by Dr Sarah Myhill
A question that most of my female patients ask me at some stage is - what about the Pill and HRT? In the last few years I have become increasingly unhappy about prescribing the Pill and HRT for my patients and I am now at the stage when I actively discourage patients from using either. I think my reasons for doing this are best explained in the following book summary I did:
Dr Ellen Grant: The effect of exogenous sex hormones on women's health
including increases in breast, endometrial, ovarian and cervical cancer, and
sexually transmitted diseases.
A summary of Grant ECG. Sexual Chemistry. London: Cedar, Reed Books, 1994.ISBN 0-7493-1363-3 prepared by Dr Sarah Myhill
The combined oral contraceptive Pill has become widely accepted as a safe contraceptive for long-term use, and when it is being administered, usually the only issue up for discussion is its efficacy in preventing pregnancy. Dr Grant argues that its use causes a whole range of clinical problems. These side effects are an extension of physiological actions and are therefore dose dependent. For the same reason, it is irrelevant whether the hormones are of natural origin or have been artificially synthesised, are taken orally or transdermally.
Corticosteroids and anabolic steroids are rightly used with caution. The female sex hormones in the Pill and HRT are related compounds with similarly profound and wide range of activity.
1. Female sex hormones stimulate target organs resulting in increases in all hormone-dependent cancers, particularly breast and cervical cancer. There is a clear link between unopposed oestrogen use and endometrial cancer. We now know that progesterone is considerably more carcinogenic than oestrogen. Indeed it has been classed by the World Health Organisation as a Class 1 carcinogen. This is when pesticides are also classed.
2. They affect the immune system depending on proportions of progestogen (which tends to suppress) and oestrogen (which tends to stimulate). Grant argues that the immuno-dysregulation caused in this way has contributed to the increasing allergic diseases we now see.
3. They interfere with trace element metabolism, particularly lowering zinc and magnesium levels as well as disturbing B vitamins and essential fatty acids levels. Low zinc is associated with anorexia, birth defects and dyslexia which, argues Grant, are diseases exacerbated by the Pill. Low magnesium is associated with cardiovascular disease, the commonest cause of death in UK.
4. They cause mental disturbances - oestrogens tend to cause euphoria (and may be addictive), progestogens tend to cause depressive symptoms. Falling levels of both hormones cause depressive symptoms - this occurs naturally in PMT, post-natal depression and menopausal depression. Taking the Pill or HRT exacerbates these natural mood swings so there is a higher incidence of depression and suicide in Pill takers. This effect may be mediated by abnormal zinc/copper ratios.
5. They cause dilatation and/or hypertrophy of blood vessels leading to thrombosis (pulmonary embolus) and increased vascular disorders (hypertension, coronary artery disease, stroke). Again, this is a physiological effect which can be seen in the veins and arterioles of the uterus, but is exacerbated when used in the pharmacological levels used in the Pill and HRT.
6. The Pill is used as a first-line contraceptive in young women. This means condoms are rarely used and women are more likely to acquire sexually transmitted diseases.
7. A combination of the immuno-dysregulation, plus hormone stimulation of the cervix, plus exposure to sexually transmitted diseases with chronic inflammation and carcinogenicity of papilloma virus has led to an epidemic of aggressive cervical cancer in young women.
8. Acute pelvic inflammatory disease may lead to chronic pelvic infection and infertility.
The main reason why these disorders have not become more apparent in clinical trials is because the women who developed side effects early on in the trial stopped taking the Pill. This meant that the women who continued on the Pill were pre-selected because they were resistant to the malign effects of the Pill so the true overall long term side-effects of the Pill and HRT have been underestimated. This view is now receiving considerable support particularly from the Dutch epidemiologists.
We know that breast cancers are hormone dependent cancers. A major line of treatment after excision is to remove oestrogen and progesterone from the body - either by using the anti-oestrogen Tamoxifen, or surgical castration. Breast cancers arising in young women carry a worse prognosis because their levels of sex hormones are higher. Breast cancers arising during pregnancy develop rapidly, like an abscess, driven by high levels of oestrogen and progesterone. So well established is this principle, that trials are being considered to treat women with a poor family history of breast cancer with the anti-oestrogen Tamoxifen as a prophylactic, to reduce their risk of this disease.
A logical extension of this principle is that giving exogenous oestrogens will increase the incidence of breast cancer, and reduce the age at which breast cancer develops. There is no doubt that breast cancer rates are rising, but is this due to the pill and HRT? Is there a demonstrable link in the epidemiological studies? Dr Grant believes there is.
She argues that the published epidemiological studies are flawed because they do not include all the women that were ever started on the Pill. This is crucial because the women who dropped out early did so because of side effects. In her book "Sexual Chemistry" Dr Grant presents compelling evidence to show that these women are in the very group who would be most likely to develop breast cancer. The same applies to cervical, uterine and ovarian cancer. The reasons she gives are well understood by doctors who are practicing a nutritional approach to medicine. The women who get side effects are those with an inefficient immune system (tendency to develop food intolerance) and poor nutritional status (particularly poor levels of B vitamins, trace elements (especially zinc and magnesium) and essential fatty acids) and therefore more likely to develop breast cancer in the first place.
This problem of pre-selection has been addressed by Vandenbroucke et al. He conducted a review of the follow up studies reported in three recent meta-analyses to determine the effect of oestrogen therapy on both total cancer and cardiovascular disease. He used "total cancer" to look for a "healthy cohort effect". He found a 'protective' effect on total cancer of almost 20% which led him to conclude that since "the beneficial effect of oestrogen on total cancer is unlikely to be real because female reproductive cancers are, if anything, increased by oestrogens, and for all other cancers no effect is known at present", therefore "the meta-analyses are based on the results of observational studies and can be influenced by unintended selection of relatively healthy women for oestrogen therapy."
Vandenbroucke has clearly demonstrated that pre-selection has taken place and therefore such retrospective trials are not just invalid but misleading.
Any trial must include all women who have ever been started on the Pill or HRT to be fully valid. However the difficulty here is that by the early 1980s, over 90% of young women have been started on the Pill. This means there are no true control subjects and so setting up such a trial is fraught.