cited regarding NFP effectiveness [1]. This was a retrospective study conducted between 1995-2002 in which 18,000 women were surveyed and asked to remember what method of birth control they were using when they got pregnant. While all other methods of birth control were put into their own specific category such as the pill, IUDs, implants, injections, anything that sounded remotely like NFP was put into one single “periodic abstinence” category.
There were many flaws within this study. First, there was recall bias because they were collecting data based off what people remembered using from years ago. Women may have misremembered or have even been using a combined version of some different methods.
Second, not all NFP methods are equal in effectiveness. However, that study classified the cervical mucus method, basal body temperature (BBT), symptom-hormonal method, and even the RHYTHM METHOD as the same “periodic abstinence” method. That would be like saying that IUDs and oral contraceptive pills should all be considered the same method when comparing effectiveness, which would extremely skew failure rates data of these methods since IUDs have a failure rate of 0.1-0.4% and OCPS have 7% failure rate. Lumping things such as the rhythm method with true NFP methods extremely skews the failure rates and makes true NFP methods appear much less effective.
Thirdly, due to the study surveying women between 1995-2002, the majority (86%) of women in the “periodic” abstinence category were using the rhythm method since more modern methods were less popular and there were less scientific advances in NFP.
Thankfully, more recent and stronger studies have been conducted to assess the actual effectiveness of NFP and compare different NFP methods to each other. This newer study was a review of multiple NFP effectiveness studies that was published in 2013 [10]. These studies show that depending on the NFP method used, there is actually only a 4.75%-0.14% failure rate. Comparatively, the failure rates of other birth control methods are as follows according to the CDC’s website:
IUD = 0.1-0.4%
Implant (Nexplanon) = 0.1%
Injection (Depo-Provera) = 4%
Combined oral contraceptive pills = 7%
Progestin only pills = 7%
Patch = 7%
Hormonal vaginal ring = 7%
Diaphragm = 17%
Male condom = 13%
Spermicides = 21%
Tubal ligation = 0.5%
Vasectomy = 0.15%
This means that NFP can be just as effective as the IUD and Nexplanon, which are considered the most effective form of contraception, despite the WP article incriminating NFP as a less effective birth control method. On top of being just as effective, NFP also respects the body’s natural process without risking the side effects that go along with the synthetic birth control choices.
Click here to read my blog post for more information about the effectiveness of NFP and inaccuracies published by the CDC regarding this topic.
Conclusion:
I think it is fair to say that most of us are tired of being gaslighted and told that pharmaceutical products are “safe and effective” when there clearly either isn’t enough studies to support this, or when the information posted by the pharmaceutical manufacturers themselves proves otherwise. It is disappointing to see the Washington Post make such inaccurate claims and try to pass it off as facts. Plus, the fact that the article tries to talk on behalf of all physicians and medical professionals as if we all agree that contraceptives are safe, have rare side effects, and that we would not recommend NFP is frustrating. This is why I wanted to use my platform as a board-certified family medicine physician to go over the real data from clinical trials and the drug companies themselves, and to discuss how effective NFP actually is.
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