Is It a Dream or a Nightmare?
When Cynde Robinson, deputy representative of the social marketing organization PSI, took a look at the contraceptives available off the shelf at Cambodian pharmacies two years ago, she found something she had never seen before. Preparing for the launch of PSI’s own daily contraceptive pill OK, she found a Chinese competitor that only had to be taken once a month.
She researched it with an eye to it being a potential PSI product next to condoms and OK, but what she found is that—although the pill is cheap, common and popular—there are many problems with it. The monthly pill, manufactured by the Beijing Chemical & Pharmaceutical Works, contains a massive dose of hormones. According to the ingredients lists provided by the manufacturers, the monthly pill provides more than 80 times more synthetic progesterone and 100 times more synthetic estrogen than the OK pill, which is manufactured by the German company Schering and marketed in the west as Microgynon.
Robinson had a PSI affiliate in China send her any information they could find and shared it with other NGOs and the Ministry of Health who were also concerned about the high use of the monthly pill.
Because of the research she and others acquired, MEDiCAM, an association of medical NGOs, has just issued a warning that the once-a-month pill is not to be recommended for use, although they don’t recommend banning it.
“We’re not saying women should not take it,” said Robinson, “but we are concerned.”
The MEDiCAM statement warned of an increased risk of blood clots, troublesome breakthrough bleeding, nausea, headaches, weight gain, and breast tenderness. Although these side effects are also associated with the daily pill, they are more common and severe in the monthly dose. Very little is known about the long-term effects of the monthly pills.
“If I thought it was good, I would love to have PSI out there looking at marketing it because it has a lot of advantages,” said Robinson. “But it seems like [health professionals] still have a lot of reservations about some of the long-term side effects and women using it incorrectly.”
The instructions that are supposed to come with the monthly pill do outline the side effects—highlighting ones that are more severe than the daily pill—and explain how to take it, but they are only in Chinese and English and rarely handed out. Women in Cambodia have been taking it incorrectly, said Robinson, because they do not have the appropriate information. They don’t know that it must be taken twice in the first month and at specific points in a woman’s monthly cycle in order to work properly and minimize the possibility of adverse reactions.
The monthly pill does operate in a similar way to the daily pill, using hormones to convince a woman’s body that it is already pregnant so it will not allow a fetus to be conceived. The amount of hormones in daily pills, however, has decreased steadily for years because higher doses were associated with increased risk of bad reactions. The monthly pill delivers a huge dose at one time.
The side effects with the monthly pill are also harder to deal with. It is very easy to just stop taking a daily pill if a woman has problems and switch to another available form of contraception—including other varieties of the daily pill, condoms or an intrauterine device. With a monthly pill, if a woman experiences any serious side effects, she is stuck with them for much longer.
“Because the pill is formulated for monthly use,” the statement issued by MEDiCAM said. “The high estrogen level will be in the blood for one month. If serious side effects appear, one cannot just stop the effects on the body.”
Many women also don’t know that the high levels of estrogen in the monthly pill can cause birth defects in babies conceived while on it or within six months of ending its use. It should also not be taken while breast-feeding.
Estrogen can reduce the amount of milk that a mother produces. For takers of the daily pill there is a progesterone-only version available, which does not impede lactation. There is no estrogen-free version of the monthly pill.
The monthly pill is popular because it is cheap—300 riel versus 700 riel for a one-month’s supply of the daily pill OK—easy and accessible, although the daily pill is sometimes available free at health centers. In the past few years, several new programs have attempted to make modern birth control methods more widely available but not everyone has access or is aware of the services.
“There are many women who live in urban areas and also women who live in small towns who do not have good access to public services,” said Dr Chhun Long, National Project Manager of the Birth Spacing program, which is funded by the UN Population Fund. “And they do not have good information about our services and so they just went to small shops and bought the monthly pill, which is not the method that we recommend.”
Experts say that the monthly pill is extremely popular throughout Southeast Asia, and there are suspicions that the monthly pill leaked through from China and was a part of the country’s one-child program, although the Chinese Embassy could not confirm this. It has been available in Cambodia for at least two years, and the National Birth Spacing Program is currently trying to estimate exactly how many women use it here.
The monthly pill, however, is not peculiar to Asia. It was studied widely in the West in the late ’60s and early ’70s by numerous research institutions but lost out to the daily pill, which appeared to have fewer side effects. Studies continued in China though the ’80s. Reports provided by the Beijing Pharmaceutical company to MEDiCAM say the pill is safe, but health professionals in Cambodia do not regard them as reliable because they are not independent and have not been corroborated by studies completed outside China.
“I disagree with the [Chinese] studies,” says Chroeng Sokhan, clinical pharmacist in charge of the Department of Drugs and Food in the Ministry, “These are provided by the seller [of the pills] so I’m not going to believe that.”
According to the Ministry of Health, the drug is smuggled in and not legally registered for use in this country. “Any drug in Cambodia must be registered through a legal import company but if they are not registered it means they come through illegally,” said Dr Chroeng Sokhan. “In Cambodia there are about 150 legal pharmacies and 600 illegal pharmacies. There’s no sense to ban because, if they are coming in illegally, it’s only banned by the law. It’s sold by illegal companies. The implementation of law in Cambodia is not quite there.” He added that educating people about their options was a more likely solution.
Some doctors, however, would like to see it taken off the shelves because some people will always opt for the cheaper option, especially if they don’t know that it is more dangerous than the others. Lim Kruy is a doctor at the Sihanouk Hospital Center of Hope, but two years ago she worked with a family planning organization in Svay Rieng and Kampong Speu provinces. She had patients who, after taking the monthly pill, had vaginal bleeding or migraines so severe that they had to be sent to the local hospital.
“I think to be no longer on sale is better,” she said. “We know that other people who have no education will just buy the one that is cheaper.”
It is unlikely to be banned anytime soon. MEDiCAM and the National Birth Spacing Program are also in favor of more education about what is available and promotion of the daily pill, the IUD, condoms and injectable contraceptives.
“Having a baby is risky to women,” said Dr Chhun Long. “but we have other methods that are less harmful and have less side effects. We have our program and the pills are available even in the pharmacy. We have the PSI who are doing the community distribution program, also they sell the pill called OK. That pill has less side effects than the monthly pill…The daily is also not very expensive. Even though the cost is a little bit higher, it doesn’t make very much difference.”