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19 Jan

The Pill: What You Need to Know About Oral Contraception

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.

Breast Cancer

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.

Cervical Cancer

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.

Gastrointestinal Issues

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.

Cardiovascular Risks

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.

Blood Clots

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

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!

You want comments? We got comments:

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  1. Hi have been on the pill for the last 14years and what to be off them for good this time (2nd try two years later) because I want to try for kids on 2 years. Last time was horrible – bad acne, depression (made worse by acne), thyroid issues causing be to lose weight and have heart palpitations, tirdness and insomnia. I thought all of these problems were something else but after reading many simalar reactions to going of the pill I realised thats what it was from because it all started after stopping the pill and went away again when I went back on it. I didn’t know any of the about the pill until now but it’s really scary (especially the link to PCOS, which my younger sister has and struggled gettting pregnant). I which I was told about this when I went on the pill, but even now most doctors (esp here in NZ) won’t acknowledges the risks of a hormonal contraceptive and try to tell you it’s something else.

    Also the comment about the lower scores on measures of sexual satisfaction and partner attraction” and “experienced increasing sexual dissatisfaction during the relationship.” is so true when I think back and even now in my current relationship. It’s great to know it could all linked to something and hopefully fingers crossed it improves once I come of the pill (straight away would be nice).

    I hope ALOT improves after I come off the pill, including weight management, moods, libido and fertility of course coz the side affects I have read are all not good being on it or the period in between when your body is getting back to normal.

    eeeekkkkk

    hoping my partner is understanding. Although I think he thinks I am reading into it all too much and just jumping on a band wagon, but he doesn’t know my body or quite understand really not does he realise the implications it could have. He thinks I am worried over nothing.

    nothing in life is ever easy is it!!

    Victoria wrote on October 5th, 2012
  2. Hi,

    I am really scared an not sure what to do. I have taken the pill for 7 years and it has served me and my partner well. I am comfortable with it. How much longer can i carry on taking it? Am I already at risk of getting cancer? I was planning on stopping it today but I am hearing two different sides that it’s very very bad for you and that’s it’s ok to a certain point. I need an answer please as I am scared.

    Thanks,

    Lindsay

    Lindsay wrote on November 2nd, 2012
    • Don’t be scared – there’ll always be people giving you opposite opinions, some for, some against and some positively scaremongering. I would go and see your doctor or nurse and discuss it with her/him. There might be better options for you, or you might be fine with the pill you’re on. It all depends on your age, your current state of health, the type of pill you’re taking and the other options available to you. In my opinion, the pill, either combined or progestogen only, are good options for some women, but of course you have to sensibly weigh up the risks and benefits.

      Liz wrote on November 2nd, 2012
  3. Thanks Liz :)

    Lindsay wrote on November 2nd, 2012
  4. I have been off the pill for a few years and have felt great since. However recently had an abnormal period and the doctor insisted I go on bc again to make it normal. 4 days later I started having gallbladder attacks for a week straight. I’ve been off the pill again for the last 2 days and my gallbladder symptoms have decreased by 95%. I’ll never touch the stuff again.

    RachC wrote on November 11th, 2012
  5. I also use a copper IUD. I’ve only taken birth control for about six months and I felt horrible. I think, in my case it was not because of the side effects of the pill, but just the feeling that there was no natural hormonal cycle. I just felt so aweful, never felt anything more unnatural before.
    I use a frameless copper IUD named ‘Gynefix’. It is said to prevent increased cramps and heavy bleeding that is usually a side effect of other copper IUD’s. I must say, during the first 4 months after insertion, the bleeding was heavier, but this stabilized after half a year. Now I’m just really happy with copper IUD. I have indeed heard of coppor toxicity when using a copper IUD but I think with a good diet it’s rare. As I’ve read somewhere in these posts, zinc supplements may be good in that case. Anyhow, I think copper IUD’s are a far better choice than hormonal contraceptives.

    Laura wrote on March 4th, 2013
  6. Great article and discussion! Wow, there’s a lot to learn from everyone’s different experiences.

    I went on the pill at 22. I asked my doctor about it and she didn’t give me one word about risks or implications, after reading this article that now makes me rather concerned. The severity of my periods did subside and my breasts grew in size. I was on the pill for 2.5 years. Then, at the same time I went primal I decided to stop taking the pill because I want my body to be completely natural. My breasts have shrunk (talk about a sign of cause and effect) and my period symptoms have incredibly decreased (even more so than when I was on the pill). I’m a firm believer in the Primal Blueprint now based on the undeniable symptoms my body has exhibited.

    Emily wrote on March 8th, 2013
  7. I think BC is to blame for my cyst. Without my cyst I would have never been diagnosed with Endometriosis though. I fought against going back on BC for years after my diagnosis and finally gave in and am finishing my 3rd month of the mini pill. It’s frustrating because it’s not well known yet so the resources are limited. And until I read this article my doctor never said the mini pill increases my risk of cysts especially if I’ve already had one… which I have. My other issue being that I’m constantly spotting or full on bleeding which is starting to really interfier with my relationship and is rather obnoxious.I was under the impression that by going on BC my cramps would be relieved. I’m not looking for a mirical but I’ve been in more pain this past month than most months without BC. So from my experience you bleed none stop you DO gain weight, I’m also breaking out horribly all over my chest (which is not usual for me) and the pain is still very much there if not worse.

    I could be just an exception. But I am very anti-bc and even the minipill is a nightmare.

    Kylie wrote on October 25th, 2013
  8. I am keen for info/opinions/experiences from other ladies (or men with experience/knowledge) for my issues as I’m really frustrated at the moment.

    I was on Micronor (mini-pill, progesterone only) for a year and did not bleed at all (it was pretty awesome/convenient but probably not very healthy). In the last few months my body has decided to make up for lost time by giving me a whole bunch of periods, usually with about a week in between the end of one and the start of the next. I don’t get much/any symptoms, only some pimples and slight anxiety/lethargy at the start, however needless to say it is annoying and inconvenient. I went to Family Planning and switched to the only other kind of progesterone-only mini pill, Microlut. That seemed to work at first (cutting off a period a day or two in) however quickly returned to the irritating week on, week off pattern. I figured I should give it a month or so to see if it settles, but I’m not liking my chances.

    I can’t take the full Pill or Nuva ring or any other oestrogen-based contraceptive because I used to get migraines with aura/numbness and doctors therefore won’t prescribe oestrogen as it means I am at an increased risk of having a stroke (even if it is still fairly low chance and I haven’t had any of said migraines for over a year.)

    The injection lowers bone density and my bones are problematic as it is, also I hate needles.

    I tried Implanon for several months way back when but had continuous bleeding/spotting. Considering trying it again seeing as it seems my hormones have changed in the last year.

    When I went to Family Planning they suggested that an IUD might be the way to go. They apparently fit them to women who have not been pregnant on a regular basis these days with fairly good results. However any time I have asked anyone about these everyone goes STAY AWAAAAAY IUDs ARE EEEEEVIL and also there is a risk of perforating the uterus or something?!? urgh. The copper one apparently likely to cause a lot of breakthrough bleeding/spotting. the idea of not having hormones appeals to me. The Mirena hormone one can stop periods completely apparently or just have breakthrough bleeding.

    At this stage I would be happy to just have normal periods.

    I’m considering these options, pending discussion with Family Planning or maybe a gyno:
    – Give my body a month or two off synthetic hormones completely and see what it’s like (it’d be the first time since I was about 16) and then try going back on the mini pill or Implanon…
    – Try a double dosage of the mini pill, or Implanon AND mini pill (they tried that back when I first had it, didn’t work then, but things may have changed)
    – Last resort, try the IUD I guess?

    Diet wise, I don’t think there’s much that would be negatively affecting my hormones. I eat soy very rarely, caffeine maybe once a week or less, and hardly any dairy, processed sugars or carbohydrates, or chemicals. Alcohol similarly rarely. Good quality meat. etc.

    Anyone got thoughts/suggestions/input?

    Becca wrote on October 27th, 2013
  9. Good article. Used pill only 2 x 2 years, two decades apart, glad it existed as an option, even gladder chemical hormones of pill lowered over the years, and that the “progesterone only” pill, the Mini Pill, was pulled off market after realization by mid 1990s it was linked to breast cancer. Not a fan of copper 7 iud, causes problems including heavy bleeds. Dutch cap conjunct with spermicide is fair alternative,only 96 percent effective as contraceptive, but better for health reasons.

    Anelissa wrote on October 30th, 2013
  10. There is a lot of talk here about the copper, non-hormonal IUD…. non-hormonal sounds good and all, but from what I have read about how it works, it actually works by causing constant inflammation. Inflammation is bad y’all. It basically makes your womb have an immune reaction that causes your cells to attack sperm and ova. Just want to put that out there so it can be considered as well.

    Kristin wrote on November 1st, 2013
  11. Hi everyone. I have been particularly concerned with this issue. I am 20 years old and have been on the pill since I was barely 12 years old (6th grade), NOT because of sexual activity but because of horrendous periods and PMS. I would transform into super witch for a week, then bleed heavily for 9 to 10 days. The pill regulated my flow and my attitude problems. However I do have breast cancer in my family history, digestive issues, and hormonal issues in general. Lots of genetic factors mixed with the added risks of taking the pill for as long as I have already. I have also been in a committed relationship for two years now, adding the family planning aspect to why I take the pill. It is a mind boggling issue for me. I have considered herbal contraceptives but many of those increase risk of miscarriage by a considerable amount. Long story short, I have been racking my brains for a better way for a long time and have no idea what. I know I have some serious hormonal imbalances that I am currently controlling with artificial hormones and I want to figure out how to naturally regulate/correct those imbalances and maintain some other sort of birth control that is acceptable for me, and us as a couple. Suggestions???

    Jenn wrote on December 2nd, 2014
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  14. I enjoyed reading this as I just took myself off of the Microgestin today. I am 48 years old with terrible premenstrual and menstrual issues as I hit perimenopause. So I thought I would try this, though the summer about four years ago that I tried Lo Loestrin, I spent the whole summer feeling physically numb and very depressed.

    So, three weeks into this trial of Microgestin the same thing starts to happen and I’m in tears feeling suicidal and completely disconnected from my body. I decided, in the end, that I will deal with my few days of extreme depression and severe cramps, heavy bleeding instead.

    I was taking Now Women’s Menopause Support more regularly at one point and that might have helped somewhat. I got off schedule with it due to travel, however.

    I also plan to try and stick to a more primal diet than I have been lately and see if that helps and ramp up my yoga and meditation practice.

    I have bipolar disorder and so this was probably never a good idea for me but I got desperate again and tired of prolonged PMS and never knowing when I was going to get my period.

    I would rather feel everything the way I was than feel totally numb like I started to recently and very very down.

    As well, I have a PFO (small hole in the heart with an atrial septal aneurysm with bilateral shunting) and this already increases my risk for stroke, so the whole thing was making me nervous anyway. But as I said, I was feeling desperate. Many people don’t even know if they have a PFO and it is quite common – like 1 in 5 people are born with that hole not closing up in the first year of life.

    Mine was found via an echocardiogram looking at something else.

    Anyway, thank you again for this article because I really did not know abut these extra add ons to formulations and read somewhere else that they increase oxidation.

    Cat wrote on July 21st, 2015
  15. I think it’s important to note that the pill can be absolutely life-saving for some women- I just advocate more balanced coverage. I find everything about the Pill seems to be either highlight the true but negative (above) or the true and positive (no unplanned pregnancy).

    For me, even as an athlete in high school on a whole foods based diets completely lacking in sugar (high protein, high fat), the endocrinological fluctuations that came with my natural cycle had far too big an impact on my mental health for me to remain functional. Like clockwork, every two days before a period started, I would be suicidally depressed- and even though I knew it was just biochemistry- I was either catatonic, crying, or pondering checking out early.

    Being on Seasonique now has been a god send. I don’t have periods. And I don’t have the monthly two-day impulse to honestly kill myself. Sometimes you have to realize primal living also means dying of childbirth at 19, and deciding to take a more modern alternative.

    Ruth wrote on May 25th, 2016

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