Dr Katie Musgrave asks whether our eagerness to make contraception and HRT easily accessible has gone too far
Over 60 years ago, the contraceptive pill was available on the NHS to married women whose health was put at risk by pregnancy, at a doctor’s discretion. Today, hormonal contraception is broadly available to any woman of child-bearing age (given there are no significant contraindications), not least as pregnancy is always considered to pose a potential threat to women’s health. Today, society’s consensus is that women should have control of their reproductive rights.
I do sometimes wonder, however, if – in our eagerness to make contraception and HRT easily accessible – the pendulum might have swung too far? Have we medicalised womanhood, and somehow communicated the message that all women need to use a form of hormonal contraception during their child-bearing years, followed by HRT to navigate the menopause?
Many of my generation were taken to a GP in our teens and started on a pill ‘just in case’ we might become sexually active. It is still common practice for teenage girls or their parents to contact GPs about period problems, with the presumption that a doctor will immediately suggest the pill. Naturally, there will be some youngsters who are discreetly trying to access contraception, which should be explored and usually supported. However, I often see girls presenting with heavy or painful periods, where parents firmly believe that a contraceptive pill is the natural first step, or somehow a rite of passage to adulthood.
I wonder if we are informing young women how unpleasant the side effects of hormonal contraception can be? That they might suffer with significant mood swings, acne, breast tenderness (to name a few of the many possible side-effects)? That their libido may fall through the floor? That there are risks with using these medications (such as increased rates of breast cancer)? Or that having an unmedicated monthly cycle may be a positive thing- and some women genuinely enjoy the rhythm and mood changes that occur naturally? I am not sure we have been.
Of course, I’m not suggesting that women shouldn’t have easy access to contraception of all types; or that for certain groups these interventions don’t offer enormous benefits. I do think, however, that more women should understand that hormonal manipulation is not an essential part of womanhood. It is, for example, perfectly reasonable for women to opt to use barrier contraception (highly effective if used properly), or to monitor their cycles to help avoid unwanted pregnancy. Likewise, shorter bursts of contraception might be a preferred option over decades on a pill.
I daren’t stray too far into the menopause (lacking personal experience yet to draw on), but, clearly, medication is not always an essential part of passing through this life stage. The pharmaceutical industry may be keen that as many women use HRT (and now testosterone) as possible. The publishers of menopause books, apps, or prescribing guides also have skin in the game, and generally promote the medicalisation of this period of female lives. As GPs we are supposed to prescribe HRT for as long as we feel the benefits outweigh the risks (yet, in most cases, neither can be reliably quantified).
Women’s bodies have evolved to perform amazing feats. Menstrual cycles, pregnancy, childbirth, breastfeeding… These experiences are messy, often painful and difficult, but they can also be wonderful. I wouldn’t give up any of them, and if my body is destined to change in middle age – then so be it. It was worth it.
Medicine, within limits, can help us to live fulfilling and healthy lives. But it can overreach, even causing harm. I don’t believe it is necessary for women to start on a hormonal contraceptive aged 13, only to transition to a form of HRT in middle age, then perhaps stay on this decades. Where possible, women should be educated and helped to benefit from medical advances, without facing the hard sell of (potentially unnecessary) medication. Our hormones and bodies should not be viewed as an industry, ripe for exploitation. I am yet to be convinced we have found the right balance.
READERS' COMMENTS [6]
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Katie, I usually agree with what you write but you probably don’t have the personal or professional experience to back up your opinions in this article.
Medicine has evolved from doing useless or harmful things eg taking the waters or bleeding people, to benign minimal intervention and psychotherapy eg homeopathy, to curing disease eg cholera, appendicitis, to improving patient’s lives rather than just putting up with natural processes eg preventative mastectomy or oophorectomy and cardiovascular disease prevention. The pill and HRT are in the latter group.
Teenage pregnancies and therefore teenage abortion are at the lowest levels in my professional career (1977-1923). The pill and long acting contraception are the reason for this. The pill may give a 25% higher relative risk of breast cancer but it also gives a lower risk of bowel and other gynaecological cancers. Total mortality is improved in ever users compared to never users.
Teenage period problems are a major difficulty for sports and studying. Exam results matter. Work attendance matters. Periods are not termed the curse for nothing. I don’t know any woman who enjoys the chocolate cravings and irritability of the pre-menstrual phase or the pain and mess of the bleeding phase. Endometriosis and period pain can be banished with proper pill protocols using Loestrin 20 and continuous rather than phased coverage. I agree that energy is increased in the ovulation phase and that libido and mood can be affected by the pill.
Barrier methods often fail. They are okay to space families where the outcome of a pregnancy would not mean abortion. But when an abortion would be the result, then they should be adjunctive rather than the sole method. The Billings method, again, is okay if used to space a family but requires training and it simply is not reliable enough nor easy enough to adhere to.
The use of HRT needs to be considered for all women, particularly as life expectancy is much greater than previously. Its benefits include reduced cardiovascular disease, bowel cancer, osteoporotic limb fractures and spinal fractures, rheumatoid arthritis and dementia. There is less breast cancer in oestrogen only therapy. Harms include more breast cancer in combined users and increased stroke and DVTs and pulmonary emboli for all users. These benefits and risks need to be discussed with each woman. The decision needs to be primarily hers. Then we will have the right balance.
If you Katie, get enjoyment out of periods, pregnancy, childbirth, breast feeding and an unsupported menopause, then you are a remarkable individual and I wish you well. I personally dreaded periods, found that sub-par was the best I felt in pregnancy, opted for 2 sections instead of the torture and brutality of labour and delivery, and was delighted with my intact perineum and brain intact children. Breast feeding didn’t work. Thank heavens for formula.
I opted for total hysterectomy so I could take unopposed oestrogen for as long as I possibly can. This is the right decision for me. You may find Dr Guillebaud’s contraception book and the Menopause Matters online site informative. I wish you and your patients well.
I suppose nature (evolution) only cares that people have the desire to procreate and live long enough that they do so. If women suffer terribly to achieve this and afterwards is irrelevant (to nature). So in the words of the old guys from the movie Cocoon “f@&k nature”
That said I did enjoy and I understand the article (I think). If certain interventions become overwhelmingly normalised it can make those people who do not want to have said intervention feel abnormal? Am I right?
Unusually, I disagree with this Dr Musgrave commentary. Much of that disagreement is covered in Dr. Morrison’s response.
Dr Morrison is correct that a 25% increased Relative Risk (RR) of breast cancer had been reported but this was in the 2002 WHI study relating to adverse outcomes of combined HRT. However, it was in post-menopausal women, not in hormonal contraceptive users.
In the 2 arms of the study, reportedly 10,000 women in each, breast cancer cases were 40 in combined HRT users and 32 in non-users: the 8 difference being a 25% increased RR.
The Absolute Risk increase calculation = 8 more cases in 10,000, statistically non-significant.
In the oestrogen only arm of the study, there was no difference in the breast Ca risk.
The other pro’s & con’s quoted also relate to the post-menopausal group, not to contraceptive pill users and, from the same WHI study, they were of the same relative and absolute risk levels.
The WHI study was discredited around 2014 and it was then noted that many of the co-investigators had, because of disagreement in presentation, had their names removed from the study’s published authorship.
It is now reported that, in post-menopausal women, whatever risks exist they relate to the timing of the initiation of HRT and whether it is at the individual woman’s menopause or delayed (> 5yrs).
An interesting article and valid point of view. Trying as best we can to effectively manage symptoms in a patient centred empathic way whilst striving to avoid the harms of over medicalisation and over treatment is always hard.
I suspect we don’t consider this enough during medical education and GP training in this country. Dr Ray Moynihan in Australia has been pivotal in highlighting the role of modern medicine in undermining societies ability to cope with what might be termed life events previously, and the potential associated harms. The pharmaceutical industry has undoubtedly played a role in this as well.
That is of course not to say that the interventions you mentioned aren’t effective and indicated in many cases. The problem is often that objectivity can be significantly skewed by celebrity opinion or individual anecdote of doctors such as the one above or Dr Newson who have clearly had awful experiences.
The other issue of course is that whilst society may now have decreed that every female over 45 should be on HRT or offered it, along with every male of the same age offered a PSA and prostate examination, the ability to deliver this has never actually been more unattainable!
An interesting article. Womanhood is evolving and our bodies have not necessarily kept pace. . I must admit I might have had similar views to you before reaching the age myself of overwhelming brain fog, fractured sleep due to night sweats and new symptoms of incapacitating anxiety all whilst holding down a GP jrole, looking after my own young children and elderly relatives. HRT was life changing for me. . I often say to my patients that the challenges we face at middle age are different to those of our mother’s and grandmothers. Todays generation of menopausal women seeking help have often put their career first before having a family resulting in a collision of life pressures just when they become deplete of oestrogen. Since becoming more interested in HRT after my own experiences and typically attracting a cohort of similarly aged patients I have started to explore if there are additional measures we should address when considering treating patients and I am becoming increasingly convinced that the more sedentary lives we lead with high pressure jobs and unhealthy diets are probably adding to the burden of menopausal symptoms. Arguably, much like type 2 DM management, should we be considering and addressing women’s metabolic health ibefore or at least at the same time as handing out HRT?
I don’t have a problem prescribing HRT, but I don’t get the downplaying of the cancer risk, and this is rarely mentioned when it’s being pushed. Whilst the risks may be small, they cannot be considered insignificant – breast cancer can be a death sentence.