Retinoids and Contraception

Marc Girard, MSc, MD 19, rue de la Glacière, F-755013 Paris (France) In their interesting paper on retinoids and contraception (Dermatology 1992; 184: 161-170), Lehucher Ceyrac et al. rightly point out that ‘every dermatologist has the moral obligation to ensure that [the teratogen-ic effect of retinoidsj is avoided’. However, weighting the risks and benefits of a medical recommendation is not always an easy task. Surely, the risk of pregnancy must be excluded in women taking retinoids; but whereas Lehucher Ceyrac et al. display a high level of awareness relative to the risk of intrauterine devices in nulliparae (which is quite correct), they seem less concerned with another potential risk in young or very young females taking oral contraceptives (OCs): the risk of breast cancer. At this time, it would be excessive to claim that there is a causal relationship between OCs and breast cancer [1]; nevertheless, according to the most recent investigations, serious doubts remain about the carcinogenic effects on the breast of the early use of OCs [2-8]. In that connection, it is also important to remember that even a moderate increase in the relative risk could be of clinical importance for a disease with a very high baseline incidence such as breast cancer. Moreover, it might be that the incidence of breast cancer presenting at a young age could be increased by the early use of oral contraception [8]. Of course, a physician can never be confident that even a young girl will not be exposed to the risk of pregnancy. On the other hand, preventing the teratogenic risk of retinoids by a systematic prescription of OCs -as some colleagues claim to do – carries another kind of risk, not negligible either. Thus, what can be done, in practice? Perhaps doctors could agree that this is not their responsibility to make choices in a patient’s or her parents’ place: the current uncertainty justifies certainly the ethical principle of the patient’s autonomy, which demands providing the interested parties with accurate information and let them be with their own responsibilities. References Harlap S: Oral contraceptives and breast cancer: Cause and effect? J Reprod Med 1991 ;36: 374395. McPherson K, Drife JO: The pill and breast cancer: Why the uncertainty. Br Med J 1986; 293:709-710. Olsson H, Möller TR, Ranstam J: Early oral contraceptive use and breast cancer among premeπopausal women: Final report from a study in southern Sweden. J Natl Cancer Inst 1989; 81:1000-1004. Girard M: Pilule et cancer: la poursuite du débat. Recherche 1989;20:802-803. Schlesselman JJ: Oral contraceptives and breast cancer. Am J Obstet Gynecol 1990; 163: 1379-1387.