“Birth control has a TikTok problem.”

“The stakes are high,” reports Lisa Jarvix in Bloomberg. “The twin forces of birth control-related misinformation, often from women sharing their personal experiences, and disinformation, typically posted by right-wing activists hiding their true agendas, is happening at a time of ever-shrinking access to abortion care in the US.”

Your clients have always turned to opinions from family members or friends. But the internet influencers “aren’t typically the ones who are happy with their birth control,” says Jarvix. “It’s the ones who have had a bad experience that are more apt to share.”

Providers can share evidence to counteract the misinformation and disinformation. Here’s an update on the most worrisome risks that contraceptive users care about, according to Contraceptive Technology authors Sarah Bradley, Chelsea Polis, Elizabeth Micks, and Markus Steiner.(2)

Safety

In general, contraceptives pose few serious health risks to the majority of users. Moreover, the use of contraceptive methods, including hormonal methods, is generally far safer than pregnancy. This fact may not be well understood: one study found that 75% of women believed COCs were at least as hazardous to a woman’s health as pregnancy.(3) Contraceptive failure (pregnancy) is associated with risk: an individual must assess the likelihood of contraceptive failure and the dangers that a pregnancy would pose. Depending on where a person lives, they may face risks associated with delayed or unsafe abortion, or risks associated with pregnancy continuation and childbirth. These risks are all affected by an individual’s health and sociocultural circumstances. Thus, people in many lower-income countries with higher pregnancy-related mortality rates will experience an even greater relative health advantage in using contraceptive methods. As people age, they are more likely to have health problems that can complicate pregnancy. Nonetheless, use of hormonal or device-based contraceptive methods (IUDs and implants), and permanent contraception, may entail potential risks.

Major Health Risks

Some contraceptive options, such as fertility awareness–based methods, are not associated with any serious health risks (beyond those associated with pregnancy via method failure). When it comes to the most serious outcome of all—death—the absolute level of risk is extraordinarily low for most people, and lower than the risks associated with pregnancy and birth. Other major health risks, such as blood clots, cancer, anaphylactic reactions, or serious infections, are uncommon. People with underlying medical conditions may have greater health risks from contraception, yet also may have greater health risks from pregnancy. The US Medical Eligibility for Contraceptive Use provides information about the safe use of contraception for individuals with selected medical conditions (see https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html) 

Risk of Death with Combined Oral Contraceptive Use

Studies using data from the 1990s and earlier compared mortality among users and users of COCs. Some early studies found increased mortality risks among older users and smokers, and especially users who were in both groups.(4-6) Many early studies were based on older formulations using far higher doses of hormones (specifically ethinyl estradol) than found in pills used today. More recent large-scale analyses have found no increase in all-cause mortality associated with oral contraceptive use either in the short term or in the long term.(6-9)

Comparing Risks of Contraceptive Use to Risks of Pregnancy

It may be useful to weigh the low risks associated with COCs and permanent contraception against the risks associated with carrying a pregnancy to term and delivery. The risk of death associated with COC use is 0.06 in 100,000 among nonsmoking users aged 15–34, and 3 in 100,000 for those aged 35 to 44; for smokers aged 15–34, the risk is 1.7 in 100,000.(6)  The risk of death among those undergoing fallopian tube surgery for permanent contraception is 1.5 in 100,000.(10) 

The most recent data available, from 2019, show an increasing maternal mortality rate in the United States.(11)  Among all women, there were 20.1 deaths due to maternal causes for every 100,000 live births. Risks are substantially higher for Black women and older women. The maternal mortality rate for non-Hispanic Black women was 44 deaths per 100,000 live births, 2.5 times the rate for non-Hispanic White women (17.9) and 3.5 times the rate for Hispanic women (12.6). Maternal mortality rates also increased with maternal age, from 12.6 for women younger than age 25, to 19.9 for those aged 25–39, and 75.5 for those aged 40 and older. The mortality risk for women aged 40 and older was 6 times higher than the rate for women younger than age 25. 

The risk of death associated with legal abortion is low, approximately 0.6 in 100,000; this varies by gestational age and method (medication or surgical).(12,13)   However, the risks of unsafe abortion are substantially greater. The risk of death is 55 per 100,000 unsafe abortions worldwide, accounting for 70,000 deaths per year.(14)  As access to abortion is restricted, the proportion of individuals seeking unsafe abortion increases.

Cardiovascular Disease

Use of combined hormonal contraceptives (CHCs), including COCs, the patch, and vaginal ring, as well as injectable contraceptives, are associated with an increased risk of arterial and venous thromboembolism (ATE and VTE). The most serious thrombotic events, myocardial infarction (MI) and stroke, are extremely rare and much less common than deep venous thrombosis (DVT). Smoking significantly increases the risk of MI, especially in users older than age 35. However, evidence is mixed regarding an increased risk of MI among CHC users of any age who do not smoke and do not have hypertension or diabetes.(15.16)  The risk of stroke in normotensive nonsmokers younger than age 35 may not be increased by use of CHCs,(4,7) except potentially in those with certain medical conditions such as migraines with aura.(18)  The risk of VTE is increased by certain contraceptive methods (two-to fourfold for DMPA, two-to sixfold for COCs, and higher for patches and vaginal rings),(19,20) but the absolute risk is low, ranging from 2 events per 10,000 woman-years among those aged 15 to 19, to 7 events per 10,000 woman-years among those aged 45 to 49.(21,22)

Cancer

Many clients have concerns about the effect of hormonal contraception on cancer risk. COCs are the best studied, as they were the first hormonal method available in the United States. Given that cancer incidence increases with age, and clients potentially use hormonal contraception for several decades, methods must be available on the market for long periods of time before researchers can identify increases in risk, especially when those increases are small. 

At the population level, the net effect of COC use across all cancers is neutral,(23-26)  and ever-users of COCs have a significantly lower death rate from all cancers than do never-users.(7)  Use of COCs (and presumably the patch and ring as well) protects users against cancers of the endometrium and ovary. Longer duration of use increases that protection. A comprehensive review concluded that use of COCs is associated with an increased risk of cancer of the cervix and liver, an increased risk of breast cancer in young women (equivalent to the risk with pregnancy), and a decreased risk of colorectal cancer.(23)  The risk of death is lower among ever-users of COCs than never-users for colorectal,(7.25) uterine,(7,8) ovarian,(6,7) and lymphatic and hematopoietic(25) cancer. Moreover, COC use has neither a harmful nor a beneficial effect on breast cancer mortality.(6,7,27) 

Fewer studies have evaluated cancer risk among users of progestin-only methods of contraception (including POPs, injectables, implants, and levonorgestrel-releasing IUDs). Use of injectable contraception, and likely other progestin-only methods, substantially reduces the risk of endometrial cancer.(28)  Though some studies have identified an increased risk of breast cancer for some progestin-only methods,(29-33)  a 2016 systematic review concluded that progestin-only methods of contraception do not appear to increase the risk of breast cancer.(34)

References

1. Jarvis L. Birth control has a TikTok problem. Bloomberg, April 11, 2024. https://www.bloomberg.com/opinion/articles/2024-04-11/tiktok-spreads-birth-control-falsehood-doctors-should-fight-back?embedded-checkout=true&leadSource=uverify wall
2. Bradley S, Polis C, Micks E, Steiner M. Effectiveness, safety, and comparative side effects. In: Cason P, Cwiak C, Edelman A, et al (Eds.). Contraceptive technology. 22nd edition. Burlington, MA: Jones-Bartlett Learning, 2023.
3. Nelson AL, Shabaik S, Xandre P, et al. Perceptions of health risks associated with pregnancy compared to oral contraceptive use. Contraception. 2019;100(3):193-5. DOI: 10.1016/j.contraception.2019.04.008. 
4. Haemorrhagic stroke, overall stroke risk, and combined oral contraceptives: results of an international, multicentre, case-control study. WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet. 1996;348(9026):505-10. 
5. Schwingl PJ, Ory HW, Visness CM. Estimates of the risk of cardiovascular death attributable to low-dose oral contraceptives in the United States. Am J Obstet Gynecol. 1999;180(1 Pt 1): 241-9. DOI: 10.1016/s0002-9378(99)70182-1. 
6. Vessey M, Painter R, Yeates D. Mortality in relation to oral contraceptive use and cigarette smoking. Lancet. 2003;362(9379):185-91. DOI: 10.1016/S0140-6736(03)13907-4. 
7. Hannaford PC, Iversen L, Macfarlane TV, Elliott AM, Angus V, Lee AJ. Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners’ Oral Contraception Study. BMJ 2010;340:c927. DOI: 10.1136/bmj.c927. 
8. Charlton BM, Rich-Edwards JW, Colditz GA, et al. Oral contraceptive use and mortality after 36 years of follow-up in the Nurses’ Health Study: prospective cohort study. BMJ 2014;349:g6356. DOI: 10.1136/bmj.g6356. 
9. Nur U, El Reda D, Hashim D, Weiderpass E. A prospective investigation of oral contraceptive use and breast cancer mortality: findings from the Swedish women’s lifestyle and health co- hort. BMC Cancer 2019;19(1):807. DOI: 10.1186/s12885-019-5985-6. 
10. Escobedo LG, Peterson HB, Grubb GS, Franks AL. Case-fatality rates for tubal sterilization in U.S. hospitals, 1979 to 1980. Am J Obstet Gynecol. 1989;160(1):147-50. DOI: 10.1016 /0002-9378(89)90108-7. 
11. Hoyert D. Maternal mortality rates in the United States, 2019. NCHS Health E-Stats. 2021. DOI: https://doi.org/10.15620/cdc:103855. 
12. Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012;119(2 Pt 1):215-9. DOI: 10.1097/AOG.0b013e 31823fe923. 
13. Zane S, Creanga AA, Berg CJ, et al. Abortion-related mortality in the United States: 1998-2010. Obstet Gynecol. 2015;126(2):258-65. DOI: 10.1097/AOG.0000000000000945. 
14. Shah I, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. J Obstet Gynaecol Can 2009;31(12):1149-58. 
15. Lewis MA. Myocardial infarction and stroke in young women: what is the impact of oral contraceptives? Am J Obstet Gynecol. 1998;179(3 Pt 2):S68-77. DOI: 10.1053/ob.1998.v179 .a93122. 
16. Lidegaard Ø, Løkkegaard E, Jensen A, Skovlund CW, Keiding N. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med. 2012;366(24):2257-66. DOI: 10.1056/NEJMoa1111840. 
17. Ischaemic stroke and combined oral contraceptives: results of an international, multicentre, case-control study. WHO Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet. 1996;348(9026):498-505. 
18. Horton LG, Simmons KB, Curtis KM. Combined hormonal contraceptive use among obese women and risk for cardiovascular events: A systematic review. Contraception. 2016;94(6): 590-604. DOI: 10.1016/j.contraception.2016.05.014. 
19. James AH. Pregnancy, contraception and venous thromboembolism (deep vein thrombosis and pulmonary embolism). Vasc Med. 2017;22(2):166-9. DOI: 10.1177/1358863X176 90601. 
20. Tepper NK, Whiteman MK, Marchbanks PA, James AH, Curtis KM. Progestin-only contraception and thromboembolism: A systematic review. Contraception. 2016;94(6):678-700. DOI: 10.1016/j.contraception.2016.04.014. 
21. Lidegaard Ø, Løkkegaard E, Svendsen AL, Agger C. Hormonal contraception and risk of venous thromboembolism: national follow-up study. BMJ 2009;339:b2890. DOI: 10.1136 /bmj.b2890. 
22. Heinemann LA, Dinger JC. Range of published estimates of venous thromboembolism incidence in young women. Contraception. 2007;75(5):328-36. DOI: 10.1016/j.contraception .2006.12.018. 
23. Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. Am J Obstet Gynecol. 2004;190(4 Suppl):S5-22. DOI: 10.1016/j .ajog.2004.01.061. 
24. Hannaford PC, Selvaraj S, Elliott AM, Angus V, Iversen L, Lee AJ. Cancer risk among users of oral contraceptives: cohort data from the Royal College of General Practitioners’ oral contraception study. BMJ 2007;335(7621):651. DOI: 10.1136/bmj.39289.649410.55. 
25. Iversen L, Sivasubramaniam S, Lee AJ, Fielding S, Hannaford PC. Lifetime cancer risk and combined oral contraceptives: the Royal College of General Practitioners’ Oral Contraception Study. Am J Obstet Gynecol. 2017;216(6):580.e1-9. DOI: 10.1016/j.ajog.2017.02.002. 
26. Vessey M, Yeates D, Flynn S. Factors affecting mortality in a large cohort study with special reference to oral contraceptive use. Contraception. 2010;82(3):221-9. DOI: 10.1016/j .contraception.2010.04.006. 
27. Wingo PA, Austin H, Marchbanks PA, et al. Oral contraceptives and the risk of death from breast cancer. Obstet Gynecol. 2007;110(4):793-800. DOI: 10.1097/01.AOG.0000284446 .22251.6e. 
28. Mueck AO, Seeger H, Rabe T. Hormonal contraception and risk of endometrial cancer: a systematic review. Endocr Relat Cancer 2010;17(4):R263-71. DOI: 10.1677/ERC-10-0076. 
29. Li CI, Beaber EF, Tang MT, Porter PL,DalingJ R, Malone KE.  Effect of depo-medroxyprogesterone acetate on breast cancer risk among women 20 to 44 years of age. Cancer Res 2012;72(8): 2028-35. DOI: 10.1158/0008-5472.CAN-11-4064. 
30. Urban M, Banks E, Egger S, et al. Injectable and oral contraceptive use and cancers of the breast, cervix, ovary, and endometrium in black South African women: case-control study. PLoS Med. 2012;9(3):e1001182. DOI: 10.1371/journal.pmed.1001182. 
31. Soini T, Hurskainen R, Grénman S, Mäenpää J, Paavonen J, Pukkala E. Cancer risk in women using the levonorgestrel-releasing intrauterine system in Finland. Obstet Gynecol. 2014; 124(2 Pt 1):292-9. DOI: 10.1097/AOG.0000000000000356. 
32. Soini T, Hurskainen R, Grénman S, Mäenpää J, Paavonen J, Pukkala E. Impact of levonorgestrel-releasing intrauterine system use on the cancer risk of the ovary and fallopian tube. Acta Oncol 2016;55(11):1281-4. DOI: 10.1080/0284186X.2016.1175660. 
33. Kaunitz AM. Depot medroxyprogesterone acetate contraception and the risk of breast and gynecologic cancer. J Reprod Med 1996;41(5 Suppl):419-27. 
34. Samson M, Porter N, Orekoya O, et al. Progestin and breast cancer risk: a systematic review. Breast Cancer Res Treat 2016;155(1):3-12. DOI: 10.1007/s10549-015-3663-1.