Oral contraceptives, also known as the “pill,” are highly effective and an easy-to-use method of contraception. When taken regularly by women, oral contraceptive pills inhibit ovulation, thicken cervical mucus, which prevents sperm penetration, and alter uterine lining, making the environment unfavorable for implantation.1) Oral contraceptives have a high efficacy rate of 99% with perfect use or 93% with typical use, and they can also be taken to improve heavy bleeding, improve menstrual cramps, reduce premenstrual syndrome (PMS), improve acne, and treat endometriosis.1) Despite its beneficial effects, the rate of oral contraceptive use in the Republic of Korea has been reported to be around 3.3%, which is similar to that in nearby Eastern Asian countries such as Japan (2.9%) and China (2.4%), but substantially lower than that in the United States (13.7%) or Europe (19.1%).2)
Studies have shown that misconceptions about oral contraceptives, such as fear of adverse events and underestimating the effectiveness of contraceptives can lead women to avoid their use.3) On the other hand, a study reported that higher knowledge levels of oral contraceptives influenced women to have higher oral contraceptive continuation rates.4) As oral contraceptives are available as non-prescription drugs in the Republic of Korea, pharmacists can play a big role in counseling and education of women on oral contraceptives.5) In fact, a previous study on Singaporean women found that efficacy and healthcare professionals’ advice were the two most important factors in contraceptive selection.6)
A qualitative study on Korean women reported that women expressed difficulty in obtaining reliable information and knowledge of oral contraceptives, were fearful of other people’s perspectives and reactions to oral contraceptive use, and felt a need for change in public awareness and policy regarding oral contraceptives.7) To date, few studies have evaluated Korean women’s knowledge level on oral contraception or perspective toward oral contraceptive purchase in the pharmacy. This study aimed to investigate Korean women’s knowledge level and social perception toward oral contraceptives as well as their perspectives on pharmacy visits, which could help pharmacists better understand women’s perspectives and provide optimal patient counseling on oral contraceptives.
This was a cross-sectional study conducted using a 37-item survey questionnaire. Korean women between the ages of 20 and 49 who were willing and able to respond to online questionnaires were included in this study. Those who did not meet the inclusion criteria or those with incomplete survey submissions were excluded from the analysis. The targeted sample size was 1,000, according to previous similar studies.4,8) Recruitment and data collection was performed through a research company, Macro Mill Embrain, to encourage participation of women from diverse age groups and backgrounds. Invitation e-mails were sent out by Macro Mill Embrain to women who were registered in their database and matched the targeted age group. Raw data results were provided to the authors for the analysis. The survey was conducted between November and December of 2017. This study was approved by the Dankook University Institutional Review Board (IRB approval no. 2017).
The survey questionnaire consisted of four categories with 37 questions: participants’ demographic information (5 items), oral contraceptive usage (11 items), social perception toward oral contraceptives (7 items), knowledge on oral contraceptives (8 items), and perspectives on oral contraceptive purchases in the pharmacy (6 items). Demographic information included questions on age, education level, marital status, living arrangements, and religion. Items on social perception and perspectives toward oral contraceptives were evaluated on a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Knowledge on oral contraceptives included questions on oral contraceptives’ effects, administration, contraception instructions, and adverse effects and was designed based on the information from Ministry of Food and Drug Safety.9) Participants were asked to respond to each statement as “Yes (True),” “No (False),” or “Don’t know,” and the results were evaluated as either correct or incorrect answers (in which “Don’t know” answers were included).
Descriptive statistics were used to summarize the participants’ characteristics and survey responses. Survey results on continuous variables were compared according to the participants’ demographics (i.e., age group, marital status, oral contraceptive use, and religion) using Student’s t-test or one-way analysis of variance. Statistical analysis was performed using SPSS Statistics version 26, and differences were evaluated at a significance level of 0.05.
The survey was sent out by e-mail to a total of 7,494 potential participants, of whom 2,322 (46.3%) opened the e-mail invitation. Among them, 1,873 (80.7%) started taking the survey, and 1,076 (46.3%) completed the survey and were included in the final analysis. The participants were compensated by being awarded with credit within the online research company for completing the survey.
The mean age of the participants was 34.3±8.4 years. Regarding marital status, 51.8% were single and 44.9% were married. Among the total participants, 397 (36.9%) reported a history of pregnancy, and among those, 343 (31.9% of total study participants) were parous. More than half (52.0%) of the participants had experience in taking oral contraceptives (“ever users”), whereas 48.0% reported that they have never taken an oral contraceptive (“never users”) (Table 1).
When participants were asked about the methods of contraception that they have used (multiple answers allowed), the most frequently reported methods were male condom (78.5%) and withdrawal (47.7%), followed by oral contraceptives (32.1%), fertility awareness methods (23.8%), emergency contraception (14.1%), etc. (Fig. 1).
Among oral contraceptive users, the reasons for taking oral contraceptives were (multiple answers allowed) menstrual cycle delay (67.6%), contraception (44.7%), lighter periods (11.3%), polycystic ovarian syndrome (5.6%), acne (4.1%), endometriosis (3.6%), and others (i.e., menstrual cramps, breakthrough bleeding, PMS) (2.7%) (Fig. 2). The mean duration of total oral contraceptive use among oral contraceptive users was 6.7±13.5 (range, 1-120 months), with a mode of 1 month (43.1%). Ever users indicated that their reasons for selecting oral contraceptives as the method of contraception were (multiple answers allowed) for additional effects of menstrual cycle and/or acne control (43.5%), high contraceptive efficacy (28.8%), ease of use (25.6%), and reasonable cost (11.5%).
Among ever users, the most concerning aspects of using oral contraceptives (multiple answers allowed) were risk of adverse events (75.1%), contraceptive failure (21.7%), concern about return to fertility (13.8%), inconvenience (13.8%), others’ perspectives (10.9%), and cost (8.6%) (Table 2). Similarly, the reasons for reluctance to use oral contraceptives among never users (n=517) were concerns for adverse events (51.6%), lack of need (indications) for the pill (28.0%), inconvenience (6.6%), fear of contraceptive failure (6.4%), others’ perspective (4.4%), cost burden (1.7%), and others (i.e., pill burden, lack of familiarity with oral contraceptives) (1.7%) (Table 2).
Among the seven items on social perception, the highest agreed items were the need for oral contraceptive education for adolescents (4.27±0.85 on a 5-point Likert scale) and the belief that there is social prejudice on the use of oral contraceptives (3.68±1.00). The least agreed item was the belief that our society is open to comfortably talk about oral contraceptives (2.16±0.98) (Table 3).
When further analyzed by marital status, statistically significant differences in responses were observed in five out of seven items (Table 3). Compared with married women, single women responded more negatively (had statistically lower scores) to following positive statements (in order of descending absolute value of mean difference): belief that our society is open to comfortably talk about oral contraceptives (single 2.00±0.92, married 2.36±1.02, mean difference −0.36, p<0.01), belief that oral contraceptive use helps to achieve sex equality (single 2.45±1.07, married 2.69±1.00, mean difference −0.24, p<0.01), and belief that Korea has an amenable environment to obtain information on oral contraceptives (single 2.73±1.06, married 2.89±1.07, mean difference −0.17, p=0.01). On the other hand, single women responded more positively (had statistically higher scores) to the following statements (in order of descending mean difference): belief that social prejudice exists on use of oral contraceptives (single 3.85±0.96, married 3.51±1.00, mean difference −0.17, p<0.01) and need for oral contraceptive education to adolescents (single 4.40±0.78, married 4.11±0.91, mean difference 0.28, p<0.01). Interestingly, subgroup analysis by age demonstrated similar trends with marital status, where younger (aged 20-29) women felt more strongly that there is social prejudice on use of oral contraceptives which lessened in the older age group (aged 20-29 3.97±0.93 vs aged 30-39 3.66±0.96 vs aged 40-49 3.43±1.03, p<0.01). Apart from the belief that Korea has an amenable environment to obtain information on oral contraceptives, four of the five items shown to be statistically different by marital status also showed significant differences by age (Table 3). Subgroup analysis by oral contraceptive usage and religion did not demonstrate any notable differences between the groups.
Out of the eight items regarding knowledge on oral contraceptives, participants scored a total of 4.4±1.4 points (54.7%). Items with the highest correct responses were administration instructions for taking one tablet daily (77.0% correct), oral contraceptive mechanism (inhibition of ovulation) (63.1% correct), and administration instructions (21 days of active pill, followed by 7 days of drug-free interval) (61.1% correct) (Table 5). Less than half of the participants answered correctly to the following knowledge items: adverse effects related to blood pressure (27.9% correct), need for additional contraception during the first 7 days of starting oral contraceptives (45.1% correct), and adverse effects related to pain and edema (49.5% correct) (Table 4).
When participants’ characteristics were analyzed, distinct differences were seen between oral contraceptive never users (3.8±1.2) and ever users (5.0±1.9) (mean difference −1.2, p<0.01), but not between single or married participants.
Among the six items on perspectives toward oral contraceptive purchase in the pharmacy, the highest agreed item was preference to be counseled on oral contraceptives by pharmacists of the same sex (3.67±1.16), followed by a wish for a private place in the pharmacy (3.50±1.14), and preference to visit pharmacy when there were few customers (3.45±1.21) (Table 5).
When further analyzed using oral contraceptive use, statistically significant differences in responses were observed in five out of six items (Table 5). Oral contraceptive never users had statistically higher scores to the following statements regarding purchase of oral contraceptives in the pharmacy (in order of descending mean difference): preference to visit pharmacy when there are few customers (never users 3.66±1.08, ever users 3.25±1.28, mean difference 0.41, p<0.01), wish for a private place in the pharmacy (never users 3.69±1.05, ever users 3.32±1.20, mean difference 0.36, p<0.01), willingness to visit pharmacy farther away from home (never users 3.20±1.18, ever users 2.84±1.30, mean difference 0.36, p<0.01), fear of meeting an acquaintance (never users 3.28±1.12, ever users 2.93±1.18, mean difference 0.35, p<0.01), and preference to be counseled by the pharmacist of same sex (never users 3.82±1.07, ever users 3.53±1.22, mean difference 0.30, p<0.01). Between single and married participants, only one out of six items showed significant differences (Table 5), and analysis by age or religion did not show notable patterns of difference.
In the present study, we evaluated oral contraceptive usage, knowledge level, and social perception toward oral contraceptives, and perspectives on pharmacy visits in Korean women. Interestingly, 52.0% of the participants in our study have experienced taking oral contraceptives, which is much higher than the Korean women’s oral contraceptive usage (3.3%) as reported by the United Nations.2) This may be due to the differences in what was actually being reported. This study asked women if they had ever used oral contraceptives, whereas the United Nations reported the contraceptive methods being used by women at the present state.2) Additionally, it was observed in this study that the most common reason for taking oral contraceptives was to delay the menstrual cycle (67.6%) rather than for contraception (44.7%). In fact, whenever contraceptive users were asked about their length of oral contraceptive use, the most common answer was 1 month (43.1%), which suggests that oral contraceptives were commonly used temporarily. These findings are similar to those of a previous report by the Korea Institute of Drug Safety & Risk Management in which 62% of Korean women took oral contraceptives to delay their menstrual cycle, followed by contraception (38.9%).10)
However, it should be noted that oral contraceptives in Korea are indicated for contraception and not for delaying menstrual cycle. Delays in menstrual cycle may occur in the early stages of starting the pill as the body adjusts to the oral contraceptives, or when the active pills are used continuously without placebo. When oral contraceptives are used for indications other than what it is approved for, it should only be performed at the discretion of the healthcare provider. A study in young women in the United States reported that women chose to use oral contraceptives most commonly to prevent pregnancy, followed by to change the frequency of the period, to reduce bleeding, pain, or PMS, as well as to reduce acne, migraine frequency, issues with excessive hair growth, to reduce weight, or to avoid side effects.11) No responses were directly related to the delay in menstrual period. In fact, there is very limited evidence or studies on the use of oral contraceptives to delay menstrual cycle temporarily. In the United Kingdom, norethisterone, a progestin pill available as a prescriptiononly drug, is the only drug approved for postponement of menstruation.12) However, evidence supporting this indication seems to be limited.12) Additionally, only combined oral contraceptives containing estrogen and progestin are available for contraception in Korea, and the use of combined oral contraceptives to delay the menstrual cycle should be considered with caution as they seem to cause more adverse events, such as spotting, compared with progestin-only pills when used for short-term delays in menstrual cycles.13)
Both ever users and never users of oral contraceptives in this study voiced that their highest concern regarding oral contraceptives was the possibility of adverse events. The fear of adverse events seems to be the biggest reason for Korean women’s reluctance to take oral contraceptives. Similar findings were observed among Japanese women in that their common responses for not wanting to use the oral contraceptives were “worry regarding side effects” (49.8%), “I am satisfied with another method of contraception” (9.3%), and “taking medicine every day is annoying” (7.1%).14) Possible adverse events of oral contraceptives include nausea, bloating, headache, breast tenderness, and breakthrough bleeding, as well as more severe adverse events such as thromboembolism.9,15) While serious adverse events like thromboembolism can be prevented through screening and avoiding use in women with high risk (i.e., history of thromboembolism, aged 35 and older who are smokers), common adverse events can lessen with continuous use or through adjusting the amount of hormonal contents in the oral contraceptives. Contrary to common misconception, no evidence exists that oral contraceptives decrease subsequent fertility, and after discontinuation of oral contraceptives, the average delay in ovulation is 1-2 weeks.1,16) Several large cohort and case-control studies have shown that women who became pregnant in the first month after discontinuation of oral contraceptives did not have higher rates of miscarriage or birth defects of the newborn than the general population.1) Consulting with the obstetrics and gynecology (OBGYN) specialist and/or pharmacist prior to oral contraceptive use can help to prevent or cope with the possible adverse events and address any concerns including the return of fertility to ensure safe and efficacious use of the medication.
The participants in this study reported that the most common method of contraception was male condom (78.5%), followed by withdrawal (47.7%), oral contraceptive use (32.1%), fertility awareness (23.8%), and emergency contraception (14.1%). As the failure rates of typical use at one year for withdrawal and fertility awareness are 22% and 24%,17) respectively, it is alarming that such methods with low efficacy are commonly used, as well as the use of emergency contraception. Therefore, the importance of effective sexual education is highlighted. When participants were inquired about their social perception toward oral contraceptives, women highly agreed with the need for oral contraceptive education to adolescents (4.27±0.85). According to the ‘Sexual Education Standards’ by Ministry of Education, education on types and usage of contraceptives are included as part of the sex education curriculum suggested for middle and high school students.18) However, this was highly criticized for its sex stereotypical contents, and appropriate revision is necessary.19) School is where adolescents can get social support and reinforcement of appropriate attitudes and behavior toward contraceptives.20) Previous studies on school-based interventions for improving contraceptive use in adolescents have found that rather than focusing only on abstinence and pregnancy prevention, interventions that addressed HIV/sexually transmitted disease prevention and pregnancy was more effective. In addition, multifaceted programs with multiple sessions including interactive activities rather than a didactic approach alone were more effective in learning and behavioral changes in adolescence.20) Although these interventions can be more costly, implementation of effective sexual education in school is key to developing a good foundation for informed and safe use of contraception.
Interestingly, single women, as compared to married women, responded more negatively to the social perception statements, and similar pattern was observed in younger women compared to older women. Examples included disagreeing to the belief that our society is open to comfortably talk about oral contraceptives (single 2.00±0.92 vs married 2.36±1.02, aged 20-29 1.92±0.86 vs aged 30-39 2.23±1.04 vs aged 40-49 2.34±0.97) or agreeing to the belief that social prejudice exists on the use of oral contraceptives (single 3.85±0.96 vs married 3.51±1.00, aged 20-29 3.97±0.93 vs aged 30-39 3.66±0.96 vs aged 40-49 3.43±1.03). In a previous qualitative interview study in Korean women with experience in taking oral contraceptives (which included 75% of single women), it has been reported that women felt fearful about others’ reactions when talking about taking oral contraceptives and wished for more open awareness on the use of contraception.7) Such findings are similar to what has been observed in this study, and it appears that married women and older women are less fearful or negative toward social perceptions on oral contraceptives.
Knowledge on oral contraceptives has also been evaluated in women. While participants in this study were more familiar with the administration instructions and mechanism of the oral contraceptives, they were less aware of the information regarding adverse events of oral contraceptives or the need for an additional form of contraceptive (i.e., barrier methods of contraception) when starting an oral contraceptive. In a previous study conducted in Korea, pharmacists’ counseling on oral contraceptives was evaluated by mystery shoppers visiting the pharmacy to purchase oral contraceptives. In the study, 75.9% of pharmacists conducted counseling on oral contraceptives, and the counseling was conducted most frequently on medication administration instructions, followed by basic counseling (i.e., indications, discussion on possibility of contraception failure, etc.), and least frequently on patient assessment (i.e., first day of last menstrual period, underlying diseases, etc.). This suggests that while pharmacists provide basic information, there is room for improvement in counseling for oral contraceptives.5) Another previous study examined the influence of oral contraceptive knowledge on oral contraceptive continuation and observed that provision of educational text messages can help increase the knowledge level and continuation rate of oral contraceptives.4)
When visiting the pharmacy to purchase oral contraceptives, women preferred to be counseled on oral contraceptives by pharmacists of the same sex (3.67±1.16) and wished for a private place in the pharmacy (3.50±1.14) when purchasing oral contraceptives. When participants’ characteristics were analyzed, such responses did not differ significantly according to marital status but showed differences based on prior oral contraceptive use. It was observed that users of oral contraceptives tended to have less preference for the number of customers in the pharmacy, a private space in the pharmacy, the distance of pharmacy from home, fear of meeting an acquaintance, etc. This suggests that ever users of oral contraceptives felt more comfortable with their surroundings, while never users felt more self-conscious when purchasing oral contraceptives in the pharmacy.
As many over-the-counter (OTC) oral contraceptives are available and pharmacists may be the only healthcare professionals women encounter when purchasing oral contraceptives, the role of pharmacists in counseling and educating women on safe and efficacious use of oral contraceptives cannot be stressed more. When women visit the pharmacy to ask for recommendations on oral contraceptives, the purpose of taking oral contraceptives should be asked first, and appropriate recommendations of oral contraceptives or referral to an OBGYN specialist can be made based on patient-specific situations. As many women, especially single women and those without experience in taking oral contraceptives, may feel uncomfortable and self-conscious, pharmacists should make special efforts to counsel women nonjudgmentally in a setting where privacy can be protected to help women feel more comfortable.
This study has several limitations. First, the study has a limited number of participants for a complete representation of Korean women. However, the study aimed to include over 1,000 participants from various age groups to obtain a good representation. Second, the study did not examine whether the oral contraceptive used was OTC or prescribed, which could have provided more information on how such differences could have resulted in women’s social perceptions and knowledge on oral contraceptives. Lastly, we did not use a developed research tool in this study, for example, to evaluate women’s knowledge on contraception or adherence to oral contraceptives, which could have enhanced the validity and reliability of our findings. Based on the findings of this study, further studies should focus on measuring such outcomes and their associations.
In conclusion, this study examined oral contraceptive usage, knowledge level, and social perception toward oral contraceptives, and perspectives on pharmacy visits in Korean women. It was observed that women most frequently used oral contraceptives for a short amount of time (i.e., 1 month) and for purposes of menstrual cycle delay. Single women agreed more with the existence of social perceptions toward oral contraceptives compared with married women, and similar pattern was observed in younger women compared to older women. Prior experience in the use of oral contraceptives, and not marital status, resulted in a higher knowledge level on oral contraceptives and impacted how comfortable women felt about their surroundings during oral contraceptive purchase in the pharmacy. This study suggests that pharmacists play a significant role in oral contraceptive counseling for women, which should be conducted in a comfortable and private setting to ensure safe and effective use of oral contraceptives.
This work was supported by the National Research Foundation of Korea (no. NRF-2017R1C1B1003141). This research has been conducted by the authors working at the Department of Pharmacy of Dankook University. Department of Pharmacy was supported by the Research-Focused Department Promotion Project as a part of the University Innovation Support Program 2020 to Dankook University.
All authors declare that they have no conflict of interest.