Book Review

Contraception

N Engl J Med 1994; 330:514February 17, 1994

Article

Contraception
(Clinical Perspectives in Obstetrics and Gynecology.) Edited by Donna Shoupe and Florence P. Haseltine. 261 pp., illustrated. New York, Springer-Verlag, 1993. $65. ISBN: 0-387-97859-3

The answers that physicians and other health care workers are most likely to be seeking in a book on contraception are predictable. What is the current view of the relation between hormonal contraception and cancer? Do progestins differ in their effects on carbohydrate and lipid metabolism? Do intrauterine devices cause pelvic inflammatory disease? How well do barrier methods prevent the spread of sexually transmitted diseases, including the human immunodeficiency virus (HIV)? Should adolescents use the Norplant levonorgestrel implant? Is vasectomy associated with an increased risk of prostate cancer? A thin book with the ambitious title Contraception would be a disappointment if it failed to address these and other questions most frequently asked by the audience for which it is intended.

The book compiled by Shoupe and Haseltine is no disappointment. The editors have assembled chapters by knowledgeable authors who have wisely selected the material they have included. The chapters on oral contraceptives and hemostasis (by Notelovitz), glucose metabolism (by Spellacy), and lipoprotein metabolism (by Krauss and Tribble) are particularly insightful in addressing the issues of interest to most readers. Spellacy argues that the concern aroused in the 1970s about abnormal carbohydrate metabolism in women using oral contraceptives has been dispelled; Krauss and Tribble evaluate the evidence regarding plasma lipoprotein metabolism and conclude that the changes are small and are likely to be of minimal clinical importance in healthy, nonsmoking women; and Notelovitz emphasizes the role of risk factors other than hormonal contraceptives, particularly smoking, lack of exercise, and age, in thrombogenic or cardiovascular accidents. Do the new third-generation progestins, recently introduced in the United States after their successful launching in Europe, offer advantages in metabolic terms? Chez has analyzed the available data and concludes that it is difficult to identify any clinical advantages over the oral contraceptives already available.

The authors chosen to write about oral contraceptives and cancer, Pike and Spicer, use the opportunity to expound their theory of the biologic basis of carcinogenesis. They conclude with a description of a hypothetical contraceptive regimen that they believe would have health benefits far beyond those of currently available hormonal products. Their claims seem somewhat extravagant, since the supporting evidence is mostly theoretical and not empirical. One suspects that this chapter is somewhat different from what the editors expected, but it does describe the published epidemiologic studies of the relation between oral contraceptives and cancer of the breast, cervix, ovary, and endometrium.

Meeting the expectations of editors and readers alike is the authoritative chapter on Norplant contraceptive implants by Sivin. Filled with tables presenting primary data, it can serve as a reference on these implants for many years to come. Sivin documents the fact that this new form of long-term contraception is equivalent in efficacy to reversible sterilization and provides reassuring answers to frequently asked questions about safety, side effects, and acceptability.

A book on contraception would not be complete without the mandatory attention to barrier methods, intrauterine devices, vasectomy, and female sterilization. Surprisingly, there is interesting new information to report on these familiar subjects. Grimes's review of the status of intrauterine devices in the United States suggests that this greatly underutilized method warrants a second look from American women and their health care providers. The most recent entry, the copper T 380A, has an excellent safety record and an efficacy that rivals that of surgical sterilization; its approved duration of use has recently been extended to eight years by the Food and Drug Administration. Taking on a controversial subject, Schlegel and Goldstein provide the most comprehensive discussion one is likely to find on the potential link between vasectomy and prostate cancer. Their conclusion is that a causal association is unlikely. The same chapter describes the percutaneous methods developed in China to simplify vasectomy and efforts to develop procedures that are more readily reversible.

The book also includes a look toward the future, with several chapters on contraceptive research in progress. Most promising is the use of hormone antagonism for contraception. In a comprehensive chapter, Gordon and Hodgen describe the potential use of gonadotropin-releasing hormone analogues for contraception in either men or women and, on the basis of their own experiments in monkeys, discuss an array of potential contraceptive applications of antiprogestins.

One of the book's best chapters is that on AIDS and contraception, by Anderson and Voeller. The authors remind us how little work has been done on issues such as the effect of contraceptive use on the transmission of HIV, the manner in which the virus actually infects the heterosexual partner of an HIV-positive male, and the scant efforts to study the virus in female genital tissues and secretions. The limited information available, however, is reported accurately and comprehensively.

The field of contraception changes rapidly, so that books on the subject risk becoming out of date shortly after they appear in print. That is not likely to be the fate of this excellent work.

Sheldon J. Segal
Population Council, New York, NY 10017