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Against the pill

A consumer's guide to the pill cover image

A consumer's guide to the pill and other drugs. John Wilks. Stafford VA: ALL Inc 1997 (xi + 346 pp.). ISBN: 1 890712 25 6.

 This is a very difficult book to review in the present climate of emphasis on evidence-based medicine -- much of the material is emotive and many of the references are newspaper accounts of interviews with women and scientists.

Many of the data on contraceptive methods are quoted correctly but emphasise negative findings without a balanced account of benefits and risks. For instance, the author provides data related to the possible increase in incidence of thromboembolism in users of third-generation combined oral contraceptive pills, but fails to mention the possible role of these combinations in reducing the risk of myocardial infarction.

In relation to breast cancer and oral contraceptive use, Wilks concludes that "early-age use of the pill carries a greater risk of breast cancer, of developing larger tumours and having a worse prognosis". This flies in the face of a study published in the Lancet in 1996,1 regarded as the most definitive to date, while quoting correctly from smaller but less definitive studies. The 1996 study reanalysed data from 54 other studies comparing the incidence of pill use in 53 297 women with breast cancer with over 100239 women without breast cancer. These concluded that women taking the pill had a slightly increased risk of breast cancer during usage and in the 10 years after cessation (relative risk ranging from 1.24 in current users to 1.07 5 to 9 years after cessation); that this risk returned to the normal risk for age 10 or more years after stopping oral contraceptives; and that, if breast cancer occurred in women taking the pill, it had a significantly better prognosis than in women who had never used combined oral contraceptive pills. The group also concluded that, for women taking the pill between the ages of 20 and 24, there would be a likelihood of 1.5 extra cancers developing per 10 000 women during the whole period of pill use and in the 10 years after stopping the pill.

Similarly, Wilks quotes from Van der Vange's work in women taking combined low-dose oral contraceptives,2 but uses these data to promote his theory that, in many instances, the pill acts as an abortifacient (by preventing implantation), and that erratic timing of pill-taking decreases the effect of progestogens on the viscosity of cervical mucus. These are assertions for which there is no scientific basis.

Based on a number of recalls of faulty condoms, he also makes the claim that "condoms cannot be made without naturally occurring holes", and suggests that quality control is poor. One could equally interpret the recalls as good quality control, ensuring faulty condoms are detected and batches recalled. The manufacturing standards for condoms are in fact very high.

The author purports to provide users with true facts about contraception and fertility drugs, and to counteract the "incomplete" data presented by pharmaceutical companies and health professionals. However, given the biased slant of this information, I would not recommend this book.

Edith Weisberg
Director of Research
Sydney Centre for Reproductive Health Research
Family Planning NSW, Sydney, NSW

 

  1. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal contraceptives. Lancet 1996; 347: 1713-1727.
  2. Van der Vange N. Ovarian activity in low dose oral contraceptives. In: Chamberlain G (editor). Contemporary obstetrics and gynaecology. London: Butterworths 1988, 317-326.
Author's response To the Editor: I thank the Journal for carrying a review1 of my book A consumer's guide to the pill and other drugs. However, in my view, Weisberg has made five verifiable errors of fact.

First, in support of her claim that my text is not evidence-based, Weisberg says "many of the references are newspaper accounts of interviews with women and scientists". This implies my book lacks scientific rigour. However, of the 375 sources listed in the bibliography, only 47 (12.5%) were from newspapers, radio interviews or "glossy" magazines. Lay media reports were principally used to develop illustrative case studies, in part because they provided coronial details. Furthermore, as the last chapter dealt heavily with the role of the media in the (mis)reporting of health issues regarding the pill, hormone replacement therapy, or RU-486, newspaper or magazine citations surely were de rigueur.

The remaining 328 sources (87.5% of the total) came from the Lancet (50 articles), JAMA (11), New England Journal of Medicine (14), British Medical Journal (14), American Journal of Epidemiology and other epidemiology journals (14), American Journal of Obstetrics and Gynecology and other gynaecology journals (23), and British Journal of Cancer and other cancer journals (25). Other respected primary sources (eg, British Journal of Haematology) comprised the remainder.

Second, Weisberg stated I failed to mention the possible role of third-generation progestogens "in reducing the risk of myocardial infarction". Not so. I referred to the study by Lewis et al,2 summarising it thus: "Their results indicated that ... third-generation products marginally decreased a woman's risk of myocardial infarction compared with second-generation pill users."

Third, Weisberg stated I offered "no scientific basis" to my claim that poor patient compliance "decreases the effect of progestogens on the viscosity of cervical mucus". Again, not so. Two references as to unreliability of the POP were provided, one from Sparrow3 and one from Weisberg.4

Fourth, in proposing the hypothesis that breakthrough ovulation could lead to an abortifacient action due to an unreceptive endometrium, I discussed two articles, the second by Grimes et al.5 Weisberg indicated I cited only one.

Fifth, Weisberg suggested that I made the conclusion that "early-age use of the pill carries a greater risk of breast cancer, of developing larger tumours and having a worse prognosis". This is incorrect. These conclusions were made by Olsson et al,6 Ranstam et al,7 and Olsson et al.8 They used the phrases "larger breast tumours", "worse prognosis", and "worse survival". I quoted from these studies.

Flowing from this error of attribution, Weisberg writes extensively against my apparent omission of the Collaborative Group study.9 Yet I did cite it, and discussed the main finding of a 24% increased risk of breast cancer, though I was critical of the study on the grounds it "pooled" data for young and old women, groups which have different risk profiles.

I conclude by noting that Professors of Applied Mathematics, Medical Ethics and Pharmacology/Toxicology, an obstetrician/gynaecologist, a consultant physician/medical oncologist and five GPs reviewed my book before publication.

John Wilks
Author, Assistant Editor, Micromedex International Editorial Board
Shop 1, 36 Johnson Avenue, Seven Hills, NSW 2147

 

  1. Weisberg E. Against the pill [book review]. Med J Aust 1999; 171: 209.
  2. Lewis MA, Spitzer WO, Heinemann LA, et al. Third generation oral contraceptives and risk of myocardial infarction: an international case-control study. Transnational Research Group on Oral Contraceptives and the Health of Young Women. BMJ 1996; 312: 88-90.
  3. Sparrow MJ. Pregnancies in reliable pill takers. N Z Med J 1989; 102: 575-577.
  4. Weisberg E. Oral contraceptives: fine tuning clinical use. Patient Management 1988; July: 19-35.
  5. Grimes DA, Godwin AJ, Rubin A, et al. Ovulation and follicular development associated with the low-dose oral contraceptives: a randomized controlled trial. Obstet Gynecol 1994; 83: 29-34.
  6. Olsson H, et al. Early oral contraceptive use and breast cancer in Southern Sweden. Proc Annu Meet Am Soc Clin Oncol 1989; 8: A367.
  7. Ranstam J, Olsson H, Garne JP, et al. Survival in breast cancer and age at start of oral contraceptive usage. Anticancer Res 1991; 11: 2043-2046.
  8. Olsson H, Ranstam J, Baldetorp B, et al. Proliferation and DNA ploidy in malignant breast tumors in relation to early oral contraceptive use and early abortions. Cancer 1991; 67: 1285-1290.
  9. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 epidemiological studies. Collaborative Group on Hormonal Factors in Breast Cancer. Lancet 1996; 347: 1713-1727.

 

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