Should government talk more about the risks of hormonal contraception?

Depression, blood clots, disease and other harms take a back-seat to birth control.

Helen M. Alvaré | Nov 23 2016 | comment

A recent study suggesting a link between depression and hormonal contraception raises larger questions about the significant role that contraception plays in government programs offered largely to poor and young women. The peer-reviewed study found that among one million women with no prior history of depression or other major psychiatric disorders, users of hormonal contraceptives were 23 percent more likely than non-users to be prescribed anti-depressants or diagnosed as suffering depression. Much higher risks of depression were found among women using the contraceptive patch, the “ring,” and the hormonal IUD. Adolescents using combined oral contraceptives experienced an 80 percent higher relative risk of being prescribed an anti-depressant for the first time, compared to adolescents not using contraceptives. While causation cannot be clearly proven in such a study, the researchers found it difficult to find a social or reverse-causation scenario that could explain the increased risk among so many ages and types of contraception.

This new study is just one of many over the past several decades suggesting that, while contraception does not badly injure large numbers of women, neither is it without various physical and psychological side-effects and wider social consequences. Given these studies, it is helpful to consider how federal programs and materials present information to the public about the risks of hormonal contraception.

A close look at pertinent federal materials indicates that while the government occasionally acknowledges studies about the risks of contraception, its overall perspective can be characterized as exceedingly positive. Executive branch agencies continuously promote easier access to a wide variety of free or lower-cost contraceptives, often citing contraception as a paramount factor in women’s health and social freedom, on the conviction that “unintended” and closely-spaced pregnancies are public health threats. In partnership with the states, the federal government spends billions of dollars annually in programs that promote contraception, ranging from Title X’s Family Planning Program to Medicaid, Medicare, and the Teen Pregnancy Prevention Program. In connection with healthcare reform, the government now requires most employers to offer contraception, cost-free, to female employees and their daughters.

Federal factsheets about contraception briefly note some of the medical risks suggested by the last 40 years of research—blood clots and strokes, in particular—albeit they confine this discussion to post-partum women. But they do not refer to the giant class action lawsuits settled against the manufacturers of some contraceptive drugs and devices associated with these outcomes.

While contraception does not badly injure large numbers of women, neither is it without various physical and psychological side-effects and wider social consequences.

Government factsheets also acknowledge the significant health risks that hormonal contraception poses to women who smoke (15 percent of the population) and women who are obese (36 percent of the population). However, these materials typically do not mention the risk of depression, though the federal government has been aware of the hormones-depression link since the 1970s. They also fail to mention the risk of mood changes, even though this is a frequently-cited reason for many women who discontinue the use of contraception—a choice the government decries.

Perhaps the most prominent warning about risk in connection with any form of contraception comes in federal materials concerning Depo-Provera injections. The Womenshealth.gov website states:

The shot should not be used more than 2 years in a row because it can cause a temporary loss of bone density. The loss increases the longer this method is used. The bone does start to grow after this method is stopped. But it may increase the risk of fracture and osteoporosis if used for a long time.

Evidence about a link between hormonal contraception (especially Depo-Provera) and increased HIV transmission has also circulated for over 25 years. Currently, even though the World Health Organization has decided to continue recommending Depo-Provera (albeit combined with a condom), there remain significant scientific concerns that it facilitates HIV transmission. Still, any mention of this risk is absent from the contraception factsheet that the federal government offers to the public. This is so, even though the National Institutes of Health’s Contraceptive Development Program has awarded nearly $500,000 each year from 2013 to 2018 for the study of possible mechanisms by which Depo-Provera might increase HIV transmission.

Also missing from federal materials on contraception is the subject of the relationship between cheap and widely-available contraception and the possibility of increased sexual risk-taking by adolescents. Experts, including our current Federal Reserve chair Janet Yellen, have debated whether or not this so-called “risk compensation” phenomenon accounts for the rise in nonmarital and unintended births, which followed the legalization and widespread availability of contraception and abortion.

The most recent debate about the ethics and efficacy of federal contraception promotion centers upon long-acting reversible contraceptives (“LARCs”), which include the IUD, injections, and the implant. Buoyed by strong recommendations from think tanks, leading medical organizations, medical journals, and interest groups, the federal government is taking active steps to boost their usage among all women, but especially among the young and poor. Medicaid authorities have issued guidance letters urging Medicaid providers to “optimize” LARCs usage among the poor by means of effective reimbursement policies, fully-stocked inventories, and ensuring that doctors offer women “one-visit” access to LARCs and the opportunity for insertion immediately following labor and delivery.

Critics have a variety of concerns about LARCs, including concerns regarding: the ethics of promoting short-term sterilization to a population that is disproportionately poor, minority, and young; the evidence that greater usage of LARCs might drive up rates of sexually transmitted infections because LARCs do not protect against these, and because users tend to reduce their use of condoms; the side-effects of hormonal contraception; and the potential effects upon the future relationships of women and men who become accustomed to sex unlinked from children and marriage.

The federal government is not ignorant of the problems associated with contraception—whether LARCs or other forms. In 2014-2015, the National Institutes of Health issued a funding request for proposals for new, nonhormonal birth control options for women, citing women’s distaste and discomfort respecting existing forms. It states, in part:

Although 62% of reproductive age women in the US are using contraception, the unintended pregnancy rates and abortion rates continue to be high. … However, hormonal contraceptives have the disadvantage of having many undesirable side effects. In addition, hormonal contraceptives are associated with adverse events, and obese women are at higher risk for serious complications such as deep venous thrombosis. The oral contraceptive pill’s failure rate among American women ranges from 9-30%. … Furthermore, a recent report found that 40% of women were not satisfied with their current contraceptive method…

Alongside years of research linking hormonal contraception to serious health risks for women, the federal government continues its robust support for contraceptive drugs and devices based on its convictions that contraception promotes women’s freedom, will eventually lower unintended pregnancies, and might help prevent the birth of more children into poverty or disadvantageous family circumstances. Controversies about the health and social effects of separating sex from children in the public mind, and altering women’s reproductive biology will no doubt continue. An important part of this debate going forward is whether the federal government should continue to employ its considerable legal and funding authority to promote hormonal contraception without educating women about all the known risks. Only with complete information can women be fully empowered to decide for themselves whether the advantages of hormonal contraception outweigh the costs for individual women and for society.

Helen M. Alvare is a Professor of Law at George Mason University where she teaches and writes in the areas of family law, and law and religion.This article is reproduced with permission from the Institute for Family Studies blog.

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