The pill should not be viewed as a daily vitamin but as a drug, approached with the same kind of informed skepticism applied to other medications.
The pill should not be viewed as a daily vitamin but as a drug, approached with the same kind of informed skepticism applied to other medications.
T he pill is an immensely popular and ubiquitous form of birth control among American women. It has become so accepted and so habitual that the question asked about other medicines — Do the potential benefits outweigh the potential risks? — is not asked nearly enough of hormonal contraception.
Nearly every woman in America has used contraception at some time in her life. According to a 2022 study, nine out of ten American women between the ages of 18 and 64 have used contraceptives during their reproductive years. According to the CDC’s 2017–19 National Survey of Family Growth, 65 percent of women between the ages of 15 and 49 were actively using contraception. The most common contraceptive methods are female sterilization (18.1 percent), followed by oral contraceptive pills (14.0 percent) and long-acting reversible contraceptives (LARCs) (10.4 percent). Assuming that 2024 statistics are similar, it’s fair to say that over one-quarter of the female population in the U.S., ages 15 to 49, uses hormonal contraception, whether pills, LARCs (e.g., an intrauterine device or arm implant), injections, rings, or patches.
Among women under 30, “the pill” is the most commonly used form of contraception. Nearly 20 percent of women ages 15 to 19, and nearly 22 percent of women ages 20 to 29, are on the pill, which is prescribed in several formulations, each with potentially different side effects. There are two main versions: a combination pill that contains both estrogen and progestin (a synthetic form of progesterone) and a “minipill” that contains only progestin.
By releasing artificial versions of naturally occurring hormones that regulate the menstrual cycle, hormonal contraceptives tell the body to skip the step of the menstrual cycle when the ovaries release an egg. While women may opt to take a week of placebos during their monthly regimen, enabling the female reproductive system to complete its monthly cycle, they will not have a real period, just the shedding of the uterus lining.
According to a 2014 study, the hormone levels (associated with the ability to make mature, healthy eggs) of younger women on the pill are more similar to those of older women than those of younger women who don’t use hormonal contraceptives. Women on the pill also have fewer structures in their ovaries that can mature into viable eggs.
If a woman is trying to get pregnant, her body needs time to return to normal hormonal levels after stopping use of hormonal contraceptives. While there is no significant difference in fertility among women who have used hormonal contraceptives previously and those who have not, it is true that the prior use of such contraceptives can cause a delay in a woman’s ability to become pregnant.
The most widespread problems associated with hormonal birth control, particularly the pill, are its side effects, psychological or physical. Women commonly report depression, anxiety, migraines, and mood swings, along with hair loss, weight gain, nausea, hot flashes, and acne.
The pill has long been prescribed for reasons other than preventing pregnancy. It has been a catch-all for natural problems that occur when girls begin puberty (such as acne, irregular periods, and cramps). Among the teens ages 15 to 19 who are prescribed birth-control pills, 82 percent receive prescriptions for non-contraceptive purposes; 33 percent of teenage girls in that same group are prescribed the pill for non-contraceptive purposes only (e.g., to clear her acne or regulate her cycle).
It’s not uncommon for a girl’s cycle to be irregular, particularly if she just went through puberty. Would she be “healthier” if the ingestion of hormones mechanically regulated her cycle, or if her body was left to naturally regulate itself? Of course, this must be determined on a case-by-case basis, but is the question even being asked? Certainly the pill has offered relief to girls suffering from severe acne and other problems, but were there other options not explored?
Very few studies exist that systematically review the correlations between the particular chemical formulation of the oral contraceptive in question and the reported side effects.
In France, however, a study showed that third- and fourth-generation birth-control pills (those with more synthetic progestin) were much more likely than second-generation pills to cause critical strokes or blood clots. In 2013, the French government removed the newer formulations from its list of reimbursed medications (a list maintained under the country’s universal-coverage system). Prescriptions for the newer version dropped by almost half.
My argument is not that hormonal birth control is especially risky, but that women should be more aware that it is not without risk. Oral contraceptives — like all other medicines — can have negative side effects. This simple fact is often masked by how often — and for what — the pill is prescribed, and by the push to make the pill accessible over the counter.
So how does hormonal birth control compare to other OTC medications?
Let’s take the example of acetaminophen, a common pain medication (the generic form of Tylenol and an ingredient in drugs such as Dayquil).
According to one recent study, “acetaminophen toxicity is responsible for 56,000 emergency department visits, 2,600 hospitalizations, and 500 deaths per year in the United States. Fifty percent of these are unintentional overdoses. More than 60 million Americans consume acetaminophen on a weekly basis, and many are unaware that it is contained in combined products.”
When we take out unintentional overdoses, there are approximately 250 unintentional deaths per 60 million American consumers of acetaminophen. In other words, approximately one out of every 240,000 Americans who regularly use acetaminophen dies unintentionally from acetaminophen toxicity.
Let’s compare that with aspirin, a non-steroidal anti-inflammatory drug (NSAID) used as a blood thinner, pain reliever, and fever reducer. Because it helps to prevent blood clots and heart attacks, it is certainly a net good. But thousands of aspirin users die each year because of some negative side effect of the drug — most often, gastrointestinal bleeding.
A 2005 study noted that in the U.S., there were an estimated 443 deaths per million users of aspirin or other NSAIDs that were attributed to NSAID/aspirin-associated gastrointestinal complications. That mortality rate — one death per 2,250 NSAID/aspirin users — seems awfully high, but the bulk of aspirin-associated fatal GI complications occur in patients over 70. According to a 2017 study by Oxford University, those over the age of 75 who take the blood-thinning pills are ten times more likely than younger patients to suffer disabling or fatal bleeds.
In short, regular aspirin use significantly increases a user’s risk of major gastrointestinal or cerebral bleeding episodes. Data from 2018 suggest “that caution should be exercised in more frequent use.”
Now, let’s turn to hormonal contraceptives.
It is estimated that 300–400 healthy women die each year in the United States as a result of using hormonal contraceptives. The leading cause of death is venous thrombosis — a blood clot that forms in some part of the body and then travels to the lungs, heart, or brain.
The number of deaths caused by hormonal contraceptives is hard to calculate for several reasons, a major one being that their negative side effects — even death — are underreported. When asked by a health-care provider about what drugs they take, many women don’t mention hormonal contraceptives such as the pill because they don’t view birth control as medication.
Assuming the offered estimate is conservative because of underreporting, I will use the upper end to calculate deaths per user. If 400 out of 17 million women die annually as a result of hormonal-contraceptive use, that means one out of every 42,500 healthy women who use such birth control dies because of taking it. Thus, more women who take hormonal contraceptives as prescribed die each year as a side effect of use than people who take acetaminophen as recommended die as a side effect of use.
A British professor of cardiovascular medicine told the Telegraph that, “although bleeding is a well-recognised side effect of aspirin, this drug is still seen by many people as harmless, perhaps because of how easily it can be bought over the counter. Prescription of any drug is a balance between the benefits of the medication against its risks, and aspirin is no different.”
The same holds true for hormonal contraceptives. For the health of women everywhere, the pill should not be viewed as akin to a daily vitamin but as a drug — one that should be approached with the same kind of informed skepticism applied to other medications. It is odd that, in discussion of women’s health, this point tends to get lost. The widespread, unquestioned use of hormonal contraceptives deserves more serious thought.