Published January 29 2018
Birth control is a very important and sometimes hot-button topic today. Between legislative changes in birth control and insurance coverage from presidency to presidency, to the risks involved in medical birth control options, this is definitely a widespread topic with a lot of implications for women’s health overall. There is so much information to cover that I decided to split this up into two separate parts. Between both parts I’ll be discussing both hormonal and non-hormonal options, although in this first part I will be focusing on oral contraceptives. In part two, I will talk about IUDs and other birth control options, including what I prefer for my patients with thyroid and autoimmune thyroid conditions.
Before discussing oral contraceptives, I’d like to briefly explain what ovulation is. Ovulation involves the release of eggs from the ovaries, and it is triggered by a peak in estrogen in a woman’s body around 14 days into a woman’s cycle. This peak causes a release of luteinizing hormone (LH) and follicle stimulating hormone (FSH) from the pituitary gland, which prompts the ovaries to release an egg.
So how does this relate to oral contraceptives? When a woman is on hormonal birth control, steady levels of estrogens and progestins trick the pituitary gland into thinking a woman is already pregnant, which stops the pituitary gland from releasing hormones that stimulate ovulation.
By the way, the reason why I’m focusing this entire first part on oral contraceptives is because in the Unites States, the birth control pill is the most commonly used contraceptive today (1), followed closely by female sterilization (i.e. tubal ligation).
Different Types of Oral Contraceptives
There are three main types of oral contraceptive pills (2):
1. Combined estrogen-progesterone. This is the most commonly prescribed combined oral contraceptive. Progesterone is the primary hormone that prevents pregnancy, while estrogen will control the menstrual bleeding, although it will also play a role in inhibiting follicular development due to its negative feedback on the anterior pituitary.
2. Progesterone only. This can be a good choice for women who can’t take estrogen (or choose not to take it). One way that progesterone can prevent pregnancy is by preventing ovulation. The negative feedback mechanism I mentioned earlier takes place in the hypothalamus, as the pulse frequency of gonadotropin releasing hormone is decreased, which in turn decreases the secretion of follicle-stimulating hormone (FSH), and also decreases the secretion of luteinizing hormone (LH).
3. The continuous or extended use pill. Oral contraceptives are classically given in a cyclic manner with 21 days of active pills followed by 7 days of placebo (3). However, other oral contraceptives are available which either shorten the placebo time, lengthen the active pills (extended cycle), or provide active pills every day (continuous) (3). Extended use contraceptive pills delay menstruation, whereas continuous use contraceptive pills eliminate menstruation. The main reason these oral contraceptives were developed was to reduce the frequency of menstruation, although just as is the case with the other two forms, the continuous or extended use pills can also help to reduce PMS symptoms.
Earlier I mentioned that progesterone can prevent pregnancy by preventing ovulation. In addition to preventing ovulation, the progesterone in birth control also causes the body to form a thick layer of cervical mucus. This makes it difficult for a sperm to reach the egg, and it also affects the uterine lining, which makes it hard for an egg to attach.
We know that birth control pills work, and now you know how they work. Let’s talk about the consequences of these synthetic estrogens and progestins. They can’t be doing anything good for anyone aside from preventing pregnancy, right? Well, that’s not necessarily true.
Other Health Benefits of Oral Contraceptives
There are plenty of women who take the pill for health reasons other than avoiding pregnancy. Here are some of the conditions that commonly result in medical doctors recommending the pill to their patients (4):
- Severe menstrual cramps/irregular cycles
- Severe acne
- Polycystic ovarian syndrome (PCOS)
- Ovarian cysts
The pill also has a benefit of decreased risk of endometrial and ovarian cancer (5). As a result, if you have a family history of endometrial or ovarian cancer, the pill might decrease your risk of developing these conditions. However, there seems to be a small increased risk of breast, cervical, and liver cancer (5). And so if you have a family history of these types of cancers, hormonal birth control might not be the best option for you.
The majority of women who take the pill for non-contraceptive purposes take it for the benefits of an improvement of acne, improving their cycle regularity, and reducing menstrual cramps. Being a functional medicine practitioner, the problem I have with this approach is that severe acne and irregular menstrual cycles are often symptoms of a bigger problem. I’m always looking for the underlying causes of conditions, so I stand to argue that the pill is merely masking the symptoms of the condition, while leaving the root causes and underlying imbalances unaddressed. So not only are patients not addressing the underlying causes of their imbalances, they are taking some risks with their health by taking the pill every day.
Risks of Oral Contraceptives
1. Increased risk of certain types of cancers. I just mentioned how oral contraceptives can cause a small increased risk of breast, cervical and liver cancer. Some may wonder if this is due to the estrogen in the combined oral contraceptives, and this does seem to be a factor. That being said, progestin-only oral contraceptives also can cause an increase in breast cancer, although the risk is higher with the combined pill (6).
2. Cardiovascular risks. There are cardiovascular risks associated with taking oral contraceptives. In fact, some of the most well known risks of the pill are the increased risk of heart attack and stroke (7) and the increased risk of blood clots (8). Once again, this isn’t to suggest that most women who take the pill will suffer from a heart attack, stroke, and/or develop blood clots, but only that it will increase the risk.
3. Nutrient deficiencies. A few studies show that oral contraceptives can result in multiple nutritional deficiencies (9) (10). Some of the key nutrient depletions involve folate, vitamins B2, B6, B12, vitamin C and E and the minerals magnesium, selenium and zinc (9). This not can only have negative health consequences on women who take oral contraceptives, but if they discontinue the pill and then become pregnant this of course can affect the health of the baby.
4. Depression. According to the research, the most commonly stated reason for discontinuation of oral contraceptives is depression (11). A pilot study showed that women on the pill were significantly more depressed than a control group (11). It’s important to mention that this involved the combined oral contraceptive pill.
Why Did Women Start Taking The Pill?
When the pill was introduced it was seen as a form of sexual empowerment for women. The pill allowed for the reliable separation of sex and reproduction, and gave women the opportunity to plan when to have children. After all, with the pill, women can have sex without the consequence of an unwanted pregnancy. This opened up a whole new kind of sexual freedom that wasn’t currently available to women. As great as this all may sound, those constant levels of synthetic estrogens and progestins can wreak havoc on your female sexual function.
Fluctuations in hormones on a cycle not adulterated by synthetic hormones provide drive and pleasure in sex. By taking the pill, sure, you can have sex whenever you want and not worry about getting pregnant. But chances are, you would enjoy having sex more if you were not on hormonal contraception.
Another factor to consider is a woman who doesn’t want to become pregnant now, but does want to have children in the future. When a woman stops taking the pill, there is typically a delay in the resumption of ovulation and conception, and so after stopping the pill it can take awhile before she becomes pregnant (12). This would be particularly important for those women who are older, and time is of-the-essence in getting and maintaining a healthy pregnancy.
The Case Against The Pill In Those With Graves’ Disease and Hashimoto’s
For women with Graves’ Disease or Hashimoto’s, there is even more evidence that taking the pill is a bad idea. For example, I find compromised adrenals to be a common problem in the majority of my patients, and so it’s important to point out that the pill decreases the cortisol response to stressors (13). While we don’t want cortisol to be too high, we also don’t want cortisol to be too low, as healthy cortisol levels are important for controlling inflammation, which is a factor in autoimmunity. As a result, if you are trying to reverse your autoimmune thyroid condition, the pill isn’t going to get you any closer to that goal.
Another common factor for autoimmune thyroid conditions is gut dysbiosis and an increase in intestinal permeability (a leaky gut). Synthetic hormones disrupt the gut’s natural microbiome, and they can increase the risk of inflammatory bowel disease (Crohn’s disease and ulcerative colitis) (14). I spend a good amount of my time with patients trying to heal their gut, and hormonal contraception can potentially hinder this process.
I’ve also had numerous patients with gallstones and bile metabolism issues. Many of them are surprised to find out that the pill increases the risk of the formation of gallstones, as this isn’t one of the more well-known side effects. My assistant Kate had been plagued with years of gallbladder attacks, and she was also on the pill for the majority of her reproductive years starting at a young age. Coincidence? Perhaps. But the research suggests that maybe it’s not a coincidence either (15) (16).
Does it make a difference what type of oral contraceptive is used? Unfortunately, both estrogen and progesterone have been shown to increase the risk of gallstones (17). The way that estrogen can cause gallstones is by increasing cholesterol production in the liver, with excess amounts precipitating in bile and leading to the formation of gallstones (18). Progesterone can also cause gallstones by decreasing gallbladder motility, which in turn impedes bile flow, and leads to the formation of gallstones (17).
On the other hand, the increased cardiovascular risk I mentioned earlier is more commonly associated with combined oral contraceptives, and not with progesterone-only contraceptives (19). While I’m not a fan of oral contraceptives in general, if someone does choose to take them I would recommend to take the progesterone-only form. But as you have learned, even these come with risks.
What Can Women Do About Menstrual Pain, Bleeding, and Irregular Cycles?
As I mentioned earlier, many women don’t take the pill to prevent pregnancy, but instead to help with symptoms such as menstrual pain, bleeding, and irregular cycles. I realize that the pill can greatly help with these symptoms, which in some cases can be extreme. Just remember that the pill isn’t correcting the cause of the problem, and so what I would recommend is to work with a natural healthcare professional who will test the adrenals and sex hormones, and then do what is necessary to correct any imbalances that are present.
Many women have an estrogen dominant state that can be the primary cause, or at least a contributing factor. This doesn’t necessarily mean an excess of estrogen, as it commonly is related to an imbalance of the estrogen/progesterone ratio, with progesterone commonly low. In other words, low progesterone in the presence of normal estrogen is considered to be a state of estrogen dominance.
Also, you need to have healthy adrenals in order to have healthy sex hormones. Because of this, in most cases you want to focus on improving your adrenal health before taking any type of oral contraceptive or bioidentical hormone. And even if you choose to take either one of these, you still want to focus on improving the health of your adrenals.
So hopefully you understand how incredibly important it is to weigh the benefits of hormonal contraception with the risks. Are the risks worth it? If you are thinking they may not be, you might now be wondering, what birth control options are left? I’ll be discussing this in Part 2, as I’ll talk about IUDs, skin patches, vaginal rings, along with natural options.