Over the years I’ve received questions about the Pill on a pretty steady basis. As one female reader put it, if you go Primal and do all the work of normalizing your hormones, does taking the Pill undo all the good? Are the cautionary rumors I hear just overblown, or are there substantial risks? What about taking the Pill for a longer period of time? Does it matter if I’m 45 as opposed to 25? Clearly, there are a lot of questions and nuances here. Let’s do what we can to unpack this subject.
Before I begin, let me offer the reasonable caveats. Yes, I’m a guy writing about a women’s medication – a rather personal one at that. I get it. I want to tread gently in these arenas. To be sure, the Pill marked a revolution in reproductive planning. It was the first convenient contraception choice over which women had full control. I don’t want to diminish the personal and social impact of that option. Nor do I want to overlook the convenience and effectiveness that the Pill (when taken as directed) offers to a woman/couple who aren’t looking to start (or increase) a family. There’s a reason some 100 million women around the globe turn to the Pill.
That said, I think most would agree we’re looking at a legitimate health question as well as intimately personal one. From my own humble perspective, I’ll go so far as to say the medical community has done a disservice to women by not being more transparent about oral (and other hormonal) contraception over the years. (Allow me to focus on oral contraceptives today, which are the oldest and most studied form of hormonal birth control.) Women understandably have a lot of questions, important questions. The problem is, the issue too often gets simplified by often well-intentioned practitioners whose main priority is respecting a woman’s choice on the issue. Yes, many personal factors go into the decision, but the conversation between a doctor and patient shouldn’t stop before it’s even begun. Physicians need to acknowledge that women care about the health implications of the decision.
As you all know, I’m first and foremost a supporter (okay, maybe diehard, soapbox, scream from the rooftops, full-on advocate) of full disclosure. People should have access to all of the details for choices they’re obliged to make – whether it be choices involving food, medical procedures, or medications. Although there’s a lot just on the medical side of oral contraceptives, let me do what I can (in the modest scope of a blog post) to at least get the ball rolling.
The fact is, when we’re dealing with matters of the body, there’s no such thing as a free lunch. I think we all know that. Taking hormones on a daily basis (whether natural or synthetic or both) will undoubtedly have repercussions. The body is a finely tuned machine of collaboration and interaction. The shifting amount of one hormone will have a corresponding effect on other hormones, which in turn influences a whole host of other physiological functions and biochemical secretions. But onward with the details….
First a little historical perspective… The dosage of today’s Pill (as many versions as there are) is minute compared to what was initially produced in those very early years. Formulations have changed over time to include lower levels of hormones. The so-called “mini-Pill” contains no estrogen at all. Nonetheless, side effects still exist in part because the human body hasn’t changed (the stubborn vessel it is) and because new formulations contain new versions of the hormones that appear to be riskier than the older versions. As for post-Pill fertility, the evidence suggests taking the Pill doesn’t impair future fertility. I can understand, however, that women would be wary of this possibility especially with new ingredients being added to formulations. I would hope the studies and reviews on this subject continue.
Now for the rundown of health risks – what you’ve heard and what’s true. There’s a lot to cover. Although I don’t claim that a single blog post can cover every study and nuance, let me hit on as much as I can.
First, the “good” news. You’ve likely heard that taking the Pill can lower a woman’s risk for ovarian cancer, endometrial cancer, uterine cancer, and endometriosis. These appear to be true. That said, I obviously wouldn’t suggest a woman take on other risks (forthcoming of course) to slightly lower the chance of developing these conditions.
According to research analysis, data from 50+ studies suggest the Pill confers a 10-30% higher risk for breast cancer. Higher estrogen pills are implicated more in this data as is prolonged use of the birth control pill and family history of cancer. Although this heightened risk is definitely worth considering, it is significantly lower than the risks of hormone therapy for post-menopausal women.
In the last few years, there’s been some talk about abandoning pap smears (the procedure that tests for abnormal cervical cells) in exchange for an HPV DNA test. The problem is, HPV is not the sole cause of cervical cancer. The birth control pill is also considered another major risk factor, especially for women who have taken the Pill for five years or more (PDF). If this plan is ever adopted, here’s the message to millions of women on the Pill who are HPV negative: good luck catching any cervical changes early. It’s inflammation at work here, folks. The Pill, particularly estrogen containing versions, causes inflammation.
It’s a known but little publicized fact that increased estrogen can contribute to irritation of the stomach lining and aggravation of existing gastrointestinal conditions like GERD and Crohn’s. Some women are more sensitive to the effect of the Pill on gastrointestinal health. Hint: if your doctor tries to put you on the Nexium (a.k.a. “the purple pill” or any of its assorted relatives), try going off the Pill first.
The Pill, particularly traditional estrogen-progestin combination formulations, can raise blood pressure in some women, particularly those who already have high blood pressure. Research also shows that the Pill very slightly raises the risk of stroke in women without stroke risk factors (e.g. migraines and high blood pressure). The difference adds up to approximately a single added stroke per 25,000 women.
This is one of the risks that’s gotten the most press over the last few years and for good reason. It’s an issue that has dogged the Pill since almost the very beginning. As formulations changed, people assumed the risk would be reduced. But there’s a wrinkle. Newer types of progestins (e.g. drospirenone, desogestrel or gestodene) heighten a woman’s risk for blood clots compared with the older form of progestin (levonorgestrel). Research has shown that women who take a birth control pill with one of these newer progestins have six times the risk of blood clots compared to women who don’t take the Pill. Women who use a Pill with an older form of progestogen have three times the risk of blood clots compared to non-users. The risk for traditional progestin is approximately 10 women in 10,000 each year.
Other Side Effects
- Overall higher CRP levels (inflammation marker)
- Lower total antioxidant activity as well as specifically measured lower blood levels of many micronutrients. (B6, E, CoQ10, zinc, selenium, phosphorus, and magnesium)
- Impaired thyroid function (Estrogen can influence the availability of thyroid hormone in the body because it increases a specific thyroid “binding” protein.)
- Potentially negative effect on lipid levels – particularly LDL
- Adverse mood symptoms
- Lower testosterone levels, which can decrease libido and make it harder to build muscle mass
- Increased risk of prostate cancer in partners (This is fairly new research that will undoubtedly get more attention in the coming years.)
Finally, then there’s the more sensitive research that’s come out in the last few years about the Pill’s effect on partner choice. Women’s monthly shift in hormones has implications for their attraction to certain traits in males. Women who met their partners while on the Pill were happier with their partners’ parenting and care taking and were less likely to separate than those who weren’t; however, they “scored lower on measures of sexual satisfaction and partner attraction” and “experienced increasing sexual dissatisfaction during the relationship.” (No comment here, btw.)
So, what’s the take home message? Readers have asked my overall opinion of oral/hormonal contraception. I know what you might infer from the course of evidence here, and you’d be mostly correct. Is there enough medical risk to give a woman pause? Absolutely. Is it enough to discount the Pill as a birth control option for a woman who is otherwise healthy, has no significant family history or risk factors in the relevant areas, and strongly prefers this contraceptive form? No, I can’t say I’d entirely take it off the table. The heightened risks for the above conditions were indeed measurable but generally not dramatic in otherwise healthy, non-smoking subjects who didn’t have significant family histories of relevant diseases. Age doesn’t appear to raise one’s risk except in the case that other risk factors develop (e.g. high blood pressure, etc.).
That said, let me throw in some caveats. I’d certainly favor the lower dose versions. I’d suggest close monitoring by a physician who acknowledges the risks of a hormonal contraceptive. I’d also strongly suggest regular exercise (not the inflammation boosting chronic cardio kind), a consistent anti-inflammatory diet (I think you know one I can recommend.), anti-inflammatory supplementation (fish oil, turmeric, etc.), and vitamin and mineral supplementation. And – although this bumps up against some rather personal factors – I’d recommend looking at other contraceptive options for the longer term. In other words, I wouldn’t suggest being on the Pill indefinitely as some physicians and medical groups say is just fine and dandy to do. Some of these heightened risks (e.g. blood clots, breast cancer) only diminish over a ten-year period after discontinuation. That’s pretty far-reaching.
Yet, I also won’t go so far as to completely count out oral contraceptives because I know every other method has its drawbacks (major or minor) as well. The reality is, there’s no 100% perfectly safe, astoundingly convenient, wholly unencumbered, completely foolproof way to dupe or circumvent nature on this front. It’s not about making a particular choice. It’s about making an informed decision. Not everyone is able to track their cycles with perfect precision. Not everyone tolerates an IUD or diaphragm or spermicides well. Not everyone wants to solely depend on the use of condoms for a host of reasons. Not everyone is ready to go the sterilization route yet. Take all of this, and that’s a whole other ball of wax – and another blog post than this one….
Thanks for reading today, everyone. Share your thoughts on the Pill. What information did your practitioner offer? Have the benefits outweighed the negatives for you, or the other way around? Do you have thoughts/suggestions for women who are considering the Pill? Have a good end to the week, everyone!