- 1Department of Pharmacy, Faculty of Pharmacy and Nutrition, Catholic University of Murcia (UCAM), Murcia, Spain
- 2“Pharmacokinetics, Patient Care and Translational Bioethics” Research Group, Faculty of Pharmacy and Nutrition, Catholic University of Murcia (UCAM), Murcia, Spain
- 3Bioethics Chair, Faculty of Medicine, Catholic University of Murcia (UCAM), Murcia, Spain
Hormone-based contraception disrupts hormonal balance, creating artificial states of anovulation and threatening women's health. We reviewed its main adverse effects and mechanisms on accelerated ovarian aging, mental health (emotional disruptions, depression, and suicide), sexuality (reduced libido), cardiovascular (brain stroke, myocardial infarction, hypertension, and thrombosis), and oncological (breast, cervical, and endometrial cancers). Other “collateral damage” includes negative effects on communication, scientific mistrust, poor physician–patient relationships, increased patient burden, economic drain on the healthcare system, and environmental pollution. Hormone-sensitive tumors present a dilemma owing to their potential dual effects: preventing some cancers vs. higher risk for others remains controversial, with denial or dismissal as non-relevant adverse effects, information avoidance, and modification of scientific criteria. This lack of clinical assessment poses challenges to women's health and their right to autonomy. Overcoming these challenges requires an anthropological integration of sexuality, as the focus on genital bodily union alone fails to encompass the intimate relational expression of individuals, complete sexual satisfaction, and the intertwined feelings of trust, safety, tenderness, and endorsement of women's femininity.
1. Introduction
If an event in nature abides by perfect synchronization to ensure a successful outcome, it is reproduction. All female physiological and biochemical processes related to fertility and the possibility of pregnancy are highly regulated, maintaining a precise hormonal balance throughout the duration of a menstrual cycle (1–3). The synchronized hormonal secretion along the menstrual cycle triggers the physiological conditions of the endometrium to receive the fertilized ovum and provide “food and shelter” to allow it to reach maturity (4–6).
When pregnancy, lactation, or menopause are not the causes of persistent irregularities in the menstrual cycle, it is likely that they are associated with stress and lifestyle, endocrine disorders, gynecological, nutritional, genetic, and even iatrogenic factors (7). This situation may disrupt the precise hormonal balance, giving rise to pathological situations that may deserve medical attention, including polycystic ovary syndrome, diabetes, Cushing's syndrome, and hypothyroidism (3). Therefore, a regular menstrual cycle is an indicator of health in women (6). Conversely, some factors facilitate regulation and normal ovulation (e.g., healthy behavior and lifestyle, calm in the face of stress, restoration of normal conditions of pathological processes, and so on), including the evaluation of specific personal needs (7).
Thus, any interference with the hormonal cycle would prevent either ovulation or implantation and constitute the pharmacological basis for all hormone-based contraceptive (HBC) methods. Therefore, understanding hormonal regulation and the evolution of the ovaries is essential to assessing the impact of HBC on women's health, including oocyte aging and the ovary reserve. When the development of physiology follows its natural course, organs or tissues evolve over time, affecting their functionality. If any tissue or organ undergoes intervention, it can be affected either positively (to restore lost functionality due to a pathology) or negatively (as trauma or infection may reduce the functionality of that organ).
The ovaries also undergo some stages that determine their functionality (8). During childhood, the follicles develop progressively, and it is not until puberty that an increase in gonadotropic hormones occurs, giving rise to a pre-ovulatory state and the first ovulation at around 12–13 years of age (8, 9). Until then, anovulation is a normal manifestation of a girl's health. From that moment onward, cyclical ovarian activity begins, which may present some irregularities until the woman is approximately of 18 years of age. During adolescence, menstrual cycle irregularities are considered healthy and normal, while the hypothalamic-pituitary axis activity gradually increases until it becomes regular, which is typical of a woman's fertile age. This cyclical activity remains regular in healthy women until ovarian functionality decreases, as does the hypothalamic-pituitary axis activity, which gradually enters a pre-menopausal period that may last several years. During this period, there is an increase in estrogen levels, promoting the growth of endometrial tissue associated with increased blood flow, irregular bleeding, and the loss of fertility, giving way to menopause.
The aging of the ovaries in women follows normal organ evolution, reducing the quantity and quality of the oocytes (10–12). A unique physiological feature of ongoing change is the “ovarian reserve,” or the ovarian capacity to generate ovules that can be fertilized (13–15). This capacity can be assessed by biomarkers that indicate the status quo of the ovaries: antimulerine hormone (AMH), antral follicle count (AFC), and ovary volume. The follicles secrete AMH, and its serum value reflects how many valid eggs remain in the woman's ovaries (16) regardless of the woman's fecundability (17); the AFC and the volume of the ovaries are determined by ultrasound. These biomarkers assess the ovarian status to evaluate fertility problems in women who use or have used oral contraceptives (12, 18–20).
All this information places a responsibility on healthcare providers, including the pharmaceutical industry (21), to better understand the impact of HBC, provide adequate information to women users, and empower them to lead a healthy and satisfactory sexuality of their choice.
1.1. Historical context: medicine, culture, and society
The first HBC introduced in the late 1950s combined high doses of estrogen and progestogen but was eventually modified (22). Current HBCs have lower doses and introduce temporality through biphasic and triphasic formulations (23, 24). This reduction strategy aimed to minimize adverse effects on lipid metabolism (obesity, accumulation of trunk fat characteristic of men, and high levels of cholesterol and triglycerides), carbohydrate metabolism, including insulin resistance and diabetes (25), homeostatic parameters associated with cardiovascular risks (26), and to produce effective control over the ovulatory cycle. A later technological step would introduce chemically structural analogs that, instead of preventing ovulation and fertilization, would prevent nesting and implantation of the fertilized ovum, causing an induced abortion, e.g., emergency postcoital contraception (27, 28) or self-induced abortion (29, 30). However, their assessment is beyond the scope of this review.
Thus, the physiological objective of current HBC is to create an artificial situation of anovulation by altering the hormonal balance and suppressing the ovulatory cycle to prevent fertilization and minimize the risk of adverse effects associated with the administration of estrogen derivatives such as ethinyl estradiol (EE). The actual rate of HBC use discontinuation reaches 59%, of which 61% is attributed to adverse effects on women's health (22).
Therefore, a review of the potential effects and their impact on women's health may provide a better understanding of women's needs.
2. Adverse effects
The adverse effects of HBC have been one of the most controversial issues in the last 40–50 years of health care. A recent review summarized their main adverse effects and other features, such as their communication (31). Besides the generally recognized adverse effects (breast and other cancers, emotional and psychiatric disorders, cardiovascular risks, and so on), other adverse effects that are not usually acknowledged and risk being underreported include increased risk of HIV transmission, immunology disorders (Crohn's disease, ulcerative colitis, lupus erythematosus), “suicide, multiple sclerosis, interstitial cystitis, female sexual dysfunction, bone fractures, and increased fat mass.” The authors also identified adverse effects for which medical information provided to the user is usually biased: cardiovascular risks (heart attack, stroke, and thrombosis) (31).
2.1. Ovarian aging
Ovarian functionality can be objectively assessed through three biomarkers: ovary volume, AMH, and AFC. The AMH serum concentration is a reliable predictor of ovarian aging approaching menopause (32, 33) to evaluate a woman's fertility (17, 18, 20). A study analyzing the ovarian reserve (16) showed that combined HBC, as compared to progestin-only HBC, leads to a statistically significant decrease in AMH levels (−31.1 and −35.6%); AFC (−31.3 and −29.7%); and ovarian volume (−57.2 and −10.5%), respectively. Intrauterine systems and vaginal rings had less pronounced effects: −17.1 and −12.2% for AMH, respectively; −5.9 and −22.7% for AFC, respectively; their effect on the ovarian volume was highly dependent on the method: the intrauterine system caused a −5.1% decrease, while the vaginal ring resulted in a −55.8% decrease (16). These results validate other studies where AMH, AFC values, and the volume of both ovaries were significantly decreased by 19%, 18%, and 50%, respectively, in HBC women users (18, 20). A relationship between HBC use duration (as well as tubal ligation) and lower AMH serum levels was found to be statistically significant (p = 0.036) and was independent of the age of first use of contraception (34), although this may not necessarily lead to early menopause (35).
Ovarian aging may also be studied through the evolution of cervical mucus. Various types of cervical mucus are secreted by specific S, L, and G glands in the cervix (36, 37). Their percentage varies with the phases of the menstrual cycle to facilitate or prevent the sperm from reaching the ovum (38, 39), similar to pregnancy or menopause (40), and deviations from their cyclical variation may show underlying problems of ovulation (38). These variations are also associated with age (41–43): the number of S-type glands decreases at an estimated 2% rate since adolescence and is replaced by type L starting from the base of the cervix (42). Pregnancy seems to exert protection against further replacement of mucus types S and L by G in the cervix due to a lower decrease rate of 1.2% or even rejuvenating the cervix, an equivalent of 2–3 years (42). However, HBC causes biochemical changes in the mucus composition (44–46) and favors its replacement by G type at a 4% rate (faster than the natural aging process regardless of pregnancies), causing a lower mucus score due to cervical atrophy lacking functionality (41, 47–49).
The changes in serum biomarkers and cervical mucus could manifest as accelerated ovarian aging. Women using HBC for 10 years may find themselves hindering the possibility of later pregnancies due to loss of functionality (42, 50) and difficulties in reestablishing fertility after HBC discontinuation (18, 35, 51).
2.2. Effects on mental health
The psychological effects associated with HBC are one of the main causes of dissatisfaction and discontinuation (22, 52). They include a variety of neuro-bio-psychological scenarios of different severity: behavioral changes, emotional and affective changes, anxiety, depression, suicide attempts, and suicide.
2.2.1. Psychological effects: affective and emotional disruptions
The first studies that observed these changes dating to the 1980s, described diagnosis rates between 20 and 50% (53). Novel approaches to HBC combined with 35 μg of EE led 47% of women to discontinue after 1 year, citing emotional and affective adverse effects in 33% of women; only 27% continued after 6 months due to mood effects (53). Comparison studies concluded that women using the vaginal ring vs. orally administered HBC had fewer negative emotional changes (54), less irritability, depression, and emotional variability (55), similar to those found in women using HBC transdermal patches (56). However, caution is needed. Some articles compare different HBC formulations without control groups, making interpretation complex (53).
Evaluation of psychotropic drug use validated the impact of HBC on mood. A study carried out in Finland (57) compared HBC women users to never users (n = 294,356 women per group) and analyzed their psychotropic drugs. The results showed HBC female users had a moderately higher relative risk (RR) ranging from 1.1 to 1.3 for all psychotropic drug classes (p < 0.0001): antipsychotics, anxiolytics, hypnotics/sedatives, antidepressants, and a combination of psycholeptics with psychoanaleptics, except for psychostimulant drugs, and a higher incidence of psychotropic drug use was found in adolescent women (57).
Women with a clinical history of adverse emotional effects from HBC, who were re-exposed to EE combined with levonorgestrel, exhibited emotional deterioration compared to the control group (who received a placebo), where no emotional change was observed. The group that received HBC also showed a lower induced emotional response in the brain areas associated with emotion recognition and regulation (58–61). Further studies in young women before and after starting HBC showed a lower volume of the gray matter in the amygdala, the parahippocampus, and the connectivity between the amygdala and the prefrontal cortex (62), highlighting the need to research HBC-induced brain changes.
Mechanistically, the synthetic hormonal analogs cross the blood–brain barrier, reach the receptors, develop their effects in the central nervous system (63–65), and induce psychological outcomes through biochemical-neurological mechanisms (66). Sex hormones exert their effects on the human brain through estrogen receptors in areas involved in the regulation of emotions (the amygdala and the hippocampus), affecting the synthesis of neurotransmitters associated with emotions, serotonin, and γ-aminobutyric acid (GABA) (67–70). Moreover, the duration of HBC use correlates with changes in the volume of the gray matter in the hippocampus, the cerebral basal nuclei (71), the amygdala, and the nucleus accumbens. This finding is particularly relevant: the effects seem more severe if HBC is used during adolescence (72, 73); they are not immediately reversible after discontinuation, and a link with depression, the prescription of psychotropic drugs, and antidepressants seem to exist (74). In addition, emotional disorders exhibit heightened severity in women who had pre-existing emotional conditions prior to using HBC, as well as in adolescent women, due to their vulnerability (68).
2.2.2. Effects on sexual life
The effect of hormonal changes caused by the HBC on women's sexual lives and man–woman relationships throughout the menstrual cycle was evident.
“…increases in estradiol negatively impacted women's and men's romantic relationships. Specifically, as estradiol increased, women evaluated their partners less positively, and they were less physically attracted to their partners. […] Increases in progesterone (which peaks after ovulation) were associated with more positive perceived relationship evaluations and personal wellbeing in women” (75).
The decreased reactivity against negative stimuli and the constant presence of estrogen derivatives (mainly EE) could cause emotional destabilization at the psychological and behavioral levels. In addition, combined HBC increased SHBG serum levels and decreased the androgen hormone testosterone regardless of the progestin and estrogen doses used (76), with high SHBG serum levels after 120 days post-discontinuation (77). These changes cause a loss of sexual drive and libido, affecting a woman's sexual life (76–79). Other studies have also shown negative effects on women's sexuality, and controversy included: “attributing a sexual dysfunction to the use of a contraceptive is to be avoided at all costs,” although acknowledging that “contraceptives could also cause a sexological disorder” (80) or sexual dysfunctions in women (78, 81–83).
2.2.3. Depression
Recent studies have used sex hormones to identify the underlying mechanisms leading to depression and ways to prevent it, including modification of serotonin transport (84, 85). Thus, it is not surprising that HBC may induce depression (52).
In a study including 815,662 women (12–30 years old), 3.1% of the participants were dispensed psychotropic drugs (52), which was 3.7% and 2.5% for HBC users and non-users, respectively, with an RR of 1.34 (95% CI: 1.30–1.37). The risk of psychotropic drug use was greater in women aged 12–20 years, with a 4–3.5% range in users vs. < 2% in non-users, and it was >4% (users) vs. 0.9% (non-users) in 12–14-year-old women with RR = 3.46 (95% CI: 3.04–3.94) or 4.47 (95% CI: 2.08–8.78) for progesterone-only formulations (intravaginal ring and transdermal patch) (52). These results agree with other studies that found an association between HBC use and the diagnosis of depression in women (particularly in women aged 12–19 years old) with a RR of 1.12 (95% CI: 1.05–1.19) vs. non-users (86, 87). Both studies have discovered that premature HBC use involves serious risks for women's mental health, including the impact on the adolescent's affectivity and future sexual relationships (88). This adverse effect seems associated with enzyme monoamine oxidase deregulation due to high estrogen and progesterone concentrations (89, 90).
2.2.4. Suicide risk
The most serious HBC adverse effect that has attracted the most attention is suicide and attempted suicide (91–93). A study carried out in Denmark (1996–2013) with 475,802 women identified as HBC users aged 15–33 years had an RR of 1.97 (95% CI: 1.85–2.1) for a first suicide attempt and 3.08 (95% CI: 1.34–7.08) for suicide (91). Young women (15–19 years) were the most susceptible, with an RR of 2.06 (95% CI: 1.92–2.21), highly significant (p < 0.0001); this RR was 2.5 after 1 month of HBC use, remained above 2 during the first year, and was 30% higher after 7 years. These findings corroborate another study with women aged 15–22 years: the suicidal behavior RR ranged from 1.56–2.13 1 month after beginning HBC use and 1.19–1.48 after one year (92). Further evidence on the higher suicide risk associated with HBC shows an RR of 1.36 (95% CI: 1.06–1.75) (94), 1.23 (95% CI: 1.1–1.37) in a Korean study (95), and others (96).
Discontinuation of HBC use did not eliminate the RR of first attempt suicide (RR = 3.4, CI: 3.11–3.71) or suicide (RR = 4.82, CI: 1.93–12.1) in women who had previously used HBC, with combined estrogen-based vs. progestin-only formulations having a similar impact (91). Although all HBC types increase suicide or suicide attempt risks, norelgestromin patches and implants increase them by 3.9 (95% CI: 2.48–6.14) and 5.85 (95% CI: 4.80–7.13), respectively, and medroxyprogesterone acetate implants by 10.2 (95% CI: 7.87–13.2).
Other studies seem to contradict these risks. Usually, these studies lack coherent longitudinal analysis or experimental design. A suicide RR reduction has been suggested, but the study was designed to evaluate depression, lacking appropriate population selection (97); similarly, HBC users showed no higher RR, but it was limited to 12 years and assessed general mortality rather than suicide (98). In other cases, the HBC effect cannot be determined because of confounding factors and population bias: study and control groups both use HBC, although different classes and mortality associated with other pathologies (ovarian, cervical cancer, and cardiovascular diseases) cannot be isolated from HBC use (99). This variability between studies seems to be a consequence of the “low or moderate methodological quality of the study” (100), including low statistical power to identify an effect (101, 102), overlap and redundancy of factors and variables (103), poor demographic data (97), high group heterogeneity (102), or drawing conclusions beyond the study design (98, 99, 101, 104, 105).
2.3. Increased cardiovascular risk
Cardiovascular risk is one of the best-studied adverse effects of HBC due to its ability to interact with estrogen and progesterone receptors present in the tissue layers of the blood vessels (106). Several studies have recognized the association between HBC and increased risk of venous or arterial thrombosis (106–113), brain stroke (114–117), myocardial infarction (118), and hypertension (119–121).
Studies carried out by the WHO showed higher thromboembolism RR associated with duration, type, and dose: one-year users had RR = 5.63, which remained >3 up to 8 years (108); the overall RR was 4.1 (95% CI: 3.2–5.2), 9.1 (CI: 4.9–17.0) for desogestrel, and 9.1 (CI: 4.9–16.7) with gestodene (110); it was dose-dependent, with twice the risk at 50 μg (106). In third-generation HBC, the thrombosis RR was 3.6 (95% CI: 2.9–4.6) for levonorgestrel, 5.6 (95% CI: 3.7–8.4) for gestodene, 6.3 (95% CI: 2.9–13.7) for drospirenone, 6.8 (95% CI: 4.7–10) for cyproterone acetate, and 7.3 (95% CI: 5.3–10) for desogestrel (106), suggesting that the third-generation HBC did not eliminate the risks. Furthermore, the RR increased synergistically (12–24 times) in women with additional risk factors, e.g., obesity (111–113). The vascular damage may be related to changes caused by EE in the homeostatic chain of coagulation (109): higher generation of thrombin and coagulation factors (fibrinogen, VII, VIII, IX, XII, XIII) and reduction of coagulation inhibitors (protein C, antithrombin). These actions could lead to cardiovascular complications, including thrombus formation. Third-generation HBC may have aggravated the problem due to increased resistance to protein C, confirming the findings of the WHO (106).
A higher incidence of cerebral stroke among HBC users compared to non-users has also been shown. For doses of EE >50 μg, the RR was found to be 5.3 (95% CI: 2.6–11), while for doses below 50 μg, the RR was 1.53 (95% CI: 0.71–3.31) (114). Additionally, HBC containing low doses of norgestrel or levonorgestrel (117) showed an increased RR for hemorrhagic stroke at 3.23 (95% CI: 1.24–8.41), and the RR for aneurysmal bleeding increased to 4.46 (95% CI: 1.58–12.53). Similar results were found in a study addressing the role of migraine, and the risk of cerebral stroke RR was 2.52 (115) in patients with and without aura, increased to 6.25 and 6.35, respectively (116), and was dose-related (122). Furthermore, the data suggest that the stroke RR in HBC users is affected by the presence and degree of other pathologies (115, 123).
Myocardial infarction and hypertension may also be mentioned. The RR of myocardial infarction increased to 2.48 (95% CI: 1.91–3.22) in HBC users vs. never users and remains moderate after discontinuation at 1.15 (95% CI: 0.98–1.35) without its complete disappearance (118). A 43% higher prevalence was observed in postmenopausal women who used HBC for over 30 months (124).
3. Oncology-related adverse effects
The incidence of various types of cancer has spurred research into their generation and progression mechanisms, revealing the role of hormones in their development (125). Specifically, types of cancer that are estrogen dependent are characterized by tumor cells that possess estrogen receptors and benefit from the hormone estrogen to progress.
Thus, antiestrogen endocrine therapy may block their growth, while progesterone-dependent types of cancer rely on the sensitivity of cancer cells to progesterone for growth, which can be blocked through endocrine hormonal treatment. On the other hand, non-dependent types of cancer lack hormone receptors, and their growth remains unaffected by hormones.
3.1. A therapeutic-based controversy
The identification of hormone-sensitive tumors has given rise to one of the most debated scientific issues over the years: whether HBC may increase the risk of developing some types of cancer in women (126–129). The rationale behind this is that most HBC formulations are analogs or identical to estrogens or other hormones that can affect tumor progression. This question has sparked much controversy in the interpretation of data, with assertions of cancer protection on one hand and denial of scientific evidence on the other, likely influenced by the desire to alleviate concerns surrounding HBC usage (82, 130–134), biased data analysis, and inadequate selection of study populations (135, 136).
Their potential dual effects present a therapeutic dilemma (135): higher RR of specific kinds of cancer (e.g., breast cancer) vs. protective effect against other types of cancer (e.g., endometrial cancer). The authors proposed their use in women who have been or are undergoing cancer treatment but also stated a lack of evidence to draw valid conclusions. An analysis of their methodology shows a lack of population selection since the study population (women with cancer) would not represent the general population. Given their study limitations, the authors appropriately warned against using HBC due to possible effects on hormone-sensitive tumors.
Another study concluded that HBC users would not have a greater long-term cancer risk but rather a reduced risk and protection against some cancers (136). Similarly, a lack of population selection leads to that interpretation: first, women who had cancer before the start of the study (even if they used HBC) were excluded; second, the stratification of HBC users vs. non-users was not well established; third, there was a notable lack of study follow-up (53% of participants stopped providing the information); fourth, only the first cancer cases were counted and subsequently censored. This meant that the sample size of HBC users who had cancer progressively decreased and, compared to non-HBC users, yielded an apparent protective effect. Nevertheless, the authors reported a RR 5 years after HBC discontinuation of 2.33 (95% CI: 0.43–12.6) for pancreatic cancer, 1.48 (95% CI: 1.10–1.97) for breast cancer, 2.32 (95% CI: 1.24–4.34) for invasive cervix cancer, 2.20 (95% CI: 0.49–9.99) for central nervous system cancer, and 1.45 (95% CI: 0.14–14.8) for thyroid cancer. Regardless of the methodological pitfalls, both studies put forward evidence of a higher cancer incidence in HBC users.
3.2. Breast cancer risk
Initial, old studies calculated a worrying increase in breast cancer RR up to 40% for women aged 20–40 (137), 88% (138), and 42% (139), and 50% RR if HBC were used within 5 years of menarche (140, 141). Overall, these studies did not address mechanisms, lacked a significantly large study population (unlike later longitudinal studies), and presented methodological errors, e.g., mixing populations of users and non-users in control groups (140). More recent studies include a mechanistic scope and have confirmed the influence of estrogens in the regulation dynamics of the transcription process (142, 143) as well as genes involved in tumor cell proliferation, especially levonorgestrel, desogestrel, and gestodene (144). This recent evidence puts forward the need for an in-depth analysis of the effects of HBC on breast cancer (145).
In a study involving 1.8 million women over nearly 11 years, the breast cancer incidence RR was 1.20 (95% CI: 1.14–1.26) for HBC women users (146). The RR was found to be 1.09 (95% CI: 0.96–1.23) for users of HBC for < 1 year and 1.46 (CI 95%: 1.32–1.61) for users for more than 10 years. The RR remained 10 years after discontinuation of HBC, and it was >2 in women who had used it for more than 10 years. However, the specific magnitude of the relative risk varied depending on the type of HBC used. Other studies have provided further confirmation, indicating a RR of 1.2 (95% CI: 1.14–1.26) for breast cancer among HBC users (147). Specifically, levonorgestrel-releasing intrauterine systems were associated with a RR of 1.16 (95% CI: 1.06–1.28). Notably, the RR differed among age groups, with a value of 1.12 (95% CI: 1.02–1.22) for women under 50 years of age and 1.52 (95% CI: 1.34–1.72) for women above 50 years of age, suggesting an underlying risk that may increase over time (148).
A causal relationship has been proposed between HBC containing EE and the development of breast cancer RR (142, 143). However, it appears that these scientific findings are often overshadowed by the perceived benefits of HBC and are only considered in particular cases. “These data should be brought to light in view of the great benefit of hormonal contraception in the female reproductive context” (149) while also acknowledging the potential adverse effects that may have been overlooked or disregarded (150–152).
3.3. Risk of cervical cancer
HBC disrupts the balance of estrogen, inducing artificial cell changes. There was a significant correlation (p < 0.01) between the duration of HBC use and the incidence of cervical cancer, with an overall RR of 4.2 (95% CI: 1.01–5.69) when its use exceeded 5 years, which reached 7.1 (95% CI: 1.74–28.9) for oral formulations (153); these findings are consistent with those from previous studies: RR was found to be 1.1 (95% CI: 1.1–1.2), 1.6 (95% CI: 1.4–1.7), and 2.2 (95% CI: 1.9–2.4) for < 5 years, 5–10, and more than 10 years of HBC use, respectively (154). Similar outcomes were observed in women aged 15–49 years in 1995–2014, with an overall RR of 1.19 (95% CI: 1.10–1.29), which increased to 1.40 (95% CI: 1.28–1.53) with duration and combined type (155). In addition, the authors identified other relevant items: first, the RR in long-term HBC users requires over 10 years to disappear post-discontinuation and remains 1.29 (95% CI: 0.65–2.56); second, the new EE-norethisterone combined formulations present the same risk as previous formulations, a RR of 2.68 (95% CI: 1.68–4.28), which was expected since both formulations have the same active components; and third, women need to be informed correctly about the risks to make an informed decision or choose other alternatives (155).
3.4. Risk of endometrial carcinoma
Endometrial carcinoma cells exhibit estrogen receptors, and their growth is stimulated by estrogens (156). Mechanistically, preclinical studies have shown that the metabolite of estradiol, 4-hydroxy-estradiol, induces DNA damage in endometrial cells (157, 158). Moreover, other metabolites (e.g., 17α-ethinylestradiol) increased the incidence of uterine adenocarcinoma (159, 160). Additionally, changes in endometrial morphology, histology, and functionality have also been associated with levonorgestrel-releasing intrauterine devices (161–163). An increase in endometrial cancer risk may be related to the hormonal balance of estrogen and progesterone concentrations modulating the endometrial mitotic activity rate changes during the menstrual cycle (164). Interferences could cause deregulated mitotic activity and a higher risk of endometrial cancer, which even led to the removal of some formulations from the market (165).
Endometrial carcinogenic damage associated with combined HBC has been reported in clinical studies (165–167) and with lesser evidence in case series (168–174). Endometrial cancer RR of 1.36 (CI 95%:0.39–4.70) was calculated for women with a BMI < 22.1 kg/m2 vs. 0.31 (95% CI: 0.11–0.92) in women with a BMI >22.1 kg/m2 (166). Obesity largely modifies the volume of distribution of lipophilic drugs due to their high affinity for the adipose tissue, leading to the removal of the drug from the bloodstream and its accumulation in the adipose tissue. This would provide a pharmacokinetic-based explanation of the 30% lower plasma concentration observed in obese women (175) and the greater failure rate of HBC in obese women (176, 177). Thus, women with a BMI above 22.1 kg/m2 who have low HBC bloodstream concentrations would be at lesser risk of endometrial cancer and significant adverse effects. To avoid a high rate of contraceptive failure, women with a high BMI were systematically excluded from clinical studies (178).
Although the assessment of HBC's protective effect exceeds the goals of this review, it is important to point out that several studies (with diverse quality) have indicated protection against endometrial cancer (136, 165, 179, 180), not without disdain for potential adverse effects (181–183). An endometrial cancer risk evaluation based on formulation type concluded a protective effect with an RR range of 0.94–0.37 (167). However, this study presents a bias in the population selection: the control group includes never HBC users together with women who had used other methods such as a diaphragm or intrauterine device (18.1%), male contraception (32.7%), tubal ligation (9.8%), or others (23.6%). Thus, no conclusion may be drawn since some of those other methods may affect hormonal balance.
However, even if these benefits were fully proven in ad hoc clinical trials, their impact on other women's health aspects cannot be overlooked, lest other adverse effects appear upon the preventive treatment of endometrial cancer (123). Conversely, there is clear evidence of a 40% reduction in endometrial cancer in parous vs. nulliparous women, probably due to progesterone's protective effect on the endometrium (184, 185).
4. Collateral adverse effects
Other general aspects related to women's health are also negatively affected, including a lack of information about adverse effects provided to current and new HBC users at prescription or dispensing levels; degradation of the patient-healthcare professional relationship; scientific relativism with two-tier validity criteria and language change; the impact of contraception on individuals and society at large; and the degradation of the environment.
4.1. Patient information delivery
Accurate and timely information on HBC is necessary to guarantee an informed decision and ensure good clinical outcomes. Studies examining the provision of information to women regarding cardiovascular risks associated with HBC have indicated inadequacy. The emphasis is often placed on the efficacy and utilization of HBC, with minimal attention given to the possible adverse effects and their reversibility (155). The seriousness of some adverse effects may influence their decision to use HBC (22, 54, 83, 186), and it could also affect a woman's physiology capacity to restore her normal physiology (51, 124) and fertility after experiencing years of hormonal imbalance (18, 19, 134, 187). Furthermore, women with pathologies could undergo more severe adverse effects, potentiation of the pathology (111–113, 115, 118, 124, 177), or undesired sequelae (155, 188–191). Thus, it is worth stressing that women with cardiovascular pathologies, such as diabetes, depression, and polycystic ovary syndrome, are particularly vulnerable and require greater attention to mitigate the risks associated with HBC for their overall health and wellbeing (192, 193).
Failing to provide accurate, correct, or inclusive information due to bias or negligence would be a disregard for women's autonomy in making health-related decisions and could hinder their ability to have healthy and fulfilling sexuality (78, 80, 81, 194). Lack of information may also lead to potential or definite therapeutic outcomes associated with the medication, leaving individuals without the possibility of opting out. This becomes particularly critical when these effects persist for the rest of their lives or for several years. A lack of information exchange undermines trust between healthcare professionals/providers and HBC users (195). This mistrust would be aggravated if there were no other drug alternatives, treatments, or fertility control approaches offered to women (196, 197).
Several recommendations have been proposed to prevent information avoidance and facilitate the dissemination of potential adverse effects (31). These include completely specifying them in the labeling, incorporating a black box warning or flags to indicate a potential increased risk in specific pathologies, or considering their removal from the market when there is sufficiently consistent evidence. Additionally, training courses may be provided to healthcare professionals to improve their service (198–203) and knowledge of alternative approaches to reach “coercion-free” contraception (197). Professionals in the scientific, commercial, or healthcare areas cannot withdraw their commitment to providing complete and truthful drug safety and efficacy information, including their adverse effects (21, 204). Online and network sources would not suffice due to the risks of unverified information and the effect that the validity of the content may have on patients' health (205–207). In reality, good quality women's health care demands that health professionals seek communication channels for accurate, reliable, precise, balanced, unbiased, and personalized information to answer the questions raised by women using contraceptives (193, 194, 197) and to prevent HBC users from avoiding gathering information that could threaten their health, wellness, or other interests (208). This attitude would secure women's right to personal autonomy, recognize their dignity, and desire to feel respected, and ensure an effective patient–physician relationship (192, 196).
4.2. Scientific language
If controversy regarding HBC adverse effects exists, Brabaharan et al. took a position completely contrary to previously published scientific evidence, stating, “the associations between hormonal contraceptive use and cardiovascular risk, cancer risk, and other major adverse health outcomes were not supported by high-quality evidence” (209). The foundation for such a categorical statement lies in the reinterpretation of the p-value (p) as a statistical criterion (210–212). The authors define “quality of evidence” based on four arbitrary categories: class 1, a “convincing” value supported by p < 0.000001 plus objective and subjective criteria; class 2, with “highly suggestive” evidence with p < 10−6; class 3, with a “suggestive” quality value and p < 0.001; and lastly, class 4, with a poor quality of evidence and p < 0.05. Then, the authors require p < 10−6 to claim statistically significant effects of any intervention rather than the generally accepted p < 0.05 value (212–215). This leads to different interpretations (216), including “no-effect” unless the intervention reaches p < 10−6 value: results without p < 10−6 would be considered irrelevant, dismissing thousands of studies carried out over decades of research. Taking a p-value of < 10−6 excludes the vast majority of studies reporting any HBC-related adverse effect. However, the study does corroborate 30 statistically significant (p < 0.05) associations with increased risk of adverse effects: cardiovascular (thromboembolism), cancer (breast, cervical), hypertension, Crohn's disease, ulcerative colitis, suicide, and higher triglyceride and cholesterol levels in women with polycystic ovary syndrome, among others. Similarly, using the same p-value (0.05), they identified 10 associations suggesting risk reduction, including cancer (glioma, colon, kidney, and ovarian) and other pathologies (209).
Thus, arbitrary changes in the reference system lacking rigor not only show contempt for previous studies but may lead to scientific relativism capable of endorsing any preconceived idea (217) and therefore put women's health at risk due to a lack of objective clinical assessment.
4.3. The social and individual impact of contraception
The widespread use of HBC over the last 60 years has brought about a radical change in the perception of sexual relations for women and couples (26). It has contributed to the emergence of a new social culture characterized by sexual freedom, which is often detached from the biological and transcendent nature of human sexual behavior rooted in the anthropological dimension of sexual intercourse (218). This viewpoint has created conflicts with long-established cultural and religious beliefs, as well as with women's own understanding of sexual health (219). The growing social acceptance of contraception has led to increased tensions regarding women's autonomy and the shared decision-making process within couples regarding birth control (or who sets the sexual control within a couple), sexual satisfaction, libido, and interest (197, 218). Moreover, this shift has resulted in significant injustices due to policies focused on “sexual functioning” and emphasizing risk-free pregnancy (218, 219), particularly among vulnerable populations (193).
A global study (93) that examined adolescents (116,820 boys and girls) aged 12–15 years from 38 countries (excluding the EU and North America) has revealed that 8.8% of boys and 9.3% of girls reported attempted suicides. Among those adolescents who are engaged in sexual intercourse, the rate was 19%, and for those with multiple partners, the rate was 28.7% (RR 1.58, 95% CI: 1.27–1.96). Among other factors, the authors identified “impersonal sex,” life dissatisfaction, and a lack of psychological maturity to integrate sexual intercourse (93). These findings might help mitigate the high rate of suicide and suicide attempts observed among young women using HBC (91, 92, 100, 188, 220). Additionally, the US Centers for Disease Control and Prevention (CDC) (221) has shown the negative impact of HBC on relationships, including increased divorce rates with associated consequences for children (poverty, education, and so on). The CDC has also noted the link between hormonal contraception and abortion, which can have negative effects on women (222), as well as the association with abuse and violence (223).
These results highlight the need for studies that go beyond mere descriptions, delve into other dimensions of sexuality beyond the physiological phenomenon, and seek solutions that prevent the deconstruction and fragmentation of natural human procreation through chemical substances. This reconfiguration of an individual's inner ethical structure may lead to a decline in sexual health and satisfaction for both men and women, particularly with prolonged use of HBC (76, 78). Resolving this issue requires understanding the meaning of human sexuality from an anthropological perspective and striving for a satisfactory and fulfilling sexual experience within a couple. Merely focusing on the physical act of genital union may not fully integrate the intimate relational expression of the individuals involved, thereby limiting the potential for complete sexual satisfaction. This could be attributed to the intertwining feelings of trust, safety, tenderness, and the endorsement of women's femininity, among others (224, 225).
4.4. Economic impact
Reducing medication-related problems continues to be a significant challenge in healthcare (226) due to the additional burden on patients and the associated costs to the healthcare system, including hospitalizations (227–229). Various efforts have been made to address this issue, such as implementing programs to identify drug–drug interactions, conducting rational analyses of polypharmacy, and optimizing prescription patterns (230, 231).
The economic burden of the widespread use of HBC was assessed by analyzing data from HBC users aged 15–49 years, as provided by the US CDC (221). The analysis specifically focused on excess adverse drug reactions (ADR) resulting from the increased RR associated with HBC use (223). Taking a conservative approach (the lowest RR for each ADR), it was estimated that “over 1.04 million women have developed diseases or disorders linked to the use of hormonal contraceptives, with costs to society of over US$16 billion annually.” The highest contributor is breast cancer (US$10B), followed by depression (US$3.35B), Crohn's disease (US$1.9B), cervical cancer (US$1.0B), and others. In addition, hyperthyroidism and uterine and ovarian cancers were considered to cause a reduction in cases and, consequently, cost savings for the healthcare system (-US$1.45B).
4.5. Environmental impact
The widespread use of HBC has led to the release of HBC molecules (natural and synthetic) and their metabolites into the environment through wastewater. This unintended consequence has been described as an “invisible menace” (232) due to its potential environmental impact (223). Environmental surface water drug analysis detected effective concentrations of levonorgestrel, dydrogesterone (233), 17α-ethynylestradiol (234), estradiol (235), progestins, and other steroids (236, 237). The long-term consequences are unknown, although some initial effects include biochemical, histological, and transcriptome changes (235, 237), fertility loss in humans and animals (232, 238), and induced feminization in fish (238). Wastewater treatment has become crucial to eliminating or decreasing HBC surface water concentrations to ensure a no-effect concentration (223).
5. Conclusions
The use of HBC involves an artificial state in women that causes physiological and psychological changes, including behavioral consequences (68). Given the utilitarian focus of the HBC information provided (239, 240), key aspects that could identify basic mechanisms underlying the adverse effects have not been researched sufficiently deeply (241, 242). Thus, it is worth asking why requirements for compliance with healthcare quality parameters, including transparency and regulations aimed at protecting women's health, have not been developed or applied. Conversely, we noticed attempts to minimize HBC adverse effects by referring to studies that minimize opposite results (243), seeking explanations outside the scope of the study (244) in populations with a different stratification (97), or disregarding scientifically established criteria (209).
These identified controversies are diverse: first, the denial or minimization of HBC adverse effects; second, their dismissal as non-relevant; third, the modification of the scientific criteria for their analysis; and fourth, information avoidance. All of them portray HBC use as something ordinary, embedded in women's daily routines, ignoring the fact that HBC creates an artificial situation in the woman's physiology. Therefore, it is necessary to explore the potential adverse effects derived from an induced physiological state, taking a holistic approach to women's health. Such an approach may help identify the pharmacological, psychological, and medical interventions to meet the needs that women face during their fertility stage. In addition, the lack of a fitting medical, pharmaceutical, and scientific ethos leads to uncertainty, insecurity, mistrust, and the degradation of the personal–patient relationship in healthcare. Conversely, unbiased, truthful investigations based on the anthropological category of respect may ensure an optimal and respectful approach to women's health.
Finally, when viewed from a historical perspective, it becomes evident that HBC did not meet an unmet medical need but rather became a tool for separating human procreation and fertility from human sexual behavior. This shift places greater emphasis on the demand for the right to sexual health (192, 196, 197). This right encompasses various aspects, including the right to avoid unfair treatment that compromises one's wellbeing and physical and mental integrity, the right to be free from discrimination or hindered access to alternative treatments, and most importantly, the fundamental right to access sufficient and transparent information to make informed and free choices regarding one's fertility and sexual life.
Author contributions
IS and MM conceptualized the main ideas. IS and MVR executed the main literature search and compilation of the information. IS, MM, and MVR developed the interpretation and relational analysis. IS wrote the manuscript. All authors read, reviewed, and approved the final version of the manuscript.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Abbreviations
ADR, adverse drug reactions; AFC, antral follicle count; AMH, antimulerine hormone; BMI, body mass index; CI, confidence interval; EE, ethinyl estradiol; GABA, γ-aminobutyric acid; HBC, hormone-based contraception/contraceptives; RR, relative risk; SHBG, sex hormone-binding globulin; WHO, World Health Organization.
References
1. Coss D. Regulation of reproduction via tight control of gonadotropin hormone levels. Mol Cell Endocrinol. (2018) 463:116–30. doi: 10.1016/j.mce.2017.03.022
2. Critchley HOD, Maybin JA, Armstrong GM, Williams ARW. Physiology of the endometrium and regulation of menstruation. Physiol Rev. (2020) 100:1149–79. doi: 10.1152/physrev.00031.2019
3. Saei Ghare Naz M, Rostami Dovom M, Ramezani Tehrani F. The menstrual disturbances in endocrine disorders: a narrative review. Int J Endocrinol Metab. (2020) 18:e106694. doi: 10.5812/ijem.106694
4. George RP, Tollefsen C. Embryo: A Defense of Human Life, 1st ed. New York, NY: Bantam Dell (2008), p. 242.
5. Deligdisch-Schor L, Mareş Miceli A. Hormonal biophysiology of the uterus. Adv Exp Med Biol. (2020) 1242:1–12. doi: 10.1007/978-3-030-38474-6_1
6. Ng S-W, Norwitz GA, Pavlicev M, Tilburgs T, Simón C, Norwitz ER. Endometrial decidualization: the primary driver of pregnancy health. Int J Mol Sci. (2020) 21:E4092. doi: 10.3390/ijms21114092
7. Vigil P, Lyon C, Flores B, Rioseco H, Serrano F. Ovulation, a sign of health. Linacre Q. (2017) 84:343. doi: 10.1080/00243639.2017.1394053
8. Rojas J, Chávez-Castillo M, Olivar LC, Calvo M, Mejías J, Rojas M, et al. Physiologic course of female reproductive function: a molecular look into the prologue of life. J Pregnancy. (2015) 2015:715735. doi: 10.1155/2015/715735
9. Biason-Lauber A, Chaboissier M-C. Ovarian development and disease: the known and the unexpected. Semin Cell Dev Biol. (2015) 45:59–67. doi: 10.1016/j.semcdb.2015.10.021
10. Ottolenghi C, Uda M, Hamatani T, Crisponi L, Garcia J-E, Ko M, et al. Aging of oocyte, ovary, and human reproduction. Ann N Y Acad Sci. (2004) 1034:117–31. doi: 10.1196/annals.1335.015
11. Park SU, Walsh L, Berkowitz KM. Mechanisms of ovarian aging. Reproduction. (2021) 162:R19–33. doi: 10.1530/REP-21-0022
12. Broekmans FJ, Soules MR, Fauser BC. Ovarian aging: mechanisms and clinical consequences. Endocr Rev. (2009) 30:465–93. doi: 10.1210/er.2009-0006
13. Jirge PR. Ovarian reserve tests. J Hum Reprod Sci. (2011) 4:108–13. doi: 10.4103/0974-1208.92283
14. Macklon NS, Fauser BCJM. Ovarian reserve. Semin Reprod Med. (2005) 23:248–56. doi: 10.1055/s-2005-872453
15. Yap C. Ontogeny: the evolution of an oocyte. Obstet Gynecol Surv. (2000) 55:449–54. doi: 10.1097/00006254-200007000-00024
16. Landersoe SK, Forman JL, Birch Petersen K, Larsen EC, Nøhr B, Hvidman HW, et al. Ovarian reserve markers in women using various hormonal contraceptives. Eur J Contracept Reprod Health Care. (2020) 25:65–71. doi: 10.1080/13625187.2019.1702158
17. Qiu W, Luo K, Lu Y, Zhao J, Wang Y, Yang H, et al. Anti-Müllerian hormone has limited ability to predict fecundability in Chinese women: a preconception cohort study. Reprod Biomed Online. (2022) 44:1055–63. doi: 10.1016/j.rbmo.2022.02.014
18. Birch Petersen K, Hvidman HW, Forman JL, Pinborg A, Larsen EC, Macklon KT, et al. Ovarian reserve assessment in users of oral contraception seeking fertility advice on their reproductive lifespan. Hum Reprod. (2015) 30:2364–75. doi: 10.1093/humrep/dev197
19. Landersoe SK, Petersen KB, Vassard D, Larsen EC, Nielsen HS, Pinborg A, et al. Concerns on future fertility among users and past-users of combined oral contraceptives: a questionnaire survey. Eur J Contracept Reprod Health Care. (2019) 24:347–55. doi: 10.1080/13625187.2019.1639659
20. Yin W-W, Huang C-C, Chen Y-R, Yu D-Q, Jin M, Feng C. The effect of medication on serum anti-müllerian hormone (AMH) levels in women of reproductive age: a meta-analysis. BMC Endocr Disord. (2022) 22:158. doi: 10.1186/s12902-022-01065-9
21. Collins J. Professionalism and physician interactions with industry. J Am Coll Radiol. (2006) 3:325–32. doi: 10.1016/j.jacr.2006.01.022
22. Vitzthum VJ, Ringheim K. Hormonal contraception and physiology: a research-based theory of discontinuation due to side effects. Stud Fam Plann. (2005) 36:13–32. doi: 10.1111/j.1728-4465.2005.00038.x
23. Kaunitz AM. Enhancing oral contraceptive success: the potential of new formulations. Am J Obstet Gynecol. (2004) 190:S23–29. doi: 10.1016/j.ajog.2004.01.062
24. Van Vliet HAAM, Grimes DA, Lopez LM, Schulz KF, Helmerhorst FM. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev. (2011) 2011:CD003553. doi: 10.1002/14651858.CD003553.pub3
25. Halperin IJ, Kumar SS, Stroup DF, Laredo SE. The association between the combined oral contraceptive pill and insulin resistance, dysglycemia and dyslipidemia in women with polycystic ovary syndrome: a systematic review and meta-analysis of observational studies. Hum Reprod. (2011) 26:191–201. doi: 10.1093/humrep/deq301
26. Velazquez, editor. Farmacología Básica y Clínica, 18th ed. Buenos Aires: Panamericana (2008), p. 668–71.
27. Glasier A. Emergency postcoital contraception. N Engl J Med. (1997) 337:1058–64. doi: 10.1056/NEJM199710093371507
28. Baird DT. Emergency contraception: how does it work? Reprod Biomed Online. (2009) 18(Suppl 1):32–6. doi: 10.1016/S1472-6483(10)60113-7
29. Mark A, Foster AM, Perritt J. The future of abortion is now: mifepristone by mail and in-clinic abortion access in the United States. Contraception. (2021) 104:38–42. doi: 10.1016/j.contraception.2021.03.033
30. Conti J, Cahill EP. Self-managed abortion. Curr Opin Obstet Gynecol. (2019) 31:435–40. doi: 10.1097/GCO.0000000000000585
31. Williams WV, Brind J, Haynes L, Manhart MD, Klaus H, Lanfranchi A, et al. Hormonally active contraceptives Part I: risks acknowledged and unacknowledged. Linacre Quarterly. (2021) 88:126–48. doi: 10.1177/0024363920982709
32. Tehrani FR, Firouzi F, Behboudi-Gandevani S. Investigating the clinical utility of the anti-Mullerian hormone testing for the prediction of age at menopause and assessment of functional ovarian reserve: a practical approach and recent updates. Aging Dis. (2022) 13:458–67. doi: 10.14336/AD.2021.0825
33. Zhang J, Wang X, Ren Z, Shao S, Hou Z, Wang Z, et al. Impact of age and menopausal stage on serum anti-Müllerian hormone levels in middle-aged women. Climacteric. (2021) 24:618–23. doi: 10.1080/13697137.2021.1965114
34. Langton CR, Whitcomb BW, Purdue-Smithe AC, Sievert LL, Hankinson SE, Manson JE, et al. Association of oral contraceptives and tubal ligation with antimüllerian hormone. Menopause. (2021) 29:225–30. doi: 10.1097/GME.0000000000001905
35. Langton CR, Whitcomb BW, Purdue-Smithe AC, Sievert LL, Hankinson SE, Manson JE, et al. Association of oral contraceptives and tubal ligation with risk of early natural menopause. Hum Reprod. (2021) 36:1989–98. doi: 10.1093/humrep/deab054
36. Menárguez M, Pastor LM, Odeblad E. Morphological characterization of different human cervical mucus types using light and scanning electron microscopy. Hum Reprod. (2003) 18:1782–9. doi: 10.1093/humrep/deg382
37. Curlin M, Bursac D. Cervical mucus: from biochemical structure to clinical implications. Front Biosci. (2013) 5:507–15. doi: 10.2741/S386
38. Katz DF. Human cervical mucus: research update. Am J Obstet Gynecol. (1991) 165:1984–6. doi: 10.1016/S0002-9378(11)90559-6
39. Martyn F, McAuliffe FM, Wingfield M. The role of the cervix in fertility: is it time for a reappraisal? Hum Reprod. (2014) 29:2092–8. doi: 10.1093/humrep/deu195
40. Chrétien FC. Ultrastructure and variations of human cervical mucus during pregnancy and the menopause. Acta Obstet Gynecol Scand. (1978) 57:337–48. doi: 10.3109/00016347809154028
41. Najmabadi S, Schliep KC, Simonsen SE, Porucznik CA, Egger MJ, Stanford JB. Cervical mucus patterns and the fertile window in women without known subfertility: a pooled analysis of three cohorts. Hum Reprod. (2021) 36:1784–95. doi: 10.1093/humrep/deab049
42. Odeblad E. The discovery of different types of cervical mucus and billings ovulation method. Bull Ovulation Method Res Ref Cent Aust. (1994) 21:3–35.
43. Erickson EN, Knight AK, Smith AK, Myatt L. Advancing understanding of maternal age: correlating epigenetic clocks in blood and myometrium. Epigenetics Commun. (2022) 2:3. doi: 10.1186/s43682-022-00010-0
44. Singh EJ. Oral contraceptives and human cervical mucus lipids. Am J Obstet Gynecol. (1975) 123:128–32. doi: 10.1016/0002-9378(75)90515-3
45. Wolf DP, Blasco L, Khan MA, Litt M. Human cervical mucus. V. Oral contraceptives and mucus rheologic properties. Fertil Steril. (1979) 32:166–9. doi: 10.1016/S0015-0282(16)44174-9
46. Han L, Taub R, Jensen JT. Cervical mucus and contraception: what we know and what we don't. Contraception. (2017) 96:310–21. doi: 10.1016/j.contraception.2017.07.168
47. Ansari AH, Gould KG. Contraception and the cervix. Adv Contracept. (1986) 2:101–15. doi: 10.1007/BF01849219
48. Bastianelli C, Farris M, Bruni V, Rosato E, Brosens I, Benagiano G. Effects of progestin-only contraceptives on the endometrium. Expert Rev Clin Pharmacol. (2020) 13:1103–23. doi: 10.1080/17512433.2020.1821649
49. Han L, Creinin MD, Hemon A, Glasier A, Chen MJ. Edelman A. Mechanism of action of a 0075 mg norgestrel progestogen-only pill 2. Effect on cervical mucus and theoretical risk of conception. Contraception. (2022) 112:43–7. doi: 10.1016/j.contraception.2022.03.016
50. Kuhn L, Denny L, Pollack AE, Wright TC. Prevalence of visible disruption of cervical epithelium and cervical ectopy in African women using Depo-Provera. Contraception. (1999) 59:363–7. doi: 10.1016/S0010-7824(99)00049-9
51. Vollenhoven B, Hunt S. Ovarian ageing and the impact on female fertility. F1000Res. (2018) 7:F1000 doi: 10.12688/f1000research.16509.1
52. Zettermark S, Vicente RP, Merlo J. Hormonal contraception increases the risk of psychotropic drug use in adolescent girls but not in adults: a pharmacoepidemiological study on 800 000 Swedish women. PLoS ONE. (2018) 13:e0194773. doi: 10.1371/journal.pone.0194773
53. Schaffir J, Worly BL, Gur TL. Combined hormonal contraception and its effects on mood: a critical review. Eur J Contracept Reprod Health Care. (2016) 21:347–55. doi: 10.1080/13625187.2016.1217327
54. Sabatini R, Cagiano R. Comparison profiles of cycle control, side effects and sexual satisfaction of three hormonal contraceptives. Contraception. (2006) 74:220–3. doi: 10.1016/j.contraception.2006.03.022
55. Lopez LM, Grimes DA, Gallo MF, Stockton LL, Schulz KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev. (2013) 2013:CD003552. doi: 10.1002/14651858.CD003552.pub4
56. Urdl W, Apter D, Alperstein A, Koll P, Schönian S, Bringer J, et al. Contraceptive efficacy, compliance and beyond: factors related to satisfaction with once-weekly transdermal compared with oral contraception. Eur J Obstet Gynecol Reprod Biol. (2005) 121:202–10. doi: 10.1016/j.ejogrb.2005.01.021
57. Toffol E, Partonen T, Heikinheimo O, But A, Latvala A, Haukka J. Associations between use of psychotropic medications and use of hormonal contraception among girls and women aged 15-49 years in Finland: a nationwide, register-based, matched case-control study. BMJ Open. (2022) 12:e053837. doi: 10.1136/bmjopen-2021-053837
58. Gingnell M, Engman J, Frick A, Moby L, Wikström J, Fredrikson M, et al. Oral contraceptive use changes brain activity and mood in women with previous negative affect on the pill–a double-blinded, placebo-controlled randomized trial of a levonorgestrel-containing combined oral contraceptive. Psychoneuroendocrinology. (2013) 38:1133–44. doi: 10.1016/j.psyneuen.2012.11.006
59. Gingnell M, Bannbers E, Engman J, Frick A, Moby L, Wikström J, et al. The effect of combined hormonal contraceptives use on brain reactivity during response inhibition. Eur J Contracept Reprod Health Care. (2016) 21:150–7. doi: 10.3109/13625187.2015.1077381
60. Petersen N, Cahill L. Amygdala reactivity to negative stimuli is influenced by oral contraceptive use. Soc Cogn Affect Neurosci. (2015) 10:1266–72. doi: 10.1093/scan/nsv010
61. Petersen N, Touroutoglou A, Andreano JM, Cahill L. Oral contraceptive pill use is associated with localized decreases in cortical thickness. Hum Brain Mapp. (2015) 36:2644–54. doi: 10.1002/hbm.22797
62. Lisofsky N, Riediger M, Gallinat J, Lindenberger U, Kühn S. Hormonal contraceptive use is associated with neural and affective changes in healthy young women. Neuroimage. (2016) 134:597–606. doi: 10.1016/j.neuroimage.2016.04.042
63. Westberg L, Eriksson E. Sex steroid–related candidate genes in psychiatric disorders. J Psychiatry Neurosci. (2008) 33:319–30.
64. Osterlund MK, Hurd YL. Estrogen receptors in the human forebrain and the relation to neuropsychiatric disorders. Prog Neurobiol. (2001) 64:251–67. doi: 10.1016/S0301-0082(00)00059-9
65. Ziylan YZ, Lefauconnier JM, Bernard G, Bourre JM. Blood-brain barrier permeability: regional alterations after acute and chronic administration of ethinyl estradiol. Neurosci Lett. (1990) 118:181–4. doi: 10.1016/0304-3940(90)90621-F
66. Robakis T, Williams KE, Nutkiewicz L, Rasgon NL. Hormonal contraceptives and mood: review of the literature and implications for future research. Curr Psychiatry Rep. (2019) 21:57. doi: 10.1007/s11920-019-1034-z
67. Toffoletto S, Lanzenberger R, Gingnell M, Sundström-Poromaa I, Comasco E. Emotional and cognitive functional imaging of estrogen and progesterone effects in the female human brain: a systematic review. Psychoneuroendocrinology. (2014) 50:28–52. doi: 10.1016/j.psyneuen.2014.07.025
68. Fruzzetti F, Fidecicchi T. Hormonal contraception and depression: updated evidence and implications in clinical practice. Clin Drug Investig. (2020) 40:1097–106. doi: 10.1007/s40261-020-00966-8
69. Del Río JP, Alliende MI, Molina N, Serrano FG, Molina S, Vigil P. Steroid hormones and their action in women's brains: the importance of hormonal balance. Front Public Health. (2018) 6:141. doi: 10.3389/fpubh.2018.00141
70. Pletzer B, Winkler-Crepaz K, Hillerer K. Progesterone and contraceptive progestin actions on the brain: a systematic review of animal studies and comparison to human neuroimaging studies. Front Neuroendocrinol. (2023) 69:101060. doi: 10.1016/j.yfrne.2023.101060
71. Pletzer B, Harris T, Hidalgo-Lopez E. Previous contraceptive treatment relates to grey matter volumes in the hippocampus and basal ganglia. Sci Rep. (2019) 9:11003. doi: 10.1038/s41598-019-47446-4
72. Vigil P, Del Río JP. Carrera Bá, ArÁnguiz FC, Rioseco H, Cortés ME. Influence of sex steroid hormones on the adolescent brain and behavior: an update. Linacre Q. (2016) 83:308–29. doi: 10.1080/00243639.2016.1211863
73. Vigil P, Orellana RF, Cortés ME, Molina CT, Switzer BE, Klaus H. Endocrine modulation of the adolescent brain: a review. J Pediatr Adolesc Gynecol. (2011) 24:330–7. doi: 10.1016/j.jpag.2011.01.061
74. Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of hormonal contraception with depression. JAMA Psychiatry. (2016) 73:1154–62. doi: 10.1001/jamapsychiatry.2016.2387
75. Righetti F, Tybur J, Van Lange P, Echelmeyer L, van Esveld S, Kroese J, et al. How reproductive hormonal changes affect relationship dynamics for women and men: a 15-day diary study. Biol Psychol. (2020) 149:107784–107784. doi: 10.1016/j.biopsycho.2019.107784
76. Zimmerman Y, Eijkemans MJC, Coelingh Bennink HJT, Blankenstein MA, Fauser BCJM. The effect of combined oral contraception on testosterone levels in healthy women: a systematic review and meta-analysis. Hum Reprod Update. (2014) 20:76–105. doi: 10.1093/humupd/dmt038
77. Panzer C, Wise S, Fantini G, Kang D, Munarriz R, Guay A, et al. Impact of oral contraceptives on sex hormone-binding globulin and androgen levels: a retrospective study in women with sexual dysfunction. J Sex Med. (2006) 3:104–13. doi: 10.1111/j.1743-6109.2005.00198.x
78. Casey PM, MacLaughlin KL, Faubion SS. Impact of contraception on female sexual function. J Womens Health. (2017) 26:207–13. doi: 10.1089/jwh.2015.5703
79. Butt MR, Lema V, Mukaindo A, Mohamoud G, Shabani J. Prevalence of and factors associated with female sexual dysfunction among women using hormonal and non-hormonal contraception at the AGA Khan University Hospital Nairobi. Afr J Prim Health Care Fam Med. (2019) 11:e1–9. doi: 10.4102/phcfm.v11i1.1955
80. Caruso S, Palermo G, Caruso G, Rapisarda AMC. How does contraceptive use affect women's sexuality? A novel look at sexual acceptability. J Clin Med. (2022) 11:810. doi: 10.3390/jcm11030810
81. Casado-Espada NM, de Alarcón R. de la Iglesia-Larrad JI, Bote-Bonaechea B, Montejo ÁL. Hormonal contraceptives, female sexual dysfunction, and managing strategies: a review. J Clin Med. (2019) 8:E908. doi: 10.3390/jcm8060908
82. Both S, Lew-Starowicz M, Luria M, Sartorius G, Maseroli E, Tripodi F, et al. Hormonal contraception and female sexuality: position statements from the European Society of Sexual Medicine (ESSM). J Sex Med. (2019) 16:1681–95. doi: 10.1016/j.jsxm.2019.08.005
83. Novick AM, Johnson RL, Lazorwitz A, Belyavskaya A, Berkowitz L, Norton A, et al. Discontinuation of hormonal contraception due to changes in mood and decreases in sexual desire: the role of adverse childhood experiences. Eur J Contracept Reprod Health Care. (2022) 27:212–20. doi: 10.1080/13625187.2022.2030702
84. Frokjaer VG. Pharmacological sex hormone manipulation as a risk model for depression. J Neurosci Res. (2020) 98:1283–92. doi: 10.1002/jnr.24632
85. Mehta D, Rex-Haffner M, Søndergaard HB, Pinborg A, Binder EB, Frokjaer VG. Evidence for oestrogen sensitivity in perinatal depression: pharmacological sex hormone manipulation study. Br J Psychiatry. (2019) 215:519–27. doi: 10.1192/bjp.2018.234
86. Ditch S, Hansen S, Roberts T. 63 Association of hormonal contraception initiation with subsequent depression diagnosis and antidepressant use in United States military health system beneficiaries: a Cohort Study...SAHM Annual Meeting, Psychological Wellbeing: International Transcultural Perspectives, March 6-9, 2019, Washington, DC, USA. J Adolesc Health. (2019) 64:S34. doi: 10.1016/j.jadohealth.2018.10.078
87. Ditch S, Roberts TA, Hansen S. The influence of health care utilization on the association between hormonal contraception initiation and subsequent depression diagnosis and antidepressant use. Contraception. (2020) 101:237–43. doi: 10.1016/j.contraception.2019.12.011
88. Lara LAS, Abdo CHN. Age at time of initial sexual intercourse and health of adolescent girls. J Pediatr Adolesc Gynecol. (2016) 29:417–23. doi: 10.1016/j.jpag.2015.11.012
89. Grant ECG. Hormonal contraception and its association with depression. JAMA Psychiatry. (2017) 74:301–2. doi: 10.1001/jamapsychiatry.2016.3701
90. Karina IM, Sivakumaran P. Hormonal contraception and its association with depression. JAMA Psychiatry. (2017) 74:301–301. doi: 10.1001/jamapsychiatry.2016.3350
91. Skovlund CW, Mørch LS, Kessing LV, Lange T, Lidegaard Ø. Association of hormonal contraception with suicide attempts and suicides. Am J Psychiatry. (2018) 175:336–42. doi: 10.1176/appi.ajp.2017.17060616
92. Edwards AC, Lönn SL, Crump C, Mościcki EK, Sundquist J, Kendler KS, et al. Oral contraceptive use and risk of suicidal behavior among young women. Psychol Med. (2020) 52:1710–7. doi: 10.1017/S0033291720003475
93. Smith L, Jackson SE, Vancampfort D, Jacob L, Firth J, Grabovac I, et al. Sexual behavior and suicide attempts among adolescents aged 12-15 years from 38 countries: a global perspective. Psychiatry Res. (2020) 287:112564. doi: 10.1016/j.psychres.2019.112564
94. Pérez-López FR, Pérez-Roncero GR, López-Baena MT, Santabárbara J, Chedraui P. Hormonal contraceptives and the risk of suicide: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. (2020) 251:28–35. doi: 10.1016/j.ejogrb.2020.04.053
95. Jung SJ, Cho SMJ, Kim HC. Association of oral contraceptive use with suicidal behavior among representative Korean population: results from Korea National Health and Nutrition Examination Survey (2007-2016). J Affect Disord. (2019) 243:8–15. doi: 10.1016/j.jad.2018.09.004
96. Weakley J, Sachs V, Crosby K, Skaftason H, Migdalski A. Is the use of hormonal contraception associated with suicide and suicide attempts? Am Fam Physician. (2022) 105:82–3.
97. Keyes KM, Cheslack-Postava K, Westhoff C, Heim CM, Haloossim M, Walsh K, et al. Association of hormonal contraceptive use with reduced levels of depressive symptoms: a national study of sexually active women in the United States. Am J Epidemiol. (2013) 178:1378–88. doi: 10.1093/aje/kwt188
98. Colditz GA. Oral contraceptive use and mortality during 12 years of follow-up: the Nurses' Health Study. Ann Intern Med. (1994) 120:821–6. doi: 10.7326/0003-4819-120-10-199405150-00002
99. Beral V, Hermon C, Kay C, Hannaford P, Darby S, Reeves G. Mortality associated with oral contraceptive use: 25 year follow up of cohort of 46 000 women from Royal College of General Practitioners' oral contraception study. BMJ. (1999) 318:96–100. doi: 10.1136/bmj.318.7176.96
100. Amarasekera S, Catalao R, Molyneaux E, Fuhr DC. Hormonal contraceptive use and risk of attempted and completed suicide: a systematic review and narrative synthesis. Psychiatr Q. (2020) 91:1075–87. doi: 10.1007/s11126-020-09815-5
101. Vessey MP, Villard-Mackintosh L, McPherson K, Yeates D. Mortality among oral contraceptive users: 20 year follow up of women in a cohort study. BMJ. (1989) 299:1487–91. doi: 10.1136/bmj.299.6714.1487
102. International Collaborative Post-Marketing Surveillance of Norplant. Post-marketing surveillance of Norplant((R)) contraceptive implants: II. Non-reproductive health(1). Contraception. (2001) 63:187–209. doi: 10.1016/S0010-7824(01)00187-1
103. Vessey MP, McPherson K, Lawless M, Yeates D. Oral contraception and serious psychiatric illness: absence of an association. Br J Psychiatry. (1985) 146:45–9. doi: 10.1192/bjp.146.1.45
104. Hannaford PC, Iversen L, Macfarlane TV, Elliott AM, Angus V, Lee AJ. Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners' Oral Contraception Study. BMJ. (2010) 340:c927. doi: 10.1136/bmj.c927
105. Charlton BM, Rich-Edwards JW, Colditz GA, Missmer SA, Rosner BA, Hankinson SE, et al. Oral contraceptive use and mortality after 36 years of follow-up in the Nurses' Health Study: prospective cohort study. BMJ. (2014) 349:g6356. doi: 10.1136/bmj.g6356
106. Brito MB, Nobre F, Vieira CS. Hormonal contraception and cardiovascular system. Arq Bras Cardiol. (2011) 96:e81–9. doi: 10.1590/S0066-782X2011005000022
107. Escalante CP, Chang YC, Liao K, Rouleau T, Halm J, Bossi P, et al. Meta-analysis of cardiovascular toxicity risks in cancer patients on selected targeted agents. Support Care Cancer. (2016) 24:4057–74. doi: 10.1007/s00520-016-3310-3
108. WHO. Venous thromboembolic disease and combined oral contraceptives: results of international multicentre case-control study. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet. (1995) 16:1575–82. doi: 10.1016/S0140-6736(95)91926-0
109. Woods GM, Kerlin BA, O'Brien SH, Bonny AE. A review of hormonal contraception and venous thromboembolism in adolescents. J Pediatr Adolesc Gynecol. (2016) 29:402–8. doi: 10.1016/j.jpag.2015.05.007
110. WHO. Effect of different progestagens in low oestrogen oral contraceptives on venous thromboembolic disease. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Lancet. (1995) 346:1582–70. doi: 10.1016/S0140-6736(95)91927-9
111. Rosano GMC, Rodriguez-Martinez MA, Spoletini I, Regidor PA. Obesity and contraceptive use: impact on cardiovascular risk. ESC Heart Fail. (2022) 9:3761–7. doi: 10.1002/ehf2.14104
112. AlSheef M, Abuzied Y, Alzahrani GR, AlAraj N, AlAqeel N, Aljishi H, et al. Combined oral contraceptives and vascular thrombosis: a single-center experience. Cureus. (2022) 14:e25865. doi: 10.7759/cureus.25865
113. Maher KN, Quint EH, Weyand AC. Management of contraception in adolescent females with hormone-related venous thromboembolism. J Adolesc Health. (2022) 71:127–31. doi: 10.1016/j.jadohealth.2022.02.009
114. Heinemann LJ. The changing scene-an unnecessary pill crisis. Hum Reprod Update. (1999) 5:746–55. doi: 10.1093/humupd/5.6.746
115. Sacco S, Merki-Feld GS, Ægidius KL, Bitzer J, Canonico M, Kurth T, et al. Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESC). J Headache Pain. (2017) 18:108. doi: 10.1186/s10194-017-0815-1
116. Schwartz SM, Petitti DB, Siscovick DS, Longstreth WT, Sidney S, Raghunathan TE, et al. Stroke and use of low-dose oral contraceptives in young women: a pooled analysis of two US studies. Stroke. (1998) 29:2277–84. doi: 10.1161/01.STR.29.11.2277
117. Schwartz SM, Siscovick DS, Longstreth WT Jr, Psaty BM, Beverly RK, Raghunathan TE, et al. Use of low-dose oral contraceptives and stroke in young women. Ann Intern Med. (1997) 127:596–603. doi: 10.7326/0003-4819-127-8_Part_1-199710150-00003
118. Khader YS, Rice J, John L, Abueita O. Oral contraceptives use and the risk of myocardial infarction: a meta-analysis. Contraception. (2003) 68:11–7. doi: 10.1016/S0010-7824(03)00073-8
119. Kovell LC, Meyerovitz CV, Skaritanov E, Ayturk D, Person SD, Kumaraswami T, et al. Hypertension and contraceptive use among women of child-bearing age in the United States from 2001 to 2018. J Hypertens. (2022) 40:776–84. doi: 10.1097/HJH.0000000000003077
120. Gunaratne MDSK, Thorsteinsdottir B, Garovic VD. Combined oral contraceptive pill-induced hypertension and hypertensive disorders of pregnancy: shared mechanisms and clinical similarities. Curr Hypertens Rep. (2021) 23:29. doi: 10.1007/s11906-021-01147-4
121. Shufelt C, LeVee A. Hormonal contraception in women with hypertension. JAMA. (2020) 324:1451–2. doi: 10.1001/jama.2020.11935
122. Batur P, Yao M, Bucklan J, Soni P, Suneja A, Farrell R, et al. Use of combined hormonal contraception and stroke: a case-control study of the impact of migraine type and estrogen dose on ischemic stroke risk. Headache. (2023) 1–9. doi: 10.1111/head.14473
123. Edelman AB, Jensen JT. Obesity and hormonal contraception: safety and efficacy. Semin Reprod Med. (2012) 30:479–85. doi: 10.1055/s-0032-1328876
124. Lee J, Jeong H, Yoon JH, Yim HW. Association between past oral contraceptive use and the prevalence of hypertension in postmenopausal women: the fifth (2010-2012) Korea National Health and Nutrition Examination Survey (KNHANES V). BMC Public Health. (2022) 22:27. doi: 10.1186/s12889-021-12410-3
125. Chen GG, Zeng Q, Tse GM. Estrogen and its receptors in cancer. Med Res Rev. (2008) 28:954–74. doi: 10.1002/med.20131
126. Khoo SK. Cancer risks and the contraceptive pill. What is the evidence after nearly 25 years of use? Med J Aust. (1986) 144:185–90. doi: 10.5694/j.1326-5377.1986.tb128354.x
128. Collins J, Crosignani PG, ESHRE Capri Workshop Group. Hormonal contraception without estrogens. Hum Reprod Update. (2003) 9:373–86. doi: 10.1093/humupd/dmb025
129. Moodley J. Combined oral contraceptives and cervical cancer. Curr Opin Obstet Gynecol. (2004) 16:27–9. doi: 10.1097/00001703-200402000-00006
130. Basciani S, Porcaro G. Counteracting side effects of combined oral contraceptives through the administration of specific micronutrients. Eur Rev Med Pharmacol Sci. (2022) 26:4846–62. doi: 10.26355/eurrev_202207_29210
131. Sedlander E, Yilma H, Emaway D, Rimal RN. If fear of infertility restricts contraception use, what do we know about this fear? An examination in rural. Ethiopia Reprod Health. (2022) 19:57. doi: 10.1186/s12978-021-01267-9
132. Al Basri SF, Al Abdali JA, Alzubaidi HM, Almarhabi AA, Alzubaidi MA, Al Qarni G, et al. Knowledge of reproductive age women about oral contraceptive pills in Al-Qunfudah, Saudi Arabia. Open Access J Contracept. (2022) 13:61–71. doi: 10.2147/OAJC.S354452
133. Le Guen M, Schantz C, Régnier-Loilier A, de La Rochebrochard E. Reasons for rejecting hormonal contraception in Western countries: a systematic review. Soc Sci Med. (2021) 284:114247. doi: 10.1016/j.socscimed.2021.114247
134. Mansour D, Gemzell-Danielsson K, Inki P, Jensen JT. Fertility after discontinuation of contraception: a comprehensive review of the literature. Contraception. (2011) 84:465–77. doi: 10.1016/j.contraception.2011.04.002
135. Pragout D, Laurence V, Baffet H, Raccah-Tebeka B, Rousset-Jablonski C. [Contraception and cancer: CNGOF Contraception Guidelines]. Gynecol Obstet Fertil Senol. (2018) 46:834–44. doi: 10.1016/j.gofs.2018.10.010
136. Iversen L, Sivasubramaniam S, Lee AJ, Fielding S, Hannaford PC. Lifetime cancer risk and combined oral contraceptives: the Royal College of General Practitioners' Oral Contraception Study. Am J Obstet Gynecol. (2017) 216:580.e1–9. doi: 10.1016/j.ajog.2017.02.002
137. Wingo PA, Lee NC, Ory HW, Beral V, Peterson HB, Rhodes P. Age-specific differences in the relationship between oral contraceptive use and breast cancer. Obstet Gynecol. (1991) 78:161–70. doi: 10.2307/1966458
138. Rosenberg L, Zhang Y, Coogan PF, Strom BL, Palmer JR. A case-control study of oral contraceptive use and incident breast cancer. Am J Epidemiol. (2009) 169:473–9. doi: 10.1093/aje/kwn360
139. Brinton LA, Daling JR, Liff JM, Schoenberg JB, Malone KE, Stanford JL, et al. Oral contraceptives and breast cancer risk among younger women. J Natl Cancer Inst. (1995) 87:827–35. doi: 10.1093/jnci/87.11.827
140. White E, Malone KE, Weiss NS. Daling JR. Breast cancer among young US women in relation to oral contraceptive use. J Natl Cancer Inst. (1994) 86:505–14. doi: 10.1093/jnci/86.7.505
141. Kahlenborn C. Breast Cancer. Its Link to Abortion and the Birth Control Pill. Dayton, OH: One More Soul (2000).
142. Hah N, Kraus WL. Hormone-regulated transcriptomes: lessons learned from estrogen signaling pathways in breast cancer cells. Mol Cell Endocrinol. (2014) 382:652–64. doi: 10.1016/j.mce.2013.06.021
143. Santillán-Benítez JG, Quiroz-Ordóñez Á, Mendieta-Zerón H, Gómez-Oliván LM. Expresión génica y receptores hormonales en cáncer mamario “El camino hacia la búsqueda de terapias preventivas”. Rev Med Inv. (2013) 1:17–24.
144. Shamseddin M, De Martino F, Constantin C, Scabia V, Lancelot A-S, Laszlo C, et al. Contraceptive progestins with androgenic properties stimulate breast epithelial cell proliferation. EMBO Mol Med. (2021) 13:e14314. doi: 10.15252/emmm.202114314
145. Depypere HT, Stanczyk FZ, Croubels S, Blondeel PN, Roche NA, Depypere BP, et al. Breast levonorgestrel concentrations in women using a levonorgestrel-releasing intrauterine system. Contraception. (2019) 100:299–301. doi: 10.1016/j.contraception.2019.07.002
146. Mørch LS, Skovlund CW, Hannaford PC, Iversen L, Fielding S, Lidegaard Ø. Contemporary hormonal contraception and the risk of breast cancer. Obstet Gynecol Surv. (2018) 73:215–7. doi: 10.1097/01.ogx.0000531328.30801.b7
147. Schneyer R, Lerma K. Health outcomes associated with use of hormonal contraception: breast cancer. Curr Opin Obstet Gynecol. (2018) 30:414–8. doi: 10.1097/GCO.0000000000000493
148. Conz L, Mota BS, Bahamondes L, Teixeira Dória M, Françoise Mauricette Derchain S, Rieira R, et al. Levonorgestrel-releasing intrauterine system and breast cancer risk: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. (2020) 99:970–82. doi: 10.1111/aogs.13817
149. Borges JBR, Torresan RZ, Borges JBR, Torresan RZ. Breast cancer and hormonal contraception: should we rethink our concepts? Rev Assoc Méd Bras. (2018) 64:201–3. doi: 10.1590/1806-9282.64.03.201
150. Vyver E, Hwang LY. A paediatric perspective on hormonal contraception and breast cancer risk: new literature about a recurring question. Paediatr Child Health. (2019) 24:224–6. doi: 10.1093/pch/pxy169
151. Del Pup L, Codacci-Pisanelli G, Peccatori F. Breast cancer risk of hormonal contraception: counselling considering new evidence. Crit Rev Oncol Hematol. (2019) 137:123–30. doi: 10.1016/j.critrevonc.2019.03.001
152. Marsden J. Hormonal contraception and breast cancer, what more do we need to know? Post Reprod Health. (2017) 23:116–27. doi: 10.1177/2053369117715370
153. Kusmiyati Y, Prasistyami A, Wahyuningsih HP, Widyasih H, Adnani QES. Duration of hormonal contraception and risk of cervical cancer. Kesmas. (2019) 14:1–1. doi: 10.21109/kesmas.v14i1.2713
154. Smith JS, Green J, Berrington de Gonzalez A, Appleby P, Peto J, Plummer M, et al. Cervical cancer and use of hormonal contraceptives: a systematic review. Lancet. (2003) 361:1159–67. doi: 10.1016/S0140-6736(03)12949-2
155. Iversen L, Fielding S, Lidegaard Ø, Hannaford PC. Contemporary hormonal contraception and cervical cancer in women of reproductive age. Int J Cancer. (2021) 149:769–77. doi: 10.1002/ijc.33585
156. Miyamoto T, Shiozawa T. Two-sided role of estrogen on endometrial carcinogenesis: stimulator or suppressor? Gynecol Endocrinol. (2019) 35:370–5. doi: 10.1080/09513590.2018.1549219
157. Wan L, O'Brien P. Molecular mechanism of 17α-ethinylestradiol cytotoxicity in isolated rat hepatocytes. Can J Physiol Pharmacol. (2013) 92:21–6. doi: 10.1139/cjpp-2013-0267
158. Metzler M, Blaich G, Tritscher AM. Role of metabolic activation in the carcinogenicity of estrogens: studies in an animal liver tumor model. Environ Health Perspect. (1990) 88:117–21. doi: 10.1289/ehp.9088117
159. Newbold RR, Liehr JG. Induction of uterine adenocarcinoma in CD-1 mice by catechol estrogens. Cancer Res. (2000) 60:235–7.
160. Metzler M. Metabolism of stilbene estrogens and steroidal estrogens in relation to carcinogenicity. Arch Toxicol. (1984) 55:104–9. doi: 10.1007/BF00346047
161. Phillips V, Graham CT, Manek S, McCluggage WG. The effects of the levonorgestrel intrauterine system (Mirena coil) on endometrial morphology. J Clin Pathol. (2003) 56:305–7. doi: 10.1136/jcp.56.4.305
162. Chang RJ, Rivera-Colon G, Chen H, Niu S, Carrick K, Lucas E, et al. Navigating through perplex morphologic changes after exogenous hormone usage. Semin Diagn Pathol. (2022) 39:148–58. doi: 10.1053/j.semdp.2021.10.001
163. Chodankar RR, Murray A, Nicol M, Whitaker LHR, Williams ARW, Critchley HOD. The endometrial response to modulation of ligand-progesterone receptor pathways is reversible. Fertil Steril. (2021) 116:882–95. doi: 10.1016/j.fertnstert.2021.02.008
164. Key TJ, Pike MC. The dose-effect relationship between “unopposed” oestrogens and endometrial mitotic rate: its central role in explaining and predicting endometrial cancer risk. Br J Cancer. (1988) 57:205–12. doi: 10.1038/bjc.1988.44
165. Bernstein L. The risk of breast, endometrial and ovarian cancer in users of hormonal preparations. Basic Clin Pharmacol Toxicol. (2006) 98:288–96. doi: 10.1111/j.1742-7843.2006.pto_277.x
166. Maxwell GL, Schildkraut JM, Calingaert B, Risinger JI, Dainty L, Marchbanks PA, et al. Progestin and estrogen potency of combination oral contraceptives and endometrial cancer risk. Gynecol Oncol. (2006) 103:535–40. doi: 10.1016/j.ygyno.2006.03.046
167. Burchardt NA, Shafrir AL, Kaaks R, Tworoger SS, Fortner RT. Oral contraceptive use by formulation and endometrial cancer risk among women born in 1947–1964: the Nurses' Health Study II, a prospective cohort study. Eur J Epidemiol. (2021) 36:827–39. doi: 10.1007/s10654-020-00705-5
168. Steshenko A, Hanna L, Collins D. Development of endometrial cancer after long-term usage of the levonorgestrel-releasing intrauterine system. BMJ Case Rep. (2021) 14:e242094. doi: 10.1136/bcr-2021-242094
169. Kuzel D, Mara M, Zizka Z, Koliba P, Dundr P, Fanta M. Malignant endometrial polyp in woman with the levonorgestrel intrauterine system – a case report. Gynecological Endocrinology. (2019) 35:112–4. doi: 10.1080/09513590.2018.1491028
170. Thomas M, Briggs P. A case of endometrial carcinoma in a long-term Levonorgestrel Intrauterine System (LNG 52 mg-IUS) user. Post Reprod Health. (2017) 23:13–4. doi: 10.1177/2053369117691201
171. Abu J, Brown L, Ireland D. Endometrial adenocarcinoma following insertion of the levonorgestrel-releasing intrauterine system (mirena) in a 36-year-old woman. Int J Gynecol Cancer. (2006) 16:1445–7. doi: 10.1136/ijgc-00009577-200605000-00077
172. Flemming R, Sathiyathasan S, Jackson A. Endometrioid Adenocarcinoma after Insertion of a Levonorgestrel-releasing Intrauterine System. J Minim Invasive Gynecol. (2008) 15:771–3. doi: 10.1016/j.jmig.2008.08.016
173. Ndumbe FM, Husemeyer RP. Endometrial adenocarcinoma in association with a levonorgestrel-releasing intrauterine system (Mirena®). BMJ Sex Reprod Health. (2006) 32:113–4. doi: 10.1783/147118906776276143
174. Jones K, Georgiou M, Hyatt D, Spencer T, Thomas H. Endometrial adenocarcinoma following the insertion of a mirena IUCD. Gynecol Oncol. (2002) 87:216–8. doi: 10.1006/gyno.2002.6817
175. Jusko WJ. Clarification of contraceptive drug pharmacokinetics in obesity. Contraception. (2017) 95:10–6. doi: 10.1016/j.contraception.2016.08.003
176. Robinson JA, Burke AE. Obesity and hormonal contraceptive efficacy. Womens Health. (2013) 9:453–66. doi: 10.2217/WHE.13.41
177. Simmons KB, Edelman AB. Hormonal contraception and obesity. Fertil Steril. (2016) 106:1282–8. doi: 10.1016/j.fertnstert.2016.07.1094
178. Mody SK, Han M. Obesity and contraception. Clin Obstet Gynecol. (2014) 57:501–7. doi: 10.1097/GRF.0000000000000047
179. Bahamondes L, Valeria Bahamondes M, Shulman LP. Non-contraceptive benefits of hormonal and intrauterine reversible contraceptive methods. Hum Reprod Update. (2015) 21:640–51. doi: 10.1093/humupd/dmv023
180. Mu N, Dong M, Li L, Xia M, Qv L, Wang Y, et al. Synergistic effect of metformin and medroxyprogesterone 17-acetate on the development of endometrial cancer. Oncol Rep. (2018) 39:2015–21. doi: 10.3892/or.2018.6236
181. Kamani M, Akgor U, Gültekin M. Review of the literature on combined oral contraceptives and cancer. Ecancermedicalscience. (2022) 16:1416. doi: 10.3332/ecancer.2022.1416
182. Karlsson T, Johansson T, Höglund J, Ek WE, Johansson Å. Time-dependent effects of oral contraceptive use on breast, ovarian, and endometrial cancers. Cancer Res. (2021) 81:1153–62. doi: 10.1158/0008-5472.CAN-20-2476
183. Bahamondes L, Makuch MY. Awareness of the non-contraceptive benefits of reversible contraceptive methods in a cohort of Brazilian women: an exploratory study. Eur J Contracept Reprod Health Care. (2022) 27:294–9. doi: 10.1080/13625187.2022.2054983
184. Raglan O, Kalliala I, Markozannes G, Cividini S, Gunter MJ, Nautiyal J, et al. Risk factors for endometrial cancer: an umbrella review of the literature. Int J Cancer. (2019) 145:1719–30. doi: 10.1002/ijc.31961
185. Wu Q-J, Li Y-Y, Tu C, Zhu J, Qian K-Q, Feng T-B, et al. Parity and endometrial cancer risk: a meta-analysis of epidemiological studies. Sci Rep. (2015) 5:14243. doi: 10.1038/srep14243
186. Niño-Avendaño CA, Vargas-Rodríguez LJ, González-Jiménez NM. Abandono, cambio o falla de los anticonceptivos hormonales en población universitaria. Ginecol Obstet Mex. (2019) 87:499–505. doi: 10.24245/gom.v87i8.2935
187. Morgante G, Massaro MG, Di Sabatino A, Cappelli V, De Leo V. Therapeutic approach for metabolic disorders and infertility in women with PCOS. Gynecol Endocrinol. (2018) 34:4–9. doi: 10.1080/09513590.2017.1370644
188. Brent D. Contraceptive conundrum: use of hormonal contraceptives is associated with an increased risk of suicide attempt and suicide. AJP. (2018) 175:300–2. doi: 10.1176/appi.ajp.2018.18010039
189. Bonfiglio R, Di Pietro ML. The impact of oral contraceptive use on breast cancer risk: state of the art and future perspectives in the era of 4P medicine. Semin Cancer Biol. (2021) 72:11–18. doi: 10.1016/j.semcancer.2020.10.008
190. Ignatov A, Ortmann O. Endocrine risk factors of endometrial cancer: polycystic ovary syndrome, oral contraceptives, infertility, tamoxifen. Cancers. (2020) 12:E1766. doi: 10.3390/cancers12071766
191. Joham AE, Norman RJ, Stener-Victorin E, Legro RS, Franks S, Moran LJ, et al. Polycystic ovary syndrome. Lancet Diabetes Endocrinol. (2022) 10:668–80. doi: 10.1016/S2213-8587(22)00163-2
192. Taylor JS. The value of autonomy and the right to self-medication. J Med Ethics. (2012) 38:587–8. doi: 10.1136/medethics-2012-100668
193. Höglund B, Larsson M. Ethical dilemmas and legal aspects in contraceptive counselling for women with intellectual disability-Focus group interviews among midwives in Sweden. J Appl Res Intellect Disabil. (2019) 32:1558–66. doi: 10.1111/jar.12651
194. Gebeyehu NA, Tegegne KD, Biset G, Sewuyew DA, Alemu BW, Yitayew AM. Discontinuation of long acting reversible contraceptive use and its determinants among women in Ethiopia: systematic review and meta-analysis. Front Public Health. (2022) 10:979231. doi: 10.3389/fpubh.2022.979231
195. Entwistle VA, Carter SM, Cribb A, McCaffery K. Supporting patient autonomy: the importance of clinician-patient relationships. J Gen Intern Med. (2010) 25:741–5. doi: 10.1007/s11606-010-1292-2
196. Senderowicz L. Contraceptive autonomy: conceptions and measurement of a novel family planning indicator. Stud Fam Plann. (2020) 51:161–76. doi: 10.1111/sifp.12114
197. Black A, Bow M, Armson BA, Guilbert É, Dunn S, Fisher WA. Committee opinion no. 419: coercion free contraceptive care. J Obstet Gynaecol Can. (2021) 43:1107–11. doi: 10.1016/j.jogc.2021.07.001
198. Hoss F, London AJ. Assessing the moral coherence and moral robustness of social systems: proof of concept for a graphical models approach. Sci Eng Ethics. (2016) 22:1761–79. doi: 10.1007/s11948-015-9743-0
199. Levin A, Berger K. Call to action: the pharmacist's role in improving contraceptive knowledge and access. J Am Pharm Assoc. (2003). 63:43–5. doi: 10.1016/j.japh.2022.08.021
200. Eckhaus LM Ti AJ, Curtis KM, Stewart-Lynch AL, Whiteman MK. Patient and pharmacist perspectives on pharmacist-prescribed contraception: a systematic review. Contraception. (2021) 103:66–74. doi: 10.1016/j.contraception.2020.10.012
201. Rodriguez MI, Edelman AB, Skye M, Anderson L, Darney BG. Association of pharmacist prescription with dispensed duration of hormonal contraception. JAMA Netw Open. (2020) 3:e205252. doi: 10.1001/jamanetworkopen.2020.5252
202. Wernow JR, Grant DG. Dispensing with conscience: a legal and ethical assessment. Ann Pharmacother. (2008) 42:1669–78. doi: 10.1345/aph.1L049
203. Stone RH, Rafie S, Griffin B, Shealy K, Stein AB. Pharmacist self-perception of readiness to prescribe hormonal contraception and additional training needs. Curr Pharm Teach Learn. (2020) 12:27–34. doi: 10.1016/j.cptl.2019.10.005
204. Altilio JV. The pharmacist's obligations to patients: dependent or independent of the physician's obligations? J Law Med Ethics. (2009) 37:358–68. doi: 10.1111/j.1748-720X.2009.00379.x
205. Tatsioni A, Gerasi E, Charitidou E, Simou N, Mavreas V, Ioannidis JPA. Important drug safety information on the internet: assessing its accuracy and reliability. Drug Saf. (2003) 26:519–27. doi: 10.2165/00002018-200326070-00005
206. Nguyen C. The accuracy and completeness of drug information in Google snippet blocks. J Med Libr Assoc. (2021). 109:613–617. doi: 10.5195/jmla.2021.1229
207. Scarton LA, Del Fiol G, Treitler-Zeng Q. Completeness, accuracy and presentation of information on interactions between prescription drugs and alternative medicines: an internet review. Stud Health Technol Inform. (2013) 192:841–5.
208. Golman R, Hagmann D, Loewenstein G. Information avoidance. J Econ Lit. (2017) 55:96–135. doi: 10.1257/jel.20151245
209. Brabaharan S, Veettil SK, Kaiser JE, Raja Rao VR, Wattanayingcharoenchai R, Maharajan M, et al. Association of hormonal contraceptive use with adverse health outcomes: an umbrella review of meta-analyses of randomized clinical trials and cohort studies. JAMA Netw Open. (2022) 5:e2143730. doi: 10.1001/jamanetworkopen.2021.43730
210. Mailankody S, Bajpai J, Gupta S. “Petite” p value: a researchers' dream! readers, beware of the pit …. Indian J Crit Care Med. (2020) 24:S140–1. doi: 10.5005/jp-journals-10071-23399
211. Griffiths P, Needleman J. Statistical significance testing and p-values: defending the indefensible? A discussion paper and position statement. Int J Nurs Stud. (2019) 99:103384. doi: 10.1016/j.ijnurstu.2019.07.001
212. Amrhein V, Korner-Nievergelt F. Roth T. The earth is flat (p > 005): significance thresholds and the crisis of unreplicable research. PeerJ. (2017) 5:e3544. doi: 10.7717/peerj.3544
213. Andrade C. The P value and statistical significance: misunderstandings, explanations, challenges, and alternatives. Indian J Psychol Med. (2019) 41:210–5. doi: 10.4103/IJPSYM.IJPSYM_193_19
214. Greenland S, Senn SJ, Rothman KJ, Carlin JB, Poole C, Goodman SN, et al. Statistical tests, P values, confidence intervals, and power: a guide to misinterpretations. Eur J Epidemiol. (2016) 31:337–50. doi: 10.1007/s10654-016-0149-3
215. Lytsy P, P. in the right place: revisiting the evidential value of P-values. J Evid Based Med. (2018) 11:288–91. doi: 10.1111/jebm.12319
216. Held L. The assessment of intrinsic credibility and a new argument for p < 0.005. R Soc Open Sci. (2019) 6:181534. doi: 10.1098/rsos.181534
217. Farrugia A, Fraser S. Science and scepticism: drug information, young men and counterpublic health. Health. (2017) 21:595–615. doi: 10.1177/1363459315628042
218. Higgins JA, Smith NK. The sexual acceptability of contraception: reviewing the literature and building a new concept. J Sex Res. (2016) 53:417–56. doi: 10.1080/00224499.2015.1134425
219. Srikanthan A, Reid RL. Religious and cultural influences on contraception. J Obstet Gynaecol Can. (2008) 30:129–37. doi: 10.1016/S1701-2163(16)32736-0
220. Song S, Lee G. Association between sexual behavior and suicidal ideation among South Korean middle school students. Jpn J Nurs Sci. (2019) 16:300–8. doi: 10.1111/jjns.12237
221. Daniels K. Current contraceptive status among women aged 15–49: United States, 2017–2019. NCHS Data Brief . (2020) 8:1–8.
222. Fehring RJ, Bouchard T, Meyers M. Influence of contraception use on the reproductive health of adolescents and young adults. Linacre Q. (2018) 85:167–77. doi: 10.1177/0024363918770462
223. Williams WV, Brind J, Haynes L, Manhart MD, Klaus H, Lanfranchi A, et al. Hormonally active contraceptives, part II: sociological, environmental, and economic impact. Linacre Q. (2021) 88:291–316. doi: 10.1177/00243639211005121
224. Bień A, Rzońca E, Chruściel P, Łuka M, Iwanowicz-Palus GJ. Female sexuality at reproductive age as an indicator of satisfaction with life – descriptive cross-sectional survey. Ann Agric Environ Med. (2020) 27:599–604. doi: 10.26444/aaem/114176
225. Robinson JG, Molzahn AE. Sexuality and quality of life. J Gerontol Nurs. (2007) 33:19–27. doi: 10.3928/00989134-20070301-05
226. Cacabelos R, Naidoo V, Corzo L, Cacabelos N, Carril JC. Genophenotypic factors and pharmacogenomics in adverse drug reactions. Int J Mol Sci. (2021) 22:13302. doi: 10.3390/ijms222413302
227. Khan LM. Comparative epidemiology of hospital-acquired adverse drug reactions in adults and children and their impact on cost and hospital stay–a systematic review. Eur J Clin Pharmacol. (2013) 69:1985–96. doi: 10.1007/s00228-013-1563-z
228. Lim R, Ellett LMK, Semple S, Roughead EE. The extent of medication-related hospital admissions in australia: a review from 1988 to 2021. Drug Saf. (2022) 45:249–57. doi: 10.1007/s40264-021-01144-1
229. Riaz M, Brown JD. Association of adverse drug events with hospitalization outcomes and costs in older adults in the USA using the Nationwide Readmissions Database. Pharmaceut Med. (2019) 33:321–9. doi: 10.1007/s40290-019-00286-z
230. Ali MU, Sherifali D, Fitzpatrick-Lewis D, Kenny M, Lamarche L, Raina P, et al. Interventions to address polypharmacy in older adults living with multimorbidity: review of reviews. Can Fam Physician. (2022) 68:e215–26. doi: 10.46747/cfp.6807e215
231. Mucherino S, Casula M, Galimberti F, Guarino I, Olmastroni E, Tragni E, et al. The effectiveness of interventions to evaluate and reduce healthcare costs of potentially inappropriate prescriptions among the older adults: a systematic review. Int J Environ Res Public Health. (2022) 19:6724. doi: 10.3390/ijerph19116724
232. Kaur H, Bala M, Bansal G. Reproductive drugs and environmental contamination: quantum, impact assessment and control strategies. Environ Sci Pollut Res Int. (2018) 25:25822–39. doi: 10.1007/s11356-018-2754-z
233. Shi W-J, Long X-B, Li S-Y, Ma D-D, Liu F, Zhang J-G, et al. Dydrogesterone and levonorgestrel at environmentally relevant concentrations have antagonist effects with rhythmic oscillation in brain and eyes of zebrafish. Aquat Toxicol. (2022) 248:106177. doi: 10.1016/j.aquatox.2022.106177
234. Tang Z, Liu Z-H, Wang H, Dang Z, Liu Y. A review of 17α-ethynylestradiol (EE2) in surface water across 32 countries: sources, concentrations, and potential estrogenic effects. J Environ Manage. (2021) 292:112804. doi: 10.1016/j.jenvman.2021.112804
235. García-Cambero JP, Corpa C, Lucena MA, Méndez P, Sierra P, Galán-Madruga D, et al. Presence of diclofenac, estradiol, and ethinylestradiol in Manzanares River (Spain) and their toxicity to zebrafish embryo development. Environ Sci Pollut Res Int. (2021) 28:49921–35. doi: 10.1007/s11356-021-14167-z
236. Ting YF, Praveena SM. Sources, mechanisms, and fate of steroid estrogens in wastewater treatment plants: a mini review. Environ Monit Assess. (2017) 189:178. doi: 10.1007/s10661-017-5890-x
237. Zhao Y, Castiglioni S, Fent K. Synthetic progestins medroxyprogesterone acetate and dydrogesterone and their binary mixtures adversely affect reproduction and lead to histological and transcriptional alterations in zebrafish (Danio rerio). Environ Sci Technol. (2015) 49:4636–45. doi: 10.1021/es505575v
238. Wedekind C. Fish populations surviving estrogen pollution. BMC Biol. (2014) 12:10. doi: 10.1186/1741-7007-12-10
239. Lukasse M, Baglo MCG, Engdal E, Lassemo R, Forsberg KE. Norwegian women's experiences and opinions on contraceptive counselling: a systematic textcondensation study. Eur J Midwifery. (2021) 5:4. doi: 10.18332/ejm/132224
240. Shiferaw M, Kassahun W, Zawdie B. Anthropometric indices, blood pressure, and lipid profile status among women using progestin-only contraceptives: comparative cross-sectional study. BMC Womens Health. (2021) 21:34. doi: 10.1186/s12905-021-01178-8
241. Bick AJ, Louw-du Toit R, Skosana SB, Africander D, Hapgood JP. Pharmacokinetics, metabolism and serum concentrations of progestins used in contraception. Pharmacol Ther. (2020) 222:107789. doi: 10.1016/j.pharmthera.2020.107789
242. Sunaga T, Cicali B, Schmidt S, Brown J. Comparison of contraceptive failures associated with CYP3A4-inducing drug-drug interactions by route of hormonal contraceptive in an adverse event reporting system. Contraception. (2021) 103:222–4. doi: 10.1016/j.contraception.2020.12.002
243. Berlin I, Aubin H-J, Thomas D. Comment on the association of hormonal contraception with suicide attempts and suicides. Am J Psychiatry. (2018) 175:683–683. doi: 10.1176/appi.ajp.2018.18010057
Keywords: contraception, health care delivery, medical humanities, women's health, autonomy, adverse effects
Citation: Segarra I, Menárguez M and Roqué MV (2023) Women's health, hormonal balance, and personal autonomy. Front. Med. 10:1167504. doi: 10.3389/fmed.2023.1167504
Received: 10 March 2023; Accepted: 30 May 2023;
Published: 30 June 2023.
Edited by:
Redhwan Ahmed Al-Naggar, National University of Malaysia, MalaysiaReviewed by:
David Archer, Eastern Virginia Medical School, United StatesAhmed Mohammed Alwan, Mashhad University of Medical Sciences, Iran
Copyright © 2023 Segarra, Menárguez and Roqué. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ignacio Segarra, isegarra@ucam.edu