Opinion: Dissonance in Attitudes between Blood Clotting in Vaccines and Oral Contraceptives

By Stella Huggins

The combined oral contraceptive pill is known to cause blood clots in some people who use it. Photo from Reproductive Health Supplies Coalition on Unsplash (2019).

As vaccines of all stripes begin to be distributed throughout the population, inevitable panic over side effects descends with them. New technology is always daunting if you do not understand it.

The psychology lying behind the fear of new phenomena is complex [1], and often begins with denial and outright refusal to partake [2]. Every individual has the right to refuse anything they wish — bodily autonomy is absolutely a human right. The recent pandemic has created a fascinating development in modern science; three distinct variations of vaccines [3]. Inevitably, some have unpredictable side effects, the most concerning being blood clots associated with the Johnson & Johnson vaccine.

The mechanisms through which the vaccine developed by Johnson & Johnson acts are not new concepts. It functions through the utilisation of adenoviruses, a common subgroup of medium-sized, double-stranded viruses that infect humans. They were discovered in 1953 [4]. However, it hasn’t been in such wide use throughout the population. The public has clutched onto the pitfalls of the vaccine with merciless scrutiny; this is a good thing in some respects. We should be wary of the scientific narrative. Scientists themselves are critical of it and are constantly reshuffling ideologies and things considered to be the ultimate truth. However, an interesting observation is that the scrutiny placed on COVID-19 vaccines does not appear to be attributed to other medications distributed nearly just as frequently in the population. To me, a striking difference in the priorities of public debate lies in who is being affected by the issues.

Johnson & Johnson has produced adverse side effects in a small majority of individuals. Blood clots, namely, have caused immense pressure on governments from certain sectors of society to discontinue their use [5]. Walking the line of caution is no easy feat, and the relative newness of the technology adds another layer of complexity to the matter. However, blood clots as a side effect of oral contraceptives are a well-documented occurrence; so where is the outcry for females taking this medication?

The advent of birth control was in the 1960s [6]. It provided an incredible amount of liberation to women, uprooting the narrative that a female must have a child if she were to enjoy the same sexual liberation as men. There is an obvious imbalance in the burdens placed upon each gender when it comes to pregnancy, and technologies to alleviate this imbalance gifted us with strides towards bodily autonomy for females.

Johnson & Johnson has a 66% efficacy rate against symptomatic infection, and an 85% efficacy rate against severe COVID-19 that produces hospitalisation. Oral contraceptives have a 99% efficacy rate with perfect use (taking the pill at the exact same time every day) and 91% success when human error is factored into the equation. Blood clots have occurred in 6 of the 7 million patients receiving the Johnson & Johnson vaccine (in the USA, one of the places Johnson & Johnson is being distributed) [7], whilst oral contraceptives (using Ava30 ED as an example, there are numerous oral contraceptives) have a risk of causing blood clots in about 5-7 out of every 10,000 females taking the medication, annually. In some cases, the blood clot risk is unknown in oral contraceptive types (estradiol + nomegestrol hormone pill Zoely, and estradiol + dienogest hormone pill Qlaira [8]). This, to some extent, could reflect the priorities of the system: why is there an unknown, for such a significant side effect risk?

The medications are clearly inherently different in a myriad of ways — a vaccine requires no effort from the patient in terms of administration. Oral contraceptives are clearly more established, and have more data in terms of the long-term risks associated with these blood clots. Females are educated, generally, on the potential side effects of their birth control. There may be less quantifiable motives underlying a female’s decision to accept the risks, and the raft of side effects, social and economic gain, bodily autonomy, are all factors that play into the decision. It’s a highly personal choice in both cases. But the general social attitudes towards them seem so wildly different when the side effects are so similar.

Of course, 100% success is an enormous task — body chemistry is ridiculously complex, and side effects are to be expected in some capacity. The curious part is the attitudes towards such side effects. Birth control is distributed at a similar frequency in the population. In New Zealand, 89% of women aged between 35-69 use the pill [9]. Our vaccination rollout programme is still in progress (though it’s important to note New Zealand is using Pfizer, a vaccine not associated with blood clots), the intent being to vaccinate as many people as possible, and cultivate herd immunity [10]. These numbers obviously do not pertain to the issue of blood clot parallels, but instead illustrate the frequency at which vaccines and oral contraceptives are distributed in populations. It begs the question; would the standard of birth control’s efficacy in relation to its side effects (which are by no means limited to blood clots), be tolerated today? Would the outcry be so outrageous, passionate and personal? Do groups who are unaffected by the immediate effects of such medications, have any regard for the health of women?

The climates under which both medications were produced were both ones of urgency, relating to a health issue. It’s clear that the COVID-19 pandemic needed a far more rapid solution, but women were still dying of at-home abortions — an epidemic of sorts, though a far more socially oriented one. I am well aware that the drugs are not directly comparable, though I do urge you to consider society’s overall attitudes to women’s health, and compare these with the public’s attitudes to the new vaccines becoming available.

It appears to reflect an insidious structural problem in the healthcare system, rooted in a historically male-dominated perspective to female health. It’s something to ponder, when women across the globe are accepting such a risk, and passionate outcry is happening for a new medication. Part of this can be attributed to the fact that people born into an age where oral contraceptives are the norm may have less trouble accepting their risks — after all, their predecessors have coped with this subpar quality of life, how bad can it be? I can imagine that there was a degree of hesitancy when the drug was first rolled out worldwide.

Again, I am by no means advocating we blindly accept subpar accuracy of vaccines, and erring on the side of caution is perfectly acceptable. We should absolutely not stride forward with a solution that isn’t quite right. However, the perception of the facts of the situation needs to change. Oral contraceptives are well established and socially accepted in most parts of the world — of course, as I have detailed, so the standards are slightly different — but maybe it’s time we reconsider these entrenched attitudes.

Image from Hakan Nural on Unsplash (2020)

Health psychology is difficult. Our attitudes to medication are understandably deeply personal, intertwined with our identity, our perceptions of our personal safety, the safety of our loved ones, and cultural attitudes. It’s not easy to ask people to unpick these things, especially in a tumultuous period in history — in times of change, people burrow further into their previously entrenched beliefs, taking the global financial crisis of 2008 as an example [11]. It’s likely that a pandemic is no exception to these psychological rules.

Oral contraceptives are by no means the only drugs that cause blood clots as a side effect. In an analysis by Ramot, Nyska and Spectre, a detailed consolidation of all known medicines to cause blood clots revealed a fascinating trend. A huge number of blood clotting drugs exist, however a huge majority of their uses relate to life-threatening or seriously quality of life impairing conditions. Chemotherapy, antipsychotics, antidepressants, acute skin conditions, pain relievers, muscular degeneration, and anemia are among the conditions treated by classes of medication that cause blood clotting side effects [12].

Whilst not to degrade the physical benefits that contraception can bring (hormone and mood regulation, alleviation of adverse menstrual experiences, treatment of mild endometriosis and PCOS cases, etc.), as well as the social-societal benefits of females having increased choice in their bodily autonomy, it seems as if the costs sometimes outweigh the benefits [13,14,15]. Or, at least, the technology simply isn’t being improved, due to a disregard (whether intentional or unintentional), for improvement and progress, and a satisfaction with subpar female healthcare. The priorities of our society are overwhelmingly directed towards other areas of progress, and the treatment of female specific ailments is decidedly average.

It’s coming to light now, too little too late, that medical research done on men and extrapolated to women is simply not directly transferable [16]. Women are not miniature versions of men, and their biochemistries are not parallel — at the most basic level, estrogen and testosterone production in each sex are inherently different. Female healthcare has long been neglected. The profession of medicine is finally becoming more gender-balanced [17], but this does not necessarily change the structures it was built on. This is not to say that we tear down frameworks of healthcare in a critical period, but rather, that we are acutely aware of their existence and origins. We must be cognisant of the fact that marginalised groups can easily fall under the radar in times of chaos [18,19]. The attitudes towards side effects are just one symptom of a larger ailment afflicting health perspectives.

References

[1] Riezler, K. (1944). The Social Psychology of Fear. American Journal of Sociology, 49(6), 489–498. https://doi.org/10.1086/219471

[2] David Ropeik (2013) How society should respond to the risk of vaccine rejection, Human Vaccines & Immunotherapeutics, 9:8, 1815-1818, DOI: 10.4161/hv.25250

[3] World Health Organization. (n.d.). Coronavirus disease (COVID-19): Vaccines. World Health Organization. https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines?adgroupsurvey=%7Badgroupsurvey%7D&gclid=CjwKCAjwtJ2FBhAuEiwAIKu19lqptp526TPSd6wN8OsiLlpctk5_oFG9wFwOhtK9XvhmOyIomEoDzBoCVF0QAvD_BwE.

[4] Desheva, Y. (2019). Introductory Chapter: Human Adenoviruses. In Y. Desheva (Ed.), Adenoviruses. essay, IntechOpen.

DOI: 10.5772/intechopen.74757

[5] Ledford, H. (2021, April 16). COVID vaccines and blood clots: five key questions. Nature News. https://www.nature.com/articles/d41586-021-00998-w.

[6] Public Broadcasting Service. (2010, May 11). A brief history of the birth control pill. PBS. https://www.pbs.org/wnet/need-to-know/health/a-brief-history-of-the-birth-control-pill/480/.

[7] Centers for Disease Control and Prevention. (2021, April 23). Agencies Underscore Confidence in Vaccine's Safety and Effectiveness Following Data Assessment; Available Data Suggest Potential Blood Clots Are Very Rare Events. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2021/fda-cdc-lift-vaccine-use.html.

[8] MEDSAFE. Oral Contraceptives and Blood Clots. (n.d.). https://www.medsafe.govt.nz/consumers/leaflets/oralcontraceptives.asp.

[9] Chesang, J., Richardson, A., Potter, J., & Coope, P. (2016). Prevalence of contraceptive use in New Zealand women. The New Zealand medical journal, 129(1444), 58–67.

[10] World Health Organization. (n.d.). Vaccines and immunization: What is vaccination? World Health Organization. https://www.who.int/news-room/q-a-detail/vaccines-and-immunization-what-is-vaccination?adgroupsurvey=%7Badgroupsurvey%7D&gclid=CjwKCAjwtJ2FBhAuEiwAIKu19p7EEwGbHCdtTp0jib3vNjxP_749a_wuGlEvrYg8IhlaZ1TSDkSsXhoCMPYQAvD_BwE.

[11] Sufi, A. (2018, September 23). Why You Should Blame the Financial Crisis for Political Polarization and the Rise of Trump. Evonomics. https://evonomics.com/blame-financial-crisis-politics-rise-of-trump/.

[12] Ramot, Y., Nyska, A., & Spectre, G. (2013). Drug-Induced Thrombosis: An Update. Drug Safety, 36(8), 585–603. https://doi.org/10.1007/s40264-013-0054-6

[13] Martinelli, I., Battaglioli, T., & Mannucci, P. M. (2003). Pharmacogenetic aspects of the use of oral contraceptives and the risk of thrombosis. Pharmacogenetics, 13(10), 589–594. https://doi.org/10.1097/00008571-200310000-00002

[14] Coata, G., Ventura, F., Lombardini, R., Ciuffetti, G., Cosmi, E. V., & Di Renzo, G. C. (1995). Effect of low-dose oral triphasic contraceptives on blood viscosity, coagulation and lipid metabolism. Contraception, 52(3), 151–157. https://doi.org/10.1016/0010-7824(95)00148-4

[15] Rosing, J., Middeldorp, S., Curvers, J., Thomassen, M. C., Nicolaes, G. A. F., Meijers, J. C. M., Bouma, B. N., Büller, H. R., Prins, M. H., & Tans, G. (1999). Low-dose oral contraceptives and acquired resistance to activated protein C: a randomised cross-over study. The Lancet, 354(9195), 2036–2040. https://doi.org/10.1016/s0140-6736(99)06092-4

[16] Zucker, I., & Prendergast, B. J. (2020). Sex differences in pharmacokinetics predict adverse drug reactions in women. Biology of Sex Differences, 11(1). https://doi.org/10.1186/s13293-020-00308-5

[17] Gender equality in medicine: change is coming. The Lancet. (2019, December). https://www.thelancet.com/journals/langas/article/PIIS2468-1253(19)30351-6/fulltext.

[18] Cairns, D., Growiec, K., & de Almeida Alves, N. (2014). Another ‘Missing Middle’? The marginalised majority of tertiary-educated youth in Portugal during the economic crisis. Journal of Youth Studies, 17(8), 1046–1060. https://doi.org/10.1080/13676261.2013.878789

[19] Kantamneni, N. (2020). The impact of the COVID-19 pandemic on marginalized populations in the United States: A research agenda. Journal of Vocational Behavior, 119, 103439. https://doi.org/10.1016/j.jvb.2020.103439