BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES 5. - Contraception
RADIO 4
TUESDAY 07/09/04 2100-2130
PRESENTER:
MARK PORTER
REPORTER:
LESLEY HILTON
CONTRIBUTORS:
ANNE SZAREWSKI
KAY WELLINGS
DIANA MASSOUR
RICHARD ANDERSON
TONI BELLFIELD
PRODUCER:
HELEN SHARP
NOT CHECKED AS BROADCAST
PORTER
Hello, today's programme focuses on three topical issues from the field of contraception - unplanned pregnancies in British teenagers, a long acting contraceptive that's proving a popular alternative to sterilisation, and the eternal quest for the male pill - just how close are we?
JONES
He wasn't planned like I wanted children, but now I see you of course I do.
There's a couple of people that I went to school with that have got children. There's - from baby clubs I've met other young people that haven't like finished school or anything. But then there's other people that I have - when I was at school my group of friends they had abortions and things like that and that's something that they're dealing with at school and with their exams and everything and I don't - I mean obviously it affects their results and stuff so.
PORTER
Clare Jones with her seven month old son Ramon, who was conceived when Clare was just 17.
The UK has the second highest teenage pregnancy rate in the developed world - around 40,000 babies will be born to girls under the age of 18 this year, and there will be nearly as many teenage abortions. UNICEF, the United Nations Children's Fund, blames poor sex education in the UK and Clare agrees.
JONES
I don't remember really having classes, I think it was just one lesson, one lesson and they just try and scare you out of having sex with like oh you're going to catch this, you can catch that and it's really high in this borough and that's it really. They showed us pictures of infections and things like that and that was it. They never covered about relationships, how to - when you know the time's right and things like that, which I think is important.
PORTER
But it's not just sex education we need to get right - I'll be discovering how our preference for the Pill could also be part of the problem.
I'll also be investigating why Mirena, the first hormone impregnated contraceptive device inserted directly into the womb, is proving such a popular alternative to sterilisation and hysterectomy among older women.
And, last but by no means least, the elusive male pill. I'll be finding out where we are in the quest for the male contraceptive, and hearing what it's like to be one of the guinea pigs involved in testing the latest prototypes - trust me gentlemen, you will be interested in the side effects!
My guest today is Dr Anne Szarewski, she's from the Margaret Pyke Centre, which is a family planning clinic here in London.
Anne, how reliable is natural family planning? I mean using our knowledge of the menstrual cycle surely we can reduce the odds on an unplanned pregnancy if we take care?
SZAREWSKI
Yes in theory it could really be quite effective because women when they ovulate the egg only lasts - it only lives for about 24 to 48 hours. The big problem - the thing that makes the actual planning go wrong is sperm because they can - there's something called the lunatic fringe sperm - have been known to survive up to seven days. So that's where everyone comes unstuck because they think oh yes okay, so round about the middle of my cycle - day 14 - mustn't have sex, they forget that sex they had on day 7 of their cycle may actually get them pregnant.
PORTER
Which is pretty early in a cycle, I mean some women might still be bleeding at that stage.
SZAREWSKI
Well that's the problem and so they think they couldn't possibly get pregnant that early but in fact it can happen.
PORTER
Okay, so we need contraception, it is a huge subject and obviously it's vital that we tailor each type of contraception to the needs of the woman. Imagine these four stereotypical groups - and let's talk about the most popular choices that we have here in the UK. So let's start with a single woman under 25.
SZAREWSKI
They're most likely to take the Pill, I think that's what most young women - but that's what they've heard about, it's what they know, it's what their friends are using and so most of them are going to want the Pill.
PORTER
And of course yes it is very effective isn't it.
SZAREWSKI
It's extremely effective and you control it - I actually think that's quite important - you control it, you decide when you want to stop if you do want to stop, it doesn't in most women have that many side effects, it also means that you can move your periods around if you want to which young women quite like. So I think it actually has a lot of the features that suit young women.
PORTER
And by moving periods around you're talking running pills back to back - if they go on holiday, for instance, they don't have a break, so they don't have a period.
SZAREWSKI
Yeah.
PORTER
Of course it doesn't protect against sexually transmitted infections, which are a problem in this age group. Do you routinely recommend that single women use Pill and condom?
SZAREWSKI
Yes we always suggest that that's a good idea - that they should take the Pill because it's a very effective contraceptive and then they should use condoms to protect themselves against sexually transmitted infections.
PORTER
What about a slightly older woman who may well be in a stable relationship, possibly married, who's looking at starting a family but wants some contraception in the meantime, so something reversible, I mean presumably they're still taking the Pill as well?
SZAREWSKI
Oh yes, many of them will still be taking the Pill. For those women, of course, there are so many options because they don't need to worry quite so much about how effective the method is. They probably won't be quite so interested, unless there's a good reason, for using the long term methods if they're thinking they might want to get pregnant quite soon, and they probably won't want to be using contraceptive injections because those are temporarily irreversible, so that's probably the one thing that if you're actually thinking of getting pregnant quite soon that's not such a brilliant idea.
PORTER
What about the mini Pill in this age group because taken properly - and let's explain the difference between the mini Pill and the conventional Pill. The conventional Pill - the Pill, as we know it - has two hormones doesn't it - oestrogen and progestogen.
SZAREWSKI
Yeah.
PORTER
The mini Pill just has one - the progestogen. But taken properly and regularly it is almost as effective as the combined Pill isn't it.
SZAREWSKI
Well in fact the good news about the progestogen only Pill is that there's a new one now called Cerazette which probably is as effective as the combined Pill and because it actually works by stopping you ovulating in the same way as the combined Pill so actually it's now been officially granted, as of a couple of months ago, a 12 hour pill taking leeway, when that was always the big problem ...
PORTER
What if you were late with the mini Pill you weren't covered?
SZAREWSKI
Yeah, you only had three hours and that's really difficult for anyone to remember. Whereas now this new one's got a 12 hour leeway.
PORTER
So why aren't we using that more often because not having the oestrogen does get rid of some of the unwanted side effects as well, it makes it safer doesn't it?
SZAREWSKI
It makes it safer in terms of sort of health risks but what you always sacrifice, the minute you remove oestrogen from the equation, is you sacrifice cycle control. So you no longer know when your bleeding's going to happen, you certainly can't move it when you want it to and so on, so you sacrifice that immediately.
PORTER
And in younger women, particularly single women, don't welcome irregular periods.
SZAREWSKI
Yeah, young women don't really like never knowing when they're going to come on.
PORTER
Let's look at the older woman now - 35 to 40 - she's had some children, she's not quite sure that she's finished having her family, so she wants a reversible method but she wants something pretty reliable, she doesn't want to get caught out either, what sort of methods are we looking at there?
SZAREWSKI
Well for them I think things like the Mirena inter-uterine system is a very good idea because that's extremely effective, so they can pretty well guarantee they won't get pregnant unless they have it taken out and then it's immediately reversible. The same thing would apply to Implanon, which is the implant that you have put in your arm.
PORTER
And this is progestogen ...
SZAREWSKI
These are all progestogen only methods.
PORTER
Different ways of giving the same hormone over a long time.
SZAREWSKI
Different ways of giving the same hormone. So all the long acting methods are based on progestogen.
PORTER
What about 40 plus, in this case we're assuming they don't want anymore children and we're looking at sterilisation probably being the most popular method in the UK?
SZAREWSKI
We're different from just about every other country in that respect, that we have sort of taken sterilisation on board in a big way.
PORTER
This is vasectomy of course and having your tubes tied. What's the - who tend to get it done most? I would presume men tend to have vasectomies more often because it's a bit easier.
SZAREWSKI
Well they do but it does depend you see because the problem is once the woman gets to 40 and especially if she's already had children, she probably won't want children anyway, even if her relationship was to break up. Now if a man aged 40 ends up getting divorced well he can potentially still be fathering children till he's about 70, so you have to think about that as well, that you're potentially taking away the man's fertility when he might want to use it again, if he then marries a younger woman.
PORTER
But it's a simpler procedure, done under local anaesthetic in men.
SZAREWSKI
Yeah.
PORTER
When should we stop using contraception?
SZAREWSKI
A woman should stop using contraception after the menopause basically and that's after their periods stop, they should wait at least a year, they should still carry on using contraception for a year minimum.
PORTER
I mean the odds of conceiving in your late 40s are pretty slim aren't they, most women are technically infertile but then but ...
SZAREWSKI
But it's devastating for most women if they do then because you're suddenly almost a grandmother but you've got a baby.
PORTER
Well thank you for now Anne.
Well the Pill may be the most popular choice among young women but has ease of use and convenience blinded us to the benefits of other approaches. Researchers in the UK are looking at offering more teenagers longer acting hormonal contraceptives - like the implants we discussed placed under the skin and the three monthly depo injections - to see whether they could help reduce the number of unplanned pregnancies in this age group. Professor Kay Wellings is Director of the Centre for Sexual and Reproductive Health Research at the London School of Hygiene and Tropical Medicine.
WELLINGS
We noticed that from the literature that in the United States the teenage pregnancy agencies were attributing a great deal of their recent success in lowering the rates to providing long acting contraception as one of the choices for young women. Something like 25% of the recent drop in the rate of teenage pregnancies has been attributed to more widespread use of long acting contraception. And so we were interested in finding out how many women used that method in this country and which women - which groups they came from. Long acting contraception we define in terms of injectibles, implants - which is the rod just under the skin, Mirena - which is the hormone linked inter-uterine device and IUDs themselves, so there's four main methods. But of those only injectibles are used widely by young women, whereas the implant is an extremely simple and effective method of contraception.
SHARP
What's the next step, is it to try and get more women access to implants?
WELLINGS
Well when we ask young women themselves we were surprised to find how little awareness there was of long acting methods. They hadn't been given that information by GPs and sometimes when they had been to the internet and found out about long acting methods they go along to their GP and say that they quite like the idea perhaps of injectibles or implants and were quite often discouraged. There was another whole group of young women who were much more the high fliers, from professional backgrounds, who were - had fast track careers - they'd go to the internet, find out about the methods and go to their GP and really push for prescription of the method. But for the women who - for whom that was not such an obvious way of behaving they were left with the old stalwarts - that's the Pill, backed up by emergency contraception - when in fact those were the very women who would need a long acting method of contraception.
SHARP
Why were people discouraged from using it?
WELLINGS
I think the medical profession probably remembers the stigma attached to long acting methods, the whole furore over depo and the fact that it was prescribed to mainly black and women in low socioeconomic groups. And then there was a whole issue about implants and the supposed incompetence of general practitioners to use it properly when in fact those difficulties have been overcome and the methods should take their place alongside the whole repertoire of contraceptive methods because we have few enough as it is. And if they took their place and they were a proper choice for young women then I think they could add greatly to the sort of weaponry we've got against unplanned pregnancy.
SHARP
So how will your research that you've done possibly have some effect on the vast numbers of teen pregnancies that we have?
WELLINGS
What we hope is that when we show the very low proportions of women who are using long acting methods of contraception that we will raise awareness amongst both women and healthcare professionals of the possibility of adding these more often to the range of methods that are offered and taken up.
PORTER
Professor Kay Wellings talking to Helen Sharp. You're listening to Case Notes, I'm Dr Mark Porter and I am discussing topical issues from the field of contraception with family planning expert Dr Ann Szarewski.
Anne, presuming these longer acting contraceptives work better because there is less margin for error?
SZAREWSKI
Yes, you just can't forget them as easily as the Pill, so it's not rocket science really.
PORTER
And that can be a problem, can't it, in younger - particularly teenagers.
SZAREWKSI
Yes, I think teenagers find it quite hard to remember almost anything regularly. But you'd be amazed how often women who are older, especially if they've got busy jobs, busy careers, it's quite difficult to remember did I take it today, did I not and this sort of thing.
PORTER
Pills only work if you take them.
SZAREWSKI
Yes.
PORTER
What about intra-uterine devices, IUDs or they've been called coils in the past - these are long acting, they can be left in for years - why aren't they suitable for younger women?
SZAREWSKI
Well there's no real reason why they shouldn't be suitable for younger women.
PORTER
How are they working first of all - perhaps we should say that?
SZAREWSKI
Well they work in several ways. First of all they work by making the environment hostile, so that the egg and sperm kind of don't get together.
PORTER
They create inflammation inside do they?
SZAREWSKI
Yes, yeah. And then if the egg and sperm manage to get together, which will be in a minority of cases, they'll stop them implanting into the womb - into the walls of the womb.
PORTER
And they can be left in for three to five years?
SZAREWSKI
Oh usually longer. There's one type which is left in for 10 years now.
PORTER
So why don't we use them in younger women?
SZAREWSKI
Really because there's a sort of myth, to an extent, about the infection risk. But the infection risk is related to the woman, rather than the coil, well in fact not to the woman but to the couple. Because if the woman is in a monogamous relationship and she knows - which is where things go wrong - that her partner is also monogamous then she is not going to be at any greater risk of infection using an IUD, a coil. But the problem comes if she is at risk of catching an infection then the IUD tends to make - tends to act a bit like a wick, that it tends to make the infection spread faster.
PORTER
So that's why we worry about it in younger women who may have more partners or not know what their partner's up to.
SZAREWSKI
And also for whom if the ultimate consequence of infection spreading is that you might become infertile and so the worry of course is that if you are very young and you haven't yet had any children and then you become infertile then that's a bigger tragedy than if you're already older and you've had children, it's still a tragedy, but it's not as bad perhaps as if you'd never had any children.
PORTER
Well one unique IUD type device that's proving very popular with older women is Mirena - unlike conventional IUDs it shouldn't make a woman's periods heavier and more painful. Dr Diana Massour is a consultant gynaecologist in Newcastle and I asked her how it differs from conventional IUDs?
MASSOUR
We've had IUDs for about 30-40 years and they're a very effective method of contraception but the only problem with them is that they tend to give quite heavy periods for some women and also some women complain of pain. The only thing that's similar between Mirena and a copper coil is that it sits in the uterus - sits in the uterine cavity. A Mirena actually is a T-shaped device but has hormone that's slowly released into the cavity over a period of five years and actually makes people's periods much lighter and less painful. So very useful for, this is gynaecologists, to help people with menstrual problems as well as providing incredibly effective contraception, as effective as being sterilised even.
PORTER
How big is the actual implant?
MASSOUR
It's about the same size as a 10p piece, it's a T-shape and along the vertical arm is just a small little capsule that releases this local hormone progestogen.
PORTER
And how is it actually providing contraception - is it purely the hormone is does the actual T-shape device have a coil type effect as well?
MASSOUR
Really - I mean from the work that's been done it seems that it is just the local hormone within the cavity of the womb. It's about - ooh a thousand times the amount of hormone that you'd get from say a progesterone only pill - it's a very local specific action. And it thickens the mucous around the neck of the womb, stopping sperms from reaching eggs. It also has an effect on the lining of the womb as well, so the endometrium is actually thinner. And it also probably effects sperm mortality, so sperm again just don't reach the egg when you ovulate.
PORTER
Is it true to say that Mirena's actually being used in women as an alternative to surgery - things like hysterectomy?
MASSOUR
Well we're definitely seeing an impact of the contraceptive implants and the minimally invasive surgery that's going on now because hysterectomy rates are falling thank goodness. Locally in the North East of England we've actually seen the impact reducing hysterectomy rates between about 30 and 40%. It's also having a real impact on female sterilisation - we've seen a reduction in over 50% of women coming forward wanting to be sterilised because why get sterilised and then have your painful heavy periods back when you can have something that's as effective and actually will sort out your menstrual problems. So yes it's having quite an impact and benefit on women's health.
PORTER
It sounds fantastic. But what are the downsides, what about side effects?
MASSOUR
A few women do complain, particularly in the first three or four months, of perhaps breast tenderness, occasionally the odd spot or headache or feeling slightly bloated. I think that the biggest issue that women will complain of in the first again three or four months is irregular bleeding and they will often come in saying - Look since you've inserted that Mirena I've been bleeding almost every day, not heavily but it's just a brown loss and it's a real nuisance. And somebody else described it a bit like climbing a hill, you think you're never going to reach the top. But something magical happens about four or five months and about one in four women at that stage becomes amenorrhoeic, i.e. they don't have any periods, and about three out of four get a lighter less painful bleed. And even if they're bleeding erratically within the first few months of use, they still have good contraceptive cover.
PORTER
Now it's available on the NHS but of course as is always the case for the NHS there's budgetary issues because Mirena's quite expensive isn't it.
MASSOUR
It is, at the moment I think my primary care trust is probably looking at my budget quite closely because last year I spent nearly 脗拢50,000 on Mirena along and if you think my pharmacy budget is normally about 脗拢25,000, so yes ...
PORTER
And how much is it for one Mirena?
MASSOUR
Obviously to women it's free. But to services, if it's general practice or ourselves, it's just under a 脗拢100.
PORTER
Compared to what for a normal IUD?
MASSOUR
For a normal copper IUD we're probably paying about 脗拢10-14 for five years contraceptive usage, so it's 10 times more expensive. But there again if you actually then add in the reduction of hysterectomies, of female sterilisation, of other sorts of medical treatments that you might give for people with heavy periods then it's very cost effective because it lasts for five years.
PORTER
Dr Diana Massour.
Anne, is this IUS an option in younger women or is it - we don't like doing it for the same reasons we don't like using conventional IUDs?
SZAREWSKI
In fact there's less problem with infection with Mirena because of the hormone that slightly protects. But the thing with young women and Mirena is that young women again don't react so well to irregular bleeding, so even though you tell them it's not going to last much more than six months but most women still bleed a bit and even if they spot irregularly young women often don't like that. So then they ask to have it removed and of course then it isn't cost effective, so then that's a problem.
PORTER
What about other developments - the patch, it's not something I'm familiar with, I don't think I've seen any of my patients on it yet, do you have much experience with it?
SZAREWSKI
I think the patch is actually quite a nice idea for young women particularly because it combines all the advantages of being on the combined Pill ...
PORTER
Because it has both hormones in it doesn't it.
SZAREWSKI
It has both hormones and so you have all the sort of comfort of knowing when your period's going to happen, being able to move them and all the rest of it, while not actually having to remember to take a pill everyday.
PORTER
So the drugs are gaining entry to your blood supply through the skin. How long do you leave the patch on for?
SZAREWSKI
Each patch is for a week and they've come up with this wonderful idea ...
PORTER
Then you have a week off do you?
SZAREWSKI
You can if you want to but you can run them together of course. But the lovely thing they've come up with the patch is that you can sign up to text messaging service, so they remind you when your patch is due to be changed and I think for young women that's great because it actually helps them remember.
PORTER
I'm going to stop you there Anne because I want to move now onto the male pill, vested interest in this. We sent Lesley Hilton to the Medical Research Council Reproductive Biology Unit in Edinburgh. That's the HQ for one of just two teams in the UK who are working on a new male contraceptive. In their case, a clever combination of the hormones progestogen and testosterone that fool the body into shutting down sperm manufacture in the testicles, while still maintaining virility and sex drive.
ACTUALITY
Okay so there's a bit of antiseptic coming up first. Just to give your tummy a clean off.
HILTON
Colin Marshall is one of the volunteers in the Edinburgh trial and today he's having the testosterone implants in his stomach replaced. This has to be done every three months. As well as the testosterone he has two progesterone implants in his arm.
Dr Richard Anderson, who's running this trial, is the senior investigator for male contraceptive studies with the Contraceptive Network. Although we've been referring to a 'male pill' for a few years now, he's not sure whether the end product will be a daily tablet or take some other form.
ANDERSON
Quite the regime that will be used will depend on what comes out at the end of the day as the best methods and there are a number of different approaches being investigated. You might want to develop a method that involved taking tablets and we've done studies where men took tablets for a year and were extremely effective. Another approach that we're also pursuing is long acting implants and one of the whole concepts of contraception is that the more methods you have available, the more an individual couple will find something that they like and will therefore use reliably. So we're not really interested in just a male pill, we're interested in a range of male methods, just as there are a range of female methods.
HILTON
Colin volunteered to take part in the trial for two reasons. He's interested in the science involved and he was fed up with hearing that men couldn't be trusted to use hormonal contraception properly. He and his partner still have to use condoms during the trial but in general it's going okay - apart from a couple of side effects.
MARSHALL
There are two notable side effects at the moment - I've actually increased my - I've got a lot more acne than I had before, I have a lot more acne than I've had even in puberty, which is annoying rather than worrying. The other is that the - my testicles have actually shrunk and yes that's a worry that they won't come back but I'm assured that they will!
HILTON
Developing male hormonal contraception is not just a question of getting the science right. For years there's been a debate about whether men would actually use it, or if women would trust them to. Toni Bellfield is director of information at the Family Planning Association.
BELLFIELD
The biggest research that's looked at this was addressing 2,000 men in Edinburgh, Shanghai, Hong Kong and Cape Town and what was so very special about this research was that it looked at countries with very different cultures and beliefs. And of those, two thirds of the survey number said they would be interested in using hormonal contraception. And if we then said well okay, this is all very well for men to use it but would women trust them? - the research also addressed that three quarters of the men's partners said they would trust their husbands or boyfriends to take a pill or another hormonal method.
HILTON
Work on the male pill has been going on for around 40 years in different parts of the world. But now that drug companies have got involved in the financing of research it's likely that a product will be on the market some time in the next 10 years. So with so much research going on is there a race to be first or do the different groups pool their knowledge? Dr Anderson.
ANDERSON
Well there is very much an ethos of sharing information and all the investigators around the world who are involved in this meet at least once a year. We are all - we have a large annual meeting once a year where we all discuss work in progress and many of the investigators are also on the WHO research group involved in this so there's a collaborative expertise involved in that too.
HILTON
Although the female contraceptive pill was a huge breakthrough over the years it's caused health concerns. Toni Bellfield thinks that men should ask the same questions if they were to consider taking the male pill.
BELLFIELD
I think this is just the same kind of ideas that women have and I think that we shouldn't suggest that men have somehow different problems than women when they're addressing contraception. So the men issues that men ask, exactly the same as women - How do I take it? Will it work? And will it harm me? And they're very relevant questions to answer and they need to be answered clearly in order to remove some of the myths. So first of all men need to know that if they take these methods it will stop all their sperm and therefore be effective. But the next question is well if I do all this will I become less sexy, will I grow breasts, will I sort of feel unusual, will it hurt me?
HILTON
Colin Marshall feels proud to be able to help research the male pill. At first he was a bit reluctant to tell his friends but now he's open about it. And has had some pleasant surprises in their reactions!
MARSHALL
They've been fine. Women have generally been slightly tongue in cheek - Oh you're off to do your bit for womankind again! But they've generally been very supportive. And there was one person who said - Ooh increased libido and zero sperm count - just my kind of man!
PORTER
Colin Marshall talking to Lesley Hilton.
Anne, are there any developments in the pipeline that excite you?
SZAREWSKI
I think the exciting thing that's happening at the moment is that women are beginning to realise that they don't have to take the Pill in the conventional way.
PORTER
You mean three weeks on ...
SZAREWSKI
And one week off and so they have to bleed 12 or 13 times a year. I think women have gradually woken up to the fact that these bleeds are artificial and so they're just a con trick basically and you don't need to have them.
PORTER
Because a lot of women do like having "a clearout" though don't they.
SZAREWSKI
But that's only because they think that that makes them feminine and natural and preserves their fertility and all the rest of it, whereas actually it has no meaning at all - the bleed on the Pill.
PORTER
Because the Americans actually have a licensed product, don't they, that you only have a four periods a year.
SZAREWSKI
That's right but they're just doing what we've been advising women for years to do - which is to take three or four packets of the pill back to back and then stop for a break.
PORTER
And that's safe?
SZAREWSKI
There's no reason why it shouldn't be - all it is is just taking the pill back to back and not having a completely artificial bleed that you don't need for any reason.
PORTER
And of course the more times they're taking it there's less margin for error, they're not coming off the Pill, they're not having to restart it, they're less likely to get it wrong and get pregnant.
SZAREWSKI
Exactly, because really almost all pregnancies are caused because of the Pill free week because women then forget to restart, so that prolongs it and that's when you get pregnant, whereas if you're just taking it all the time even if you forgot a couple in the middle it probably wouldn't matter.
PORTER
I am afraid that's all we've got time for Anne. Dr Anne Szarewski, thank you very much.
Next week's programme explores the reasons behind, and the consequences of, the rising incidence of diabetes in the UK. I'll be discovering how it's not so much how overweight you are, as where that extra fat sits on your body, that determines your odds of developing diabetes.
ENDS
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