So who should avoid the? Generally doctors have two classifications: absolute contraindications (women who under no circumstances should take the ) and relative contraindications (women who may be able to take the pill under close medical supervision). Several relative contraindications together may add up to an absolute contraindication.
- Thrombosis, or history of.
- Stroke, or history of.
- Coronary artery disease, or history of.
- Hepatic adenoma, or history of.
- Present impaired liver function.
- Malignancy of the breast or reproductive system. Pregnancy or possible pregnancy.
- Very severe migraine.
- Severe sickle-cell anaemia.
- Angina or other heart disease.
- Any high risk factors for thrombosis (e.g. abnormal blood fats, severe diabetes, very heavy smoker, aged over forty-five, very overweight, very high blood pressure).
- Pituitary gland disorder.
- Recent molar pregnancy.
- Recent abnormal, undiagnosed uterine bleeding. History of any serious condition caused by past pill-taking.
Obviously some of these conditions are transient, such as pregnancy or recent molar pregnancy. Others may be transient, such as obesity, very high blood pressure, and undiagnosed uterine bleeding. Some of the others, however, indicate that the woman should never take the pill at any stage of her life.
- Family history of cardiovascular disease. Diabetes.
- High blood pressure.
- Heavy smoker.
- Aged thirty-five to forty-five.
- Long history of pill use (10 years or more).
- Severe fluid retention (e.g. from kidney disease). Obesity.
- Scanty or absent periods (or history of).
- Severe .
- Use of drugs which interfere with the pill, or which the pill affects (e.g. some drugs used to treat TB and epilepsy).
- Severe headaches.
- Gallbladder disease.
- Gilbert’s disease.
- Surgery or childbirth within the last four weeks.
- Major injury, or large plaster cast, on calf of one or both legs.
- History of weight gain on the pill.
- Conditions likely to make the woman unreliable at taking the pill (e.g. mental retardation, alcoholism, major psychiatric problems, poor previous history of pill-taking).
- Severe .
- Severe epilepsy.
- Severe varicose veins or phlebitis (ordinary varicose veins should not need to prevent pill-taking).
Once the woman has been screened regarding the above contraindications and been found suitable for the pill, the chances of her developing any of the life-threatening conditions related to pill use are very small. However, all women given the pill should be taught the danger signs to watch out for, just in case. They are the following:
- Severe pain in one calf, especially if accompanied by swelling.
- Severe central or side chest pain. Unexplained breathlessness. Cough with bloodstained phlegm. Severe abdominal pain.
- Prolonged, severe, unusual headache, especially if this happens for the first time after starting the pill, or if it gets progressively worse each time, or if the headaches keep recurring.
- Bad fainting attack or other collapse.
- Sudden weakness or very marked numbness and tingling on one side of the body or face.
- Sudden disturbance of the eyesight or speech. Severe generalized skin .
- Sudden confinement to bed.
These signs are occasionally contracted to a mnemonic for easy memory-jogging; they spell out the word ACHES.
- Abdominal pain (severe).
- Chest pain (severe) or shortness of breath. Headaches (severe).
- Eye problems (blurred or lost vision).
- Severe pain in calf or thigh.
Notice, however, that these do not cover all the danger signs in the longer list. If any of these warning signs occur, stop pill-taking immediately and contact a doctor.
Some drugs, especially some of those for treating tuberculosis and epilepsy, can interfere with the pill’s functioning. In these cases, a higher dose pill or an alternative contraceptive may be necessary. Large doses of vitamin C (e.g. lg or more daily) can turn a low-dose pill into a high-dose one, so this kind of vitamin C intake is not recom-
mended for women on the pill. With some drugs the opposite effect occurs; the pill can interfere with the other drug’s efficacy. This can be true of some (not all) drugs taken for diabetes, anxiety, depression, high blood pressure and migraine. A few studies seem to show that pill-users may need to take in more vitamin B6. This is still being investigated.
The pill should be stopped, if at all possible, at least six weeks before having major surgery, and also for at least four weeks afterwards. This will help to reduce the risk of clotting in the legs. Obviously pill use will not prevent you from having emergency surgery if this becomes necessary, but extra vigilance will be needed. If you know you are going to have an operation, prepare yourself beforehand with an alternative contraceptive. Incidentally, none of the rhythm methods is satisfactory as a back-up to pill-taking, as dates, temperature and mucus signs will all be inaccurate.
Women who have used the pill for several years can be tempted to blame the method if they later discover that they are infertile. It is extremely unlikely that their condition can be blamed on the pill. Remember that roughly 1 woman in 10 will have great difficulty conceiving in any case, and you are unlikely to discover this until you have stopped the pill and tried to conceive — then it can be all too easy to blame the pill. Similarly, if you have left it for a long time before starting to try for children (e.g. middle to late thirties), then your fertility will have declined because of your age, just as it does with women using other (or no) forms of. The pill cannot restore you to a more fertile state than before you started it, any more than any other method of can. On average, full fertility returns about three months later than if stopping other methods of , but it may return immediately, even in the first few days of stopping the pill, especially if the woman is young — so be warned!
Many women are worried that if they conceive by accident while they are taking the pill, the baby will be dam aged. There was some concern about this a few years ago when there seemed to be some evidence that such babies had a higher incidence of neural tube defects (such as spina bifida). In 1981 a WHO major report concluded that if there was any risk, it was so small as to be immeasurable. However, twins did seem to be more common among such pregnancies. To be on the safe side, most doctors recommend that you stop the pill three months before you want to conceive and use an alternative method of contraception. You should also stop taking the pill immediately if you become pregnant or suspect that you might be; it is never a good idea to subject a developing baby to unnecessary drugs. All the evidence currently available shows that there is no adverse effect on children of women who have used the pill in the past, although it does seem that in these cases twins may be less common.