The Story with the Pill…
by Dr Peta Wright
This is a big post. About a tiny little pill that has had a huge impact on Western society.
As women, we have a lot to thank the pill for. It has bought us a whole level of reproductive freedom not known before its introduction in the 1960s and with it the liberation of generations of women now able to have choices that our great grandmothers could not imagine.
The pill has allowed women to become educated, enter and stay in the workforce, travel the world and have sex for pleasure without the fear of an unplanned pregnancy.
It has truly been a massive contributor in freeing women from the shackles of a reproductive prison and allowed us to decide when and how we become parents.
The world we live in today is different to that of previous generations however. Women’s desire for opportunities and paths outside of motherhood is accepted in our western world, we are free to have sex outside of marriage without fear or shame and our contraceptive choices today go beyond the pill.
The pill can also be a saving grace for some women with heavy or painful periods or severe PMS that is unresponsive to other treatments, but it doesn’t come without risks or side effects. So, although the pill is a tool in our tool kit to help women who have difficult or painful periods, it isn’t our only weapon.
Around 70% of reproductive aged women use contraception and in Australia just under 50% of those women use the pill. That is an enormous number of women.
I see more and more women who are being put on the pill for contraception or for period problems without a discussion about the other options, an exploration about underlying factors which can contribute to troublesome periods and without adequate education on how the pill actually works and properly informed consent about possible risks and side effects. This is not a criticism of doctors trying to do their best to help the patient in front of them. I was one of those doctors not so long ago and didn’t think twice about prescribing the pill.
It was what we were taught at medical school. It also says something about our broken health care system that it is easier to simply prescribe a pill than explore and investigate the intricacies of a women’s life to discover what might be at the root of her period issues, or to spend a considerable amount of time explaining the menstrual cycle, fertile times and mechanism of action of different hormonal options.
Don’t we learn about our cycle and fertility at school you might say? I have found in my work that it is very common to see women who are pretty shady on the details of how their bodies function and especially on how the pill actually works. This is not their fault either. We are still working within a system that hides menstruation and the complexity of a woman’s body behind the curtain of social taboo.
This is probably a major factor in why it’s seen as easier to simply completely switch off a woman’s reproductive system and with it her hormones, than to embrace the wonder that is the hormonal dance that occurs in our bodies each month, educate and empower women to choose the best option for them when it comes to contraception and to support them in making choices that may make periods easier.
This is changing though. I am seeing more and more young women who are questioning the almost ubiquitous use of the pill. They feel uncomfortable with synthetic hormones and would rather try more natural options.
For other women the pill can be a game changer and a life saver. The important thing is that when you make that decision for yourself or with your doctor you understand all the ins and outs of it so you can make a properly informed choice. No more being prescribed the pill like its a lolly, no more normalisation of side effects and no more viewing women who are suspicious of the pill like they are crazy, fringe-dwelling hippies. The decision to go on the pill is a big deal and needs to be given the respect it deserves. If half of the reproductive aged men in Australia were taking something to switch off their hormones and replace them with synthetic versions that have risks and side effects you better believe this would be a bigger issue. In fact I think it would never have got over the line in the first place.
So here is your complete no-nonsense, nothing left out guide to the pill.
How effective is the pill?
When used correctly the pill is 99% effective in preventing pregnancy but because of missed pills and other incorrect use the typical use efficacy is around 91%.
The pill can also improve painful heavy periods, improve PMS/PMDD symptoms and improve acne by decreasing testosterone levels. For some women the pill is a great thing, for other women there are other treatments that may help with these conditions.
How does the pill work?
The combined pill contains hormones like the hormones your ovaries make — oestrogen and progesterone — however they are not totally the same. The oestrogen usually found in the pill (ethinyl oestradiol or oestradiol valerate) are fairly similar to the oestradiol made by our ovaries. Zoely is one pill that does contain body identical oestradiol. The progestins in all pills are synthetic versions of our bodies progesterone and are not the same. Some pills have a progestin that more specifically target progesterone receptors (Zoely) while others act on testosterone and other receptors which can account for side effects like acne or bloating.
Some pills such as Yasmin, Yaz and Diane contain an anti-testosterone progestin which have been marketed to reduce acne. These pills may also have an increased blood clot risk. In truth, all pills decrease testosterone by shutting off the ovaries’ production of testosterone and increasing sex hormone binding globulin, a protein which binds testosterone in the blood.
While our ovaries make oestradiol predominantly in the first half of the cycle and then progesterone after ovulation in the second half of the cycle, most modern day pills have equal amounts of both hormones throughout the whole month. A normal period happens at the end of the cycle when an egg fails to fertilise, progesterone and oestradiol levels fall and the lining of the uterus dies and sheds as it is not being supported by the hormones any longer.
The pill works by tricking your brain into thinking that the ovaries are making high levels of hormones, so it essentially has a holiday and stops sending the stimulating messages to the ovaries to produce an egg and make oestrogen and progesterone. The pill essentially turns off the conversation between the brain and the ovaries, shuts off the whole reproductive system and replaces ovarian hormones with synthetic versions of our hormones.
A period when a woman is on the pill is not a real period. It is simply a withdrawal bleed caused by taking the sugar pills (a break from the hormone pills) which mimics the bodies fall in hormones at the end of a real cycle. There is no reason to have a bleed every month on the pill and in reality the only reason most pills have a simulated period each month was to make the pill more palatable to women when it was first introduced and make it seem more natural.
I would be a rich woman if I had a dollar for every time a woman tells me she went on the pill to ‘regulate’ her cycles without first exploring what was going on to cause them to be irregular in the first place. They then think they have regular periods because they are on the pill when their underlying cycles have not been fixed, just replaced with a simulated bleed. Women just aren’t being informed about how the pill actually works in their bodies.
What about the risks and side effects?
Most doctors will tell you that there is a slightly higher risk of venous thromboembolism or clots in the legs or the lungs when women take the pill. The risk is small and is 7-10 per 10000 women studied over one year compared to 2/10000 in women not taking the pill. To put it in perspective women have an almost 30/10000 risk of blood clots during pregnancy.
The rate of arterial thrombosis is about 1.6 times higher in women taking the pill.
Breast cancer risks are only slightly increased On the pill. To break it down, for every 100000 women 55 not taking the pill will get breast cancer each year compared to 65 women taking the pill.
Cervical cancer rates in women taking the pill are increased very slightly when we look at women who have HPV (the virus that causes pre-cancerous changes). This may be due to the hormones in the pill making cells in the cervix more susceptible to the HPV virus. Hopefully the cervical cancer vaccine and screening programs will blunt this extra risk.
It’s not all bad news for cancer and the pill. Rates of endometrial and ovarian cancer are decreased in women taking the pill for a long time – the benefit is greatest over 10 years. So that roughly 185 women would need to take the pill for over five years to prevent one case of ovarian or endometrial cancer.
The bottom line with cancer is that while the pill may very slightly increase breast and Cervical cancer rates, it decreases endometrial and ovarian rates.
Side effects you commonly hear about are potential for weight gain, bloating, headaches, breast tenderness, and irregular bleeding,
Other side effects can include mood changes – depression, anxiety or just not feeling like yourself. Studies are mixed on the effect of the pill on mood but a large Danish study recently in over a million women reported an association between the pill and use of an anti- depressant. Pill users were 1.2 times more likely to be prescribed an antidepressant than non-users and in younger women the effect was more pronounced with a 1.8 times higher likelihood of an antidepressant. This shows an association but not causation.
Mood effects are mostly thought to be due to the synthetic progestins in the pill and possibly because the pill shuts off our ovaries from making their own progesterone. Natural progesterone converts into a neurohormone called allopregnanalone which activates GABA in our brain to have a calming soothing effect.
Synthetic progestins do not have this effect.
In addition the pill stops our ovaries from making testosterone which is the hormone of confidence and agency as well as (alongside oestradiol) being a driver of sexual desire. This may be why the pill often causes many women to experience a decrease in libido.
The lack of testosterone, while effective for treating acne, can also have an effect on the vaginal and vulval skin in some women. The vulva has testosterone receptors and needs testosterone and oestradiol to be healthy – without this some women can develop thin, sensitive skin which can lead to pain with sex.
While a 2014 Cochrane review found that the pill didn’t have a significant effect on bone density, a 2011 study and a recent 2018 meta analysis showed that young women who take the pill have lower bone density than non-users This may be important given that many women start the pill as a teenager and are on it for many years. There is a need for randomised, control studies to investigate the true impact.
The pill is also known to be associated with nutritional and other metabolic changes. The pill can cause elevation of triglycerides and a decline in glucose tolerance. This is important because many women with polycystic ovarian syndrome and impaired glucose tolerance are put on the pill to regulate cycles and drive down testosterone. So without also making changes to diet and lifestyle the pill could potentially worsen insulin resistance.
Pill users have shown to have lower levels of folate and vitamins C, B2, and B6. B6 deficiency in pill users may also be connected to mood changes as we need B6 to convert the amino acid tryptophan into serotonin which is one of our feel-good neurotransmitters. If you do choose the pill, supporting your body with these nutrients in the form of a supplement or in your diet may be something to consider.
Most women’s fertility returns to normal when they go off the pill but sometimes it can take months for periods to return if the hypothalamus (the master controller of all the hormones in the body) is particularly sensitive and the brain and ovaries take a longer time to restart the conversation they were having before the pill.
Most women are never told about the possibility of these side effects and even though many women will be fine, I think it’s still important to properly inform women about a medication they may end up taking for years. The reality is many women who end up suffering with some of these side efffects are dismissed and many told that it’s not the pill and must be something else. You should always have your symptoms taken seriously so you can experiment and work out what feels right for you – especially when there are many more options for contraception or for troublesome periods than just the pill.
And while for some women the pill is the answer and can be life changing, it shouldn’t be the default and it should definitely come with a proper discussion about how it works, potential side effects and an offering of other options.
Our world has changed and I think the pill purely for contraception may be too blunt an instrument to be the predominant contraceptive method in our modern world. It shuts off women’s complete reproductive hormonal system just to avoid pregnancy on our five or so fertile days a month. Women are questioning it. And I think as a medical establishment we have to question it too.
So how did I get here? A gynaecologist who has probably written thousands of scripts for the pill in the course of my professional life?
A woman who was on the pill for over fifteen years?
I went off the pill. I had a baby who just turned two. I felt like myself again. I felt more in touch with my body and started listening to it rather than ignoring and beating it into submission like I’d done for 15 years.
I also listen to women every day who tell me similar things, who have had side effects normalised and want to regain control of their bodies.
This piece isn’t about bashing the pill or making women for whom it works feel bad. Its about providing information that often women don’t get before being prescribed the pill for contraception or to ‘fix’ periods. The pill has a place for many women but they need to be able to choose it in the context of complete informed consent. We are lucky to live in an age now where we can be informed about how our bodies work and make choices about what we do with them.
I still prescribe the pill (I prefer Zoely as it has body identical oestradiol and a progestin that has more affinity for progesterone receptors and less side effects than other pills). I make sure the woman in front of me knows what it is, how it works and how it may effect her. I explore all the options and try to get to the root of the issue before using the pill as a one stop cure-all.
I also listen when something is not right. Please make sure your doctor is letting you in on all the facts and does not dismiss you if you have concerns. @LaraBriden is an amazing naturopath who has inspired me and writes a lot about the pill and natural cycles in her book ‘ The Period Repair Manual’. It is a wonderful resource for any woman wanting to learn more about her body. Also follow @lucyspeaches and watch her wonderful TEDx talk on the power of the period for more information about hormonal changes in your menstrual cycle.
Talking about periods and the pill and women’s bodies and demystifying things shouldn’t be revolutionary in 2019 but I think it still is. As a gynaecologist I care deeply about getting information into the hands of women and can speak from the knowledge and research I’ve done, the experiences I hear from women everyday, and from my own experience — which is also somehow supposed to be unspoken if you are a serious doctor. But I am a woman and a human first, and I think being vulnerable sometimes makes me a better doctor.
I said at the outset it was a big post for a teensy tiny pill…
Please feel free to send through any questions here.
Websites for reference:
– https://www.cancer.gov/about-cancer/causes-prevention/risk/hormones/oral-contraceptives-fact-sheet
– https://www.ncbi.nlm.nih.gov/pmc/articles/PMC81536/
– https://www.nps.org.au/australian-prescriber/articles/choosing-a-combined-oral-contraceptive-pill
– https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796
– https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016495/
