If you’ve been paying attention to the U.S. healthcare debate and the way insurance changes could affect women’s health, you probably know that the Trump administration is not a fan of employer-sponsored birth control. The President signed an executive order in May seeking to roll back the Obama-era requirement that most insurance policies cover contraception costs, and the issue remains a looming question as Senate Republicans work to pass a replacement for the Affordable Care Act (ACA).
There are plenty of reasons why top medical groups and public health experts support the ACA mandate that eliminated out-of-pocket costs for birth control. But let’s look, for a minute, at one argument being made against it: Katy Talento, President Trump’s special assistant for health policy, has previously referred to oral contraceptives as “a bunch of carcinogens” and as “dangerous, carcinogenic chemicals,” as the New York Times reported this week.
Talento—who holds a master’s degree from Harvard University’s School of Public Health, and has worked as an infectious disease specialist and spent time as a nun—has also linked birth control pills to infertility and miscarriage. In 2015, she wrote that “the longer you stay on the pill, the more likely you are to ruin your uterus for baby-hosting altogether.”
These are some pretty serious accusations, especially from someone who is shaping policies that will affect women and families all over the country. So do Talento’s claims hold up? Can birth control actually cause cancer, or contribute to these other health issues? Here’s what you should know.
Birth control may temporarily increase some risks
It’s not clear what, exactly, Talento is referring to when she describes birth control as carcinogenic. But some studies have linked oral contraception use to a temporary increased risk of breast and cervical cancer. The most commonly cited research, a 2014 paper published in Cancer Research, found that women who had recently used oral contraceptives with high-dose estrogen had a higher risk of breast cancer than those who’d used other versions or none at all.
But the authors of that study wrote that their findings “should be interpreted cautiously.” Although the results suggest an increased risk of breast cancer, they explained in their paper, “the many established health benefits associated with [oral contraceptive] use … and decreased risk of benign breast conditions, must also be considered when making individual choices.” (Those “established benefits” include menstrual-cycle regulation, decreased PMS, and, of course, reproductive planning.)
Laura MacIsaac, MD, associate professor of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai, says there are other caveats to consider about these findings, as well: Studies that show an increase in cancer risk while a patient is on birth control are likely picking up on what’s called “surveillance bias,” she tells Health.
“When patients are on the pill, they have to come into their gynecologist or family doctor more frequently to get checked and get more prescription refills,” says Dr. MacIsaac, who also holds a leadership role with the American Congress of Obstetricians and Gynecologists. “So they get more breast exams, Pap smears, and can report things to their doctor more frequently.”
In other words, doctors pick up more cancers in pill users than they do in women who don’t have to see their doctors as frequently—like those who've had their tubes tied, who have IUDs, or who aren’t using birth control at all.
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But overall, the pill protects against several types of cancer
A more recent analysis—using data from the world’s longest-running study on the health effects of birth control—did support the finding that current or recent oral-contraceptive users were more likely to be diagnosed with breast and cervical cancers. But researchers also found that the apparent difference in risk disappeared within five years of going off the pill.
What’s more, the study found that, in the long run, birth control actually seemed to guard against several types of cancer. For the 46,000 study participants, being on the pill was associated with about a 33% reduced risk of developing endometrial and ovarian cancer, and about a 20% reduced risk of developing colorectal cancer.
Those reduced risks seem to last many years after women take their last pill, too—perhaps as long as 35 years or more for colorectal and ovarian cancer. “These results provide strong evidence that most women do not expose themselves to long-term cancer harm if they choose to use oral contraception,” the authors wrote in the American Journal of Obstetrics and Gynecology; “indeed, many are likely to be protected.”
Very few studies have looked at cancer associations with other forms of hormonal contraception, like intrauterine devices (IUDs) and implants. But limited evidence (related to research on birth control and blood clots) suggests that non-oral forms have a “similar or slightly higher risk” than pills, the authors wrote.
Dr. MacIsaac says the increase in diagnosis of breast and cervical cancers in current pill users “is not equal to the protective effects on uterus, ovary, and colorectal cancer—which last a lifetime and create a huge effect.” In fact, she says, doctors are even performing clinical trials to treat endometrial cancer with hormonal birth control, “because we know that high doses of progestin at the uterus prevents, halts, even reverses early endometrial cancer.”
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What about those other claims?
Talento’s ideas about birth control affecting fertility and causing miscarriages also don’t hold up, says Dr. MacIsaac. Most women resume normal ovulation within a month or two of stopping most forms of birth control, and there’s no evidence to suggest that long-term exposure to birth control can reduce a woman’s chances of getting pregnant.
“Women on the pill for a long time may have reduced fertility when they are off the pill,” she says, “but not because of any chemical effects of the pill over time.” Rather, she says, it could be because they (and their ovaries and eggs) have aged, especially if they are older than 35. Women who have underlying fertility problems may also not discover them until they’re off the pill and want to become pregnant, she adds.
As for the idea that birth control can cause a woman to lose a pregnancy? “Miscarriages are very common naturally,” says Dr. MacIsaac. “We know how easily women can get pregnant and have normal healthy babies when they were trying to contracept with the pill, and maybe missed a pill or two. The pill does not make that pregnancy miscarry; we are absolutely sure of that.”
Hormonal birth control certainly isn’t perfect. It can increase the risk of blood clots, it has been linked to mood changes and lower quality of life for some women, and some methods have higher failure rates than others.
But calling them “dangerous” is unhelpful, says Dr. MacIsaac—and linking them to cancer or fertility problems doesn’t make sense at all. “There are dangers to estrogen naturally, or synthetically,” she says, “but it has to be taken into context of all the other needs and benefits that hormones, naturally or exogenously, provides.”
Her bottom line? She tells her patients that birth control pills “are synthetic versions of their natural hormones” that have been in use for 50 years, all over the world. “We know what the dangers are, and we know what the benefits are,” says Dr. MacIsaac, “and we have to balance those out for each individual patient.”