"[T]here was something else that Greenhouse said that immediately caught my attention: for some women with more extreme cyclical mood changes, going on the pill could be disastrous."
This past weekend, Dr. Alice Roberts published an article on the combined oral contraceptive pill in The Guardian. I was excited to see a media article on contraception by a scientist and a Professor of Public Engagement, assuming it'd be evidence-based and teach me more on writing about science for lay audiences.
The article implies a link between premenstrual dysphoric disorder (PMDD) and oral contraceptive pills, based in part on the opinion of Peter Greenhouse, a consultant in sexual health who sat next to Roberts at a conference dinner. Roberts writes:
A strong assertion! Intrigued, I kept reading, eager for a discussion of the epidemiological evidence behind this statement (which contradicts information in resources like the evidence-based, frequently-updated book, Contraceptive Technology).
Science reporting and evidence on contraception: women deserve to know the good, the bad, and the uncertain
When reporting on new scientific research, journalists sometimes seem to sacrifice accurate representation of scientific data for an eyeball-catching headline/story. The scarier the news, the more compelling the headline.
To my understanding, journalists don't always get to write their own headlines, but they do have control over the balance of reporting within the story. When reporting on issues related to contraception, some stories seem to focus exclusively on risks (or present risks out of context), without reporting the benefits of a given contraceptive method.
Women deserve to know both the risks and the benefits (and any lingering scientific uncertainties!) related to any contraceptive method they may consider using.
As an epidemiologist interested in research on the safety of contraceptive methods, a recent story by Val Willingham on CNN.com entitled "IUD may carry higher risk for breast cancer in certain women" caught my attention. Like many news stories, the study abstract was not directly linked (journalists, can we please fix this?). To Ms. Willingham's credit, she linked to the journal and provided the name of the first author (Dr. Tuuli Soini), so the actual study abstract was not too hard to track down (at least not for someone who regularly mucks around in scientific journals...).
The abstract clearly noted that among Finnish women treated with use of a levonorgestrel IUD for heavy menstrual bleeding, levonorgestrel IUD use appeared to be associated with several cancer-related outcomes. These outcomes (in the order in which they were reported in the abstract) included:
(1) A statistically significant 50% decreased risk of endometrial adenocarcinoma (which changed to a statistically significant 75% decreased risk for women who were presumed to have used a second LNG-IUD),
(2) a statistically significant 40% decreased risk of ovarian cancer,
(3) a statistically significant 50% decreased risk of pancreatic cancer,
(4) a statistically significant 32% decreased risk for lung cancer, and
(5) a statistically significant 19% increased risk of breast cancer.
This information was plainly available in the results section of the abstract, and also quite clearly summarized in the conclusion of the abstract, which reads:
[I'm not even going to scratch the surface of any epidemiological issues in this post, which is focused on the fidelity of what is reported in a scientific study (or even just the abstract!) to what is reported by a journalist. But, to add an obligatory epidemiological disclaimer: None of these associations are definitive; as these are observational data comparing observed cases of cancer to "expected" cases of cancer. To the credit of the study authors this is thoroughly discussed in the manuscript, and to Ms. Willingham's credit, her story notes that: "The research does not say that this type of IUD causes breast cancer" (Sadly, this important detail mattered little to some folks on social media...but that's for another post!)]
Despite the numbers above, Willingham's story focused almost exclusively on the possible 19% increase in breast cancer risk -- and not at all on the possible 32%-75% decreases in risk of other cancers.
About halfway through the article, Willingham writes: "Investigators found that over time, the device did not significantly raise the risk of uterine cancer or ovarian, pancreatic and lung cancers."
Err, yes, but!...
Not only did the levonorgestrel IUD "not significantly raise" those particular risks, but it appeared to be associated with a significant decrease in those risks. Is that not information that readers should know, too? That got lost in Willingham's report (except for a small quote by Dr. Soini buried near the end of the article, which mentions only endometrial cancer).
So, who cares? Well, given the current climate around contraception - such as the recent Hobby Lobby decision which stands to have serious consequences on a woman's ability to access the contraceptive method of her choice and on a physician's ability to provide highly effective contraceptive methods such as IUDs, and recent conversations about poorly researched materials focused exclusively on the risks of oral contraceptive pills (which could be more useful if evidence-based and balanced with discussion of method benefits) - there is an awful lot of misunderstanding (or even deliberate misinformation campaigning) around scientific evidence on contraception these days. I've spent the last few years of my professional life grappling with some of the fallout and confusion that occurred from articles like this one by Pam Belluck in the New York Times.
When I tried to discuss this issue with Ms. Willingham on Twitter, this was her initial response:
To which I said...
We simply need to expect more from journalists covering scientific issues, especially those in respected outlets like CNN.com. As Dr. Soini and colleagues note in the concluding sentence of their manuscript: "It is important to always counsel patients about the potential benefits and risks of hormonal therapies."
I couldn't agree more.
Soini T, Hurskainen R, Grénman S, Mäenpää J, Paavonen J, Pukkala E. Cancer Risk in Women Using the Levonorgestrel-Releasing Intrauterine System in Finland. Obstetrics and Gynecology 2014;doi: 10.1097/AOG.0000000000000356 (in press).
Willingham, V. "IUD may carry higher risk for breast cancer in certain women" Published on CNN Health, July 9, 2014. http://www.cnn.com/2014/07/08/health/iud-cancer-risk/
A reproductive health epidemiologist who hopes to transmute her rage at social injustice and scientific denialism into something useful.