Health: A bitter pill to swallow

A knee-jerk response to research findings can sometimes have catastrophic consequences. By Annabel Ferriman
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Last week it was revealed that pregnant women who drank as little as one glass of wine a day could be causing neurological damage to their babies. Did the Department of Health immediately call a press conference and alert all doctors to the research through a personal letter? Of course it didn't. And quite right, too, since such pieces of research are published every day of the week in learned journals across the world. Some findings are confirmed by later research and some aren't. Some turn out to apply to thousands of people; some to only a handful. Some findings matter; some don't.

Yet three and a half years ago, when a piece of research showed that women who took the most up-to-date contraceptive pills might be at a slightly increased risk of blood clots, the Department leapt into action. It sent out a letter to every GP in the country telling them to advise women to change their contraceptive. It then announced its move to the nation's press.

The immediate result, as we now know, was that thousands of women stopped taking the Pill and there were almost 30,000 extra unintended pregnancies; 14,000 more women than usual had abortions (some put it as high as 30,000, but that is debatable) and 12,500 more babies than usual were born.

This has been well publicised and probably contributed to the decision by the Department of Health to change its advice. The new official advice is that while women should be informed of these "very small risks", the type of Pill is for her, together with her doctor, to decide.

What has been less well aired is the fact that the 1995 episode is still having repercussions. Young women are still not as confident about taking the contraceptive pill as they were. "That sort of scare has two effects," says Ann Furedi, communications director of the British Pregnancy Advisory Service, Britain's largest provider of abortion services. "One is short term and the other long term.

"The immediate effect is to discredit certain brands of the Pill - in this case those containing gestodene and desogestrel, which are known as third generation pills - but, in the long term, it also creates a general sense of uncertainty. Women lose confidence in doctors and government experts. They say to themselves: `Yesterday, the experts thought that those brands were safe and today they don't. So which brands will they find problems with tomorrow?"'

Does it matter that confidence in the Pill has been shaken? Most family planning experts think that it does for two reasons: first, because the Pill's safety profile is extremely good (the risk of having a blood clot during pregnancy is twice as high as having one while on a third generation pill), and secondly, the Pill is a more reliable method of contraception than most others.

As for the Pill's safety, the research findings in 1995, which sparked the scare, could have been presented as good news rather than bad news, according to Furedi. The Health Department told the public that new research showed that women taking the third generation pills had an increased risk of blood clots, whereas it could have said that new research showed that the Pill was safer than previously thought.

"We all knew that the contraceptive pill carried a risk of venous thrombo- embolism. That has been known since the 1960s. All properly trained doctors should have informed their patients of that fact and normally advised anyone who had a history of blood clots not to take it. Doctors usually quoted the risk of a clot as being 30 in 100,000.

"The irony is that the research findings published in 1995, showed that even the third generation Pills, which were denounced as less safe, were safer than we had realised. The risk of a getting a blood clot with them turned out to be 25 in 100,000.

"But because the research showed that the older Pills, the second generation Pills, were even safer than that, the Government focused on the difference between the two generations of Pill, saying that the latest Pills almost doubled your chances of having a clot (the risk being 25 in 100,000, compared to 15 in a 100,000 with the older Pills).

"The Government could equally well have announced the study as good news instead of bad news. That would have given a more accurate picture," Ms Furedi adds.

But disillusionment with the contraceptive pill cannot be attributed only to the 1995 scare, according to Toni Belfield, director of information and research, at the Family Planning Association.

"We have to look more generally at what it is about hormonal contraception that women do not like and work out how to engender confidence in it. Women need time and information when they are trying to decide on which method of contraception to use and they need to see a trained and up-to- date professional.

"The calls we get to our helpline are depressing. Some women are given a prescription for the Pill with no advice, no information and without a blood pressure check.

"They often do not realise that if one type of Pill does not suit them, another might.

"The long-term study on the Pill, by Professor Valerie Beral of the Imperial Cancer Research Fund, published in the British Medical Journal in January, showed quite clearly that if women are properly selected and a proper medical history is taken, the Pill is extremely safe and effective."

So are there any women who should not take Pills containing gestodene or desogestrel? "Yes. Women who have had a thrombosis in the past, or who have a family history of thrombosis, who are seriously overweight or who have varicose veins, would be better on another method of contraception or on the progestogen-only Pill," says Walli Bounds, research co-ordinator of the Margaret Pyke Centre, London. "But that has been known for a long time. It is true now but it was also true before the 1995 episode."

Ann Furedi would like to see the Government, through the Health Education Authority, launch a campaign to restore confidence in the Pill. "A year after the scare, the proportion of women who said they would never consider the Pill as a method of contraception was a third, compared to only a quarter in 1993. We need to change perceptions.

"If the Health Education Authority devoted only half the resources that it devotes to persuading people to stay out of the sun because of skin cancer on informing people accurately about the Pill, the public health gain could be immense," she says.