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Helping Your Patients Decide: Making Informed Health Choices About Hormonal Contraception

(Published June 2006)

Risk Misperception

To communicate about risk, providers need to have a clear and accurate understanding of the basic statistics underlying risk comparisons. That understanding starts with a clear definition of risk. Simply stated, risk is “the possibility of loss or harm.”1 Risk is the probability—or chance—of an event occurring; it does not indicate certainty that it will occur.

Misperception of risk by health providers may cause them to limit a patient’s contraceptive options by denying information or access to a potentially useful method or leading her toward a particular decision. The headline reprinted in Figure 1 was published in The Wall Street Journal in November 2005. It describes a change in the prescribing patterns of some physicians based on Food and Drug Administration data about the contraceptive patch.2 Note that these prescribing decisions were based on data that showed an increase in serum estrogen with the patch, not data on clinical outcomes, such as venous thromboembolism (VTE). One physician quoted in the article stated that he had stopped writing new prescriptions for the contraceptive patch and was suggesting that his patch users switch to other contraceptive methods. On the basis of available data, curtailing prescriptions for the contraceptive patch for all women was not warranted. Prescribing decisions like these, which are based on a misperception of risk, restrict women’s options for effective contraceptive methods.

Risk misperception also directly affects patients’ decisions about contraceptives. Women may not use effective contraceptive for several reasons, including incorrect perception of risk. Such misperception “may lead women to use them [hormonal contraceptives] less than effectively or not at all.”3 Inaccurate understanding of the true risk associated with a contraceptive method can have a profound effect on a woman’s choice and can result in consequences related to ineffective use.

Almost half (49 percent) of all pregnancies in the United States are unintended.4 The proportion is highest among those 15- to 19-years-old, but is about 40 percent among women who are 40 or older. In the United States, about 42 percent of unintended pregnancies end in abortion.4 Misperception of risk may partially explain the high rate of unintended pregnancy in the United States. That is, some women may choose less effective contraceptive methods or not use contraceptives consistently because of concerns about unsubstantiated or exaggerated risks.

In 1995, the consequences of risk misperception played out in Europe to unfortunate effect. In that year, the British Committee on Safety of Medicines issued a warning of a possible increased risk of VTE with third-generation OCs compared with second-generation OCs. Many women across Europe stopped taking OCs or switched to a different formulation. Providers’ prescribing patterns also changed because of this warning.

In the months after this event, the number of pregnancies and abortions dramatically increased. In 1996, there were 26,000 more pregnancies and 13,600 more abortions in Wales and England than in 1995.5 For the five years before this event, the abortion rate in these countries had been steadily declining.6 Subsequent review found that preferential prescribing may have been responsible for at least part of the association between third-generation OCs and increased risk of VTE.7 In other words, health care providers may have been more likely to prescribe thirdgeneration OCs to women whom they perceived to be at higher risk for VTE.8 Whether or not the absolute risk of VTE with third-generation OCs is increased in a clinically important way, the course of many women’s lives was substantially affected by the response to the reported risk.

References

  1. The American Heritage Dictionary of the English Language, 3rd ed. Boston: Houghton Mifflin Company; 1996.
  2. Chaker AM. Doctors Back Off Birth-Control. The Wall Street Journal. 2005 Nov 22. Available at: http://online.wsj.com/ article_print/SB113262165542103693.html. Accessed May 03, 2006.
  3. Gardner J, Miller L. Promoting the safety and use of hormonal contraceptives. J Womens Health. 2005;14:53-60.
  4. Finer LB, Henshaw SK. Disparities in unintended pregnancy in the United States, 1994 and 2001. Perspect Sexual Reprod Health. 2006;38(2):90-96.
  5. Furedi A, Paintin D. Conceptions and terminations after the 1995 warning about oral contraceptives. Lancet. 1998;352:323-4.
  6. Drife J. Oral contraception and the risk of thromboembolism: what does it mean to clinicians and their patients? Drug Saf. 2002;25:893-902.
  7. Chasen-Taber L, Stampfer M. Oral contraceptives and myocardial infarction—the search for the smoking gun. N Engl J Med. 2001;345:1841-2.
  8. Heinemann LA, Lewis MA, Assmann A, Gravens L, Guggenmoos-Holzmann I; Working Group for Pharmacoepidemiology Berlin-Brandenburg. Could preferential prescribing and referral behaviour of physicians explain the elevated thrombosis risk found to be associated with third generation oral contraceptives? Pharmacoepidemiol Drug Saf. 1996;5:285-94.