- #1 Myth or Reality? Blood Clots
- #2 Myth or Reality? Causes Cancer
- #3 Myth or Reality? Causes Depression
- # 4 Myth or Reality? Changes Your Brain
- #5 Myth or Reality? Causes Autoimmune and Inflammatory Conditions
- #6 Myth or Reality? Depletes Your Nutrients
- #7 Myth or Reality? Interferes with Bone Growth
- #8 Myth or Reality? Causes Weight Gain and Blood Sugar Problems
- #9 Myth or Reality? Squashes Sex Drive
- #10 Myth or Reality? Affects Mate Selection and Attraction
- Should You Take the Pill?
Have you heard rumors like the ones in those TikTok posts that taking the Pill can influence your choice of partner, only later to go off the Pill and say WTF – who did I marry and why? What about whether the Pill, ‘patch,’ or NuvaRing™️ can cause blood clots? Have you taken the Pill, felt depressed, and had a doctor tell you it couldn’t possibly be related to the Pill?
The Pill has been on the market for nearly 60 years and has been a hard-won source of tremendous sexual liberation for women. For some women it also provides seemingly miraculous relief of symptoms. For others it is a source of sometimes tolerable, and at other times intolerable, side-effects. And for a few but not an insignificant number of women, it has been a source of misery!
So is the Pill (and other forms of hormonal contraception and symptom relief) friend or foe? What’s myth and what’s reality?
If one were to ask most doctors, many would say they are totally safe, or perhaps that there are a few risks, but not too many, not for most women, and any small risks are worth the benefits. If you then asked most doctors how much actual training they got on the risks of the Pill and how to best prescribe them, most would have to think pretty hard about that – maybe squint to remember that nearly invisible 30-minute discussion that they may possibly have had amidst the 100,000 odd facts they had to learn in medical school alone.
If you look toward the wellness community for answers, you might come away thinking that taking the Pill could make you grow three heads, or in the least, might ruin your hormones forever.
And if you chat with women who have used the Pill, or are currently on it, as I’ve done more times than I can count – you’d get a variety of responses as to how the Pill made them feel – from “it’s best thing I ever did for my acne” to “the worst thing I ever did for my mood”; to “the easiest birth control I’ve used” to “it made me feel like hell on wheels.”
In my recent On Health podcast episode and accompanying article Did the Pill Ruin My Fertility? I explored the impact the Pill has on ovulation and fertility.
Today I dispel some of the most common myths, misconceptions, and misinformation about the Pill, and I talk about the real risks of the Pill that everyone using it should know. And ditto that if you have a daughter considering it or for whom it’s being prescribed. While I focus on the Pill, the same considerations and concerns largely apply to other forms of hormonal contraception.
When it comes to making any choices about starting or staying on a medication, it’s important to understand the global risks and benefits, as well as your personal risks, based on your own and your family’s medical history. Too often, women are prescribed hormonal contraception (HC) without being fully counseled on their risks and potential side effects. Like any medications, contraceptives do carry some risks/side effects. Unlike most medications, these are also commonly prescribed to otherwise healthy women – so evaluating the risks when a medication is optional becomes all the more urgent. For many women, the costs may be worth the benefit of reliable birth control or symptom relief. But in order for us to make the best decisions, health care providers need to be transparent about the risks and the side effects.
And side effects are common, which is one of the major reasons women aren't very satisfied with the options currently available. Women in the US try an average of 3 different contraception methods. With trial-and-error, some women are able to find a method they really like, but many just settle on one they can tolerate: A 2004 study by the Guttmacher Institute found that nearly two-fifths of women in the US said they chose their current method mostly because they didn’t like any other available options. As Maya Dusenbery, author of Doing Harm, said in her 2019 Scientific American article, “Why Women – and Men – Need Better Birth Control,” “what women really want is a highly effective method with few or no side effects. And as the researchers explain…‘that combination does not exist.’
A 2022 survey done by the Kaiser Family Foundation (KFF) that included 5201 women found that almost one-third of contraceptive users said they were experiencing side effects from their current method, and just over half (52%) said their side effects were more severe than they expected. Among the most common are mood changes (48%) and weight gain (47%), while 80 percent say they experienced more than one side effect. Just over half (54%) say they have talked to their health care provider about these side effects. When women do experience side effects from HC and report them to their doctor, they are often dismissed – especially if they're reporting a side effect that hasn't been definitively linked to HC in major studies. So it’s important to take your experience into account – and to trust it.
Most women who take the Pill, or who use other hormonal contraceptives, do so either voluntarily for birth control, or are using them for hormonal symptoms. In both cases, alternative options are typically available, and may be better choices for you. About a third of teens on the Pill in the US are not using it for pregnancy prevention at all. While OC can be an appropriate treatment in some cases, too often doctors simply prescribe the Pill rather than thoroughly investigating when a young woman comes in with a gynecological or hormonal concern.
And while studies may be equivocal about a particular side-effect, if you don’t tolerate a medication or if you experience side-effects, even if those aren’t well-documented for a medication, or your care provider dismisses your concerns or symptoms, that medication might not be right for you. While in some cases a life-saving medication is needed for a serious disease, and the side-effects are an unfortunate consequence one has to accept, this is not typically the case with oral contraception.
Okay, now let’s take a look at 10 Pill myths – and realities – which I’m bringing to you in a 2-part series, at the end of which I’m going to walk you through my thoughts on whether the Pill and other hormonal contraceptives are ever okay to use, who should avoid them, and how to make the decisions that are best for you – your needs, concerns, preferences, and lifestyle. And if you’re wondering about the answer to whether the Pill can affect your mate choice, I’ll be bringing that to you, too!
I hope this episode helps to answer questions you may have and provides you with the information you need to make the most informed decisions about whether to start or continue the Pill, or other hormonal contraceptives, whether for gynecologic symptoms or birth control, or whether you might be someone who should consider coming off of it for medical reasons. And I’m going to give you some tips for how to optimize your health if you are going to remain on the Pill for any reason.
So get comfy and have a listen.
#1 Myth or Reality? The Pill Causes Blood Clots
This is definitely true and is perhaps the most well-known risk of taking the Pill. Combined oral contraceptive (COC) users are 3 to 5 times more likely to have a venous thromboembolism (VTE) – or blood clot – than non-users, and that risk is highest if you’re a smoker, overweight, have a clotting disorder, or are older. For a woman with thrombophilia or a history of thrombosis, the risk becomes substantial. However, it can happen to anyone.
VTE risk is important to take into consideration, particularly if you are in a higher risk group. But before you get completely freaked out – keep in mind that the rate of VTE in younger women is very low. Among women not on the Pill, 1–5 per 10,000 women have a VTE in any given year. That number rises to 3-10 per 10,000, depending on the type of Pill, for OC users. So even with the increased risk, the absolute risk of VTE in combined oral contraceptive (COC) users is still small.
Medical guidelines when it comes to the Pill rightly point out that pregnancy itself increases the risk of developing blood clots even more: to about 5–20 per 10,000 during pregnancy and 40–65 per 10,000 in the postpartum period. However, most women don’t get pregnant at 15 and stay pregnant until we’re 35 and given that the average number of children per family in the US is less than two, most women in the US are pregnant for less than 2 years total. In contrast, many women remain on the Pill for 10, 15, or more years; many start the Pill in their teens and remain on it for more than a decade. So it’s not an apples to apples comparison.
The Pill also affects the cardiovascular system in more ways than increasing clotting risk; it increases the risk of other cardiovascular problems, including heart attack and stroke. A 2015 meta-analysis concluded that women using COCs had a 1.6‐fold increased risk of risk of myocardial infarction or ischemic stroke. The risk seemed to be twice as high in women taking Pills with higher doses of estrogen.
Other studies suggest the risk of stroke roughly doubles in people using COCs. The increased risk of stroke on the Pill seems to rise with increasing age. The data also suggests that this risk is a short-term effect – mostly during the first year after starting OC – and the lifetime stroke risk might not be that different between women who have used OCs and those who have not. Again, the risk of heart attack and stroke in young women is low to begin with: For women in the United States aged 18 to 44 years, the baseline prevalence of stroke ranges from 0.6 to 0.7 percent. COCs may also cause a mild elevation in blood pressure, though it usually stays within the normal range.
It’s not only the Pill that puts women at increased risk; the new patches possibly increase the risk slightly more, since the amount of estrogen absorbed is higher than is absorbed with the Pill. And while there is little information about the risk of blood clots with the birth control ring (NuvaRing), like patches they also contain an estrogen and a progestin, and, therefore, probably pose a risk similar to patches, and there have been widely spread reports of women who have had blood clots – including fatal clots – from using these methods.
My take away? If you meet any of the risk criteria I’ve mentioned, consider a non-hormonal or at least non-combined hormone form of contraception; if you are using the Pill or hormonal contraception to treat hormonal symptoms rather than for contraception, explore lower-risk options that might be available to you and similarly effective. And stay tuned for my list of risk factors when it comes to using the Pill; if you have those, then avoid using combined or possibly even any hormonal contraceptives.
#2 Myth or Reality? Taking the Pill Causes Cancer
Perhaps one of the biggest concerns women have about taking the Pill, or any hormonal therapies, is increased cancer risk, and that’s understandable. Many women are vaguely familiar with the history of DES, a synthetic estrogen used to prevent miscarriage, that did cause cancers in not only the women who used it during their pregnancies in the 1950s and 1960s, but in many of their daughters and even some of their sons. And there’s been a tremendous amount of concern and confusion over the safety of hormones used for menopause since the abrupt discontinuation of the Women’s Health Initiative hormone trials in the early 2000s, due to an increased risk of breast cancer in certain groups who took it.
While COCs do not increase overall risk of cancer, we’ve long known that estrogen-containing OCs do come with a small increased risk of breast cancer. Over the years, meta-analyses have shown that the risk of breast cancer on oral contraception increases anywhere from 8-24% and the longer you’re on the Pill, the higher the risk. So yeah, that’s scary.
But what does that increase mean in terms of actual likelihood of developing breast cancer from taking the Pill? While this roughly 20% increased risk sounds like a lot, again, it’s important to put risk into context. Since the absolute risk of breast cancer is small to begin with (especially for younger women), 20% of a small number is still a small number. It translates to 1 additional case of breast cancer for every 7,690 women using oral contraception for one year. And for women younger than 35 years, it’s 1 case for every 50,000 women..
Until recently, we haven’t had much data on whether progestin-only contraceptives have the same breast cancer risks. But just this spring, a new UK study found a similar elevated risk associated with the progestin-only pill, the implant, the Depo-Provera injection, and the hormonal IUD. They concluded that with current or recent use of any kind of hormonal contraception, there is a 20% to 30% increased risk of breast cancer, which gradually goes back to baseline by 10 years after stopping the method.
Of course, for each of the women who develop breast cancer, that’s a devastating adverse effect. But again, the risk is extremely low. And here’s something that’s not as widely discussed: Oral contraceptives are also associated with a reduced risk of other cancers. According to a large 2021 UK study, women who had used oral contraceptives had a 30% reduced risk for both ovarian and endometrial cancer compared to those who never had. For women using birth control pills for 20 or more years, there was a 40% reduced risk of ovarian cancer and a 60% reduced risk of endometrial cancer.
Another alarm was sounded about the Pill and cancer when a 2018 study published in The Lancet Oncology suggested that a woman’s use of the Pill close to the time of becoming pregnant could increase her child’s later risk of developing leukemia, especially the nonlymphoid types. The researchers followed a Danish nationwide group of nearly 1,200,000 children born between 1996 and 2011 for an average of 9.3 years, correlating any cases of leukemia listed with the Danish Cancer Registry and hormone prescriptions from the National Prescription Registry. Compared to the rates for children of women who never used contraception, the leukemia risk was 25% higher in children born to women who had stopped use of hormonal contraception more than 3 months before pregnancy. It was 46% higher when the women had used it within 3 months of conception. And it was 78% higher when the women used it during pregnancy. The increased risk was associated mainly with use of estrogen-containing OC; they found no effect from progestin-only products.
This is certainly scary data; especially because so many women discontinue the Pill in order to try to get pregnant soon after. It was, however, just one population-based study; more studies are needed to determine cause and effect. The authors of the study themselves acknowledge that, since leukemia is very rare, the small increased risk “is not a major safety concern for hormonal contraceptives.”
The researchers also found that the increased risk among women who’d previously used HC decreased and became non-significant with exposure more than 6 months prior to conception. So is it prudent to discontinue estrogen-containing Pill use 6 or more months prior to trying to conceive until we know much more? Perhaps, and I certainly don’t recommend against this. I feel it’s ideal to reduce all potential harmful exposures 6 months prior to trying to conceive. But to date, there are no medical precautions against using it even close to conception.
If you had been on the Pill and conceived within one of the windows described in the study, I am reiterating that childhood leukemia is rare and a causal relationship is not certain – so please try not to worry. I am including this because it’s important to note, more research is needed, and I wanted to address this in case you’d read about it elsewhere as a risk of the Pill.
#3 Myth or Reality? The Pill Causes Depression
With 1 in 4 women already struggling with depression, and as many as 1 in 4 on an antidepressant even before the COVID-19 pandemic threw us all onto an emotional rollercoaster, it makes sense that we’d be wary of anything that might cause or increase depression. Plus women are twice as likely to suffer from depression as men, partly due to hormonal causes. So who wants to add to that?
Which begs the question: What’s the story with hormonal contraception and depression? Should you avoid it if you already struggle with depression or have in the past? Should you be concerned even if you haven’t?
These are legitimate concerns. In a 2023 study, which included 188 women, nearly half reported experiencing mood changes as a side effect of hormonal contraception at some point in their lives. The rate was worse for women who’d previously experienced mental health symptoms (61.2%) compared to participants with no history of psychiatric illness, but it was still substantial for the latter (29.5%). And we all personally know women who have said being on the Pill made them feel ‘emotional’ or ‘crazy.’
And yet, shockingly, over 80 percent of the women in that study said that their medical provider never mentioned the possibility of psychological side effects when discussing hormonal contraception options. And as a women’s physician, I’ve had numerous women come to me for care in part because they were having symptoms and their prior medical provider dismissed the association. Clearly, there is a major disconnect in what women are experiencing and how and what physicians are communicating!
Part of the disconnect is because studies that have investigated whether OC is linked to an increased risk of depression have yielded mixed results, with some studies reporting no or even protective mood effects of OC. But in recent years, several studies have provided substantial evidence that OC significantly increases the risk of depression, especially among teens. These confirm what so many women know: That for at least some women (and teens), the Pill can cast a dark cloud over our moods.
The most headline-grabbing report was a 2016 Danish study, published in JAMA Psychiatry, that followed 1 million women over several years. The largest study on this question to date, it included all the women living in that country and concluded that hormonal contraception was associated with subsequent antidepressant use and a first diagnosis of depression. Taking COC increased the risk of taking antidepressants by 23 percent in women in general. Teens were particularly vulnerable: For 15-19 year olds using COC, the risk of taking antidepressants jumped up by 80 percent. The increased risks were even higher for progestin-only pills: Teens taking these were over twice as likely to start taking antidepressants after starting the Pill. There were increased risks with other methods as well: With the patch, antidepressant use doubled while risk increased by 60 percent for vaginal rings and 40 percent for hormonal IUDs.
In a follow-up study a couple years later, the same research team found increased rates of suicide and attempted suicide among women who currently or recently used HC compared to those who never had. Again, the results for progestin-only pills and other methods were even worse and teens were most affected.
Most of the research looking at the link between OC and depression thus far has focused on the short‐term effects. But in 2020, researchers from the University of British Columbia published a study investigating whether women who had first used OC in adolescence show an increased risk of depression later in life. They were concerned by animal studies showing that exposure to sex hormones during critical developmental periods like puberty/adolescence can cause long-lasting changes in the brain and behavior.
Using data on over a thousand women in the US, they found that women who had used OCs during adolescence were more likely to have had depression within the past year, compared to both women who had never used OCs and women who only started using OC in adulthood. While it was only an observational study, they controlled for a large number of potential contributing factors that have been previously pointed to, to explain the link between hormonal contraception and depression.
In 2022, they published a follow-up study in the Journal of Child Psychology and Psychiatry, that was the first to look at the long‐term associations of oral contraceptive use during adolescence with depression in adulthood in a large, prospective study – meaning they followed women over time. Again, they found that women who had used OCs during adolescence (from ages 16–19 years of age) had a “small but robust” increased risk of having an episode of major depressive disorder (MDD) during early adulthood (ages 20-25), a finding that was most pronounced in women who had not suffered from depression before or during adolescence.
There are various theories for why hormonal contraception during the teen years may have long-term effects. For one thing, important regions of the brain that are involved in emotion regulation, such as the amygdala, prefrontal cortex, and hippocampus, are still maturing during adolescence and may be sensitive to sex hormones during this period. Hormonal contraception may also alter the hypothalamic pituitary adrenal (HPA) axis and the cortisol stress response. For example, one study found that, in contrast to naturally cycling adolescents, OC users showed no cortisol reactivity in response to a social stress test. We’re supposed to experience a response – that’s how we buffer our stress reactions. Another found that adults who had continuously used CHC since puberty showed blunted stress responses to a similar social stress test, compared to those who had continuously used OC only since adulthood.
These researchers are now testing some of these theories in an ongoing study that is following a group of adolescent girls over the span of three years, giving them various tests to assess their emotional health and cortisol levels starting when they are between 13–15 years of age and then again, approximately 18 months and 36 months later.
So why have different studies come to such different conclusions especially when so much evidence suggests it does? Some researchers say the inconsistency could be explained by the so-called “healthy user bias.” Since women who do experience mood effects on hormonal contraception often discontinue the method, they aren’t as likely to be part of the studies, while women who don’t experience mood effects will be overrepresented – which means studies may tend to underestimate the negative mood effects.
A new large study of over a quarter million women in the UK, which tried to correct for this bias, was just published this month. It concluded that compared to women who’d never taken COC, women had a 79% higher risk of depression in the first 2 years after starting the pill. This was true for both adults and teens but, like prior studies have found, teens were more affected: Women who began using OC before or at the age of 20 had a 130% higher rate of depressive symptoms. And women who used OCs during adolescence (but not adult OC users) remained at slightly increased risk for depression even after they discontinued. Another strength of this study, compared to other observational studies, is that they did an analysis of sibling pairs, which allowed them to say with more confidence that there seems to be a cause-and-effect relationship between OC and depression.
While I’ve focused a lot on the increased risks of depression and mood changes, for so many women it should be noted that many women experience no mood effects at all. And for some women, the Pill seem to provide a mood-stabilizing effect – perhaps the steady controlled hormone state is less of a roller coaster for some women than their typical cyclic fluctuations, or other symptoms, whether acne, irregular periods, or heavy bleeding, are more controlled, thus providing some level of freedom from the depression related to chronically experiencing these symptoms.
So what’s the takeaway? Perhaps the most profound one is to realize that if you do experience mood changes or outright depression after you start taking the Pill, or at any time you’re on it, it’s not “in your head.” The Pill (or other form of hormonal contraception) should be considered a possible cause that your medical provider should not dismiss as unrelated, which happens all too often.
If you have experienced depression in the past, maybe this is not the most appropriate form of either contraception or symptom relief for you; you’ll want to find a provider who can support you in finding another method of contraception or other methods of symptom relief that are best for you.
If you’re using hormonal contraception of any form for medical reasons and it’s helping you, or it’s your preferred method of birth control, but you’re experiencing depression, discuss other doses and forms with your medical provider – just lowering the dose, for example, or changing the formulation (i.e., a progestin-only form), may help. It’s also not uncommon to start taking an antidepressant to enable you to continue using the hormonal contraceptive. However, for non-essential, non life-saving medications, I think it’s generally preferable not to add medications for side-effects onto medications causing side-effects, and rather to explore other medical, or even preferably, non-pharmaceutical options, whenever possible.
If you’re on the Pill (or other HC) and experiencing mood changes, I also think it’s worthwhile to get labs to check your nutrient status for or possibly supplement those vitamins and minerals that might be depleted by the Pill (more on how the Pill can affect vitamin/mineral levels later in the episode!) and could possibly cause depression, for example, B vitamins or zinc; it’s possible that some of the mood changes associated with the Pill are secondary to nutrient depletion.
# 4 Myth or Reality? The Pill Changes Your Brain
In addition to its effects on mood, there has been some concern about – and emerging research into – how HC impacts the brain when it comes to cognition. Some brain imaging studies have suggested that, compared to naturally cycling women, women using HC may have changes in the brain structure and function in areas that are important for executive function and the cognitive control of behavior.
And there’s some evidence that these changes could be connected to actual changes in behavior: One 2017 randomized controlled study found women using HCs reported having lower self-control (in addition to lower well-being and vitality) compared to the placebo group.
But studies looking at whether women on HC perform any worse on particular cognitive tasks have been very mixed. A 2014 review of 22 studies on the impact of oral contraceptives on cognition concluded that “the quality of evidence is poor.” Most studies haven’t been well-designed and have included just a couple dozen subjects. The “most consistent finding,” according to this review, was that women on OC have improved verbal memory. In most other areas, the results have been inconsistent. For example, a few studies have found improvement in attention, concentration and working memory with OC use, while a handful of others demonstrated impairment.
A more recent review published in 2023 summarized the findings from 50 studies. Again, overall, the results were often contradictory, but they concluded that “Our overall findings suggest that OCs may improve cognitive performance within the domains of verbal memory and visuospatial abilities, as well as possibly decrease performance in relation to mental arithmetic accuracy and emotion recognition.”
It’s certainly plausible that HC affects cognition since we know that sex hormones impact the brain, and studies in teens have shown us that there may be changes in the brain in areas that control emotional regulation. So more high quality research in this area is definitely needed. But at this point, there’s no evidence of a major detrimental effect. But, as with all of these side effects, if you feel mentally sharper or that you have better self-control when you’re not on the pill, pay attention to that, explore, and trust your experience and observations.
#5 Myth or Reality? The Pill May Cause Autoimmune and Inflammatory Conditions
Autoimmune disease, which has been on the rise in recent decades due to a variety of factors associated with modern-day living: poor nutrition, stress, and myriad environmental exposures,
affects nearly 28.5 million Americans. Of these, 80 percent are women. Autoimmune conditions are a leading cause of discomfort, worry, affect quality of life, and can ultimately cause significant disability. It’s thought that the X chromosome, in combination with hormonal changes we experience throughout our lives, explains women’s significantly increased risk. Given the relationship between hormonal changes and autoimmune conditions, it’s reasonable to ask whether using hormonal contraception contributes to our risk of developing autoimmune conditions.
Indeed, some studies have suggested that using oral contraceptives is associated with increased risk of developing certain autoimmune and inflammatory diseases, including Crohn's disease and ulcerative colitis, systemic lupus erythematosus, and interstitial cystitis.
A large 2013 study of over 200,000 women enrolled in the Nurses Health Study found that current Pill users had nearly 3 times the risk of Crohn’s disease as women who had never used OC. The risk increased with longer duration on the Pill and decreased once women stopped using it. In fact, the researchers concluded, “Beyond smoking, perhaps the most consistent environmental risk factor for Crohn’s disease is the use of oral contraceptives.”
Researchers think OC may affect immune-related conditions in a few potential ways: For one thing, OC leads to changes in sex hormone levels, increasing estrogen and sex-hormone binding globulin (SHBG), while decreasing testosterone. And we know sex hormones play important direct roles in the immune system; that’s one theory for why women generally have higher rates of most autoimmune diseases compared to men. And these conditions sometimes relapse and remit triggered by hormonal shifts, as occur in pregnancy, postpartum, and menopause.
OC may also affect the immune system through their effect on the gut microbiome. Changes in the gut microbiome may play a key role not only in inflammatory bowel diseases, like Crohn’s, but in many autoimmune conditions (as well as affecting mental health through the brain-gut axis). But researchers are just beginning to study how OC impacts the microbiome. Recent small studies have shown that OC shifts the composition of certain gut bacteria and changes certain pathways.
On the other hand, OC use seems to have no effect on other autoimmune diseases—in fact, some evidence points to a protective effect on some, like rheumatoid arthritis, for unclear reasons, but possibly due to protective effects of estrogen on joints and inflammation.
The bottom line is that given the prevalence and impact of autoimmune conditions in women’s lives, I always prefer to minimize risk factors. Particularly if you already have an autoimmune condition, or if you have a family history or other personal risk factors for developing one, if a non-hormonal form of contraception is just as agreeable to you to use, consider that. If you have a hormonal or gynecologic condition and can find alternative solutions, that might be preferable. But overall, the risk does remain low for most women. If you do start hormonal contraception and begin having symptoms suggestive of autoimmune disease – like fatigue or pain – speak with your medical provider and discontinue the HC. This may be enough to halt the progression of any nascent changes, or put a condition which has developed in relationship to being on HC into remission.
#6 Myth or Reality? The Pill Depletes Your Nutrients
Research dating back to the 70s has suggested that taking OC can deplete several important vitamins and minerals. According to a 2013 review, the key ones are:
- Folic acid
- Vitamins B2, B6, and B12
- Vitamin C
- Vitamin E
This research is mostly based on studies showing that women taking OC have lower levels of these vitamins/minerals than those not on the Pill, however it’s not clear whether this preceded use of the Pill or whether there are confounding dietary or absorption factors contributing to lower specific nutrient status in the women studies. In fact, the most recent (2021) Centers for Disease Control and Prevention (CDC) NHANES, found that many women of childbearing and menopause age, the same age for women to be on the Pill, are chronically low in these nutrients.
In my clinical opinion, taking a multivitamin is a low risk daily habit, and since there may be an association between Pill nutrient depletion and nutrient status, I encourage all women taking the Pill (or using other forms of hormonal contraception) to take a ‘women’s multi’ (or a prenatal vitamin) daily, both while on the Pill, and for a minimum of 3 months after discontinuing it, particularly one with methylated folate, if planning to conceive in the months after discontinuing OC use. In one older study that found OC users had lower serum levels of folate, it took 3 months for their levels to return to baseline after stopping OC. This is incredibly important because a mother’s folate intake in early pregnancy is essential for the healthy development of a baby’s brain and spinal cord.
Interestingly, researchers have speculated some of OC’s side effects and risks could be caused by vitamin/mineral depletion. For example, the cardiovascular risk that women have on OCs may actually be due to low levels of vitamins E, C, and folate, which play important roles in cardiovascular health as antioxidants. As I mentioned earlier, mood effects that some women experience could be due to depletion of B vitamins or zinc. So supplementation to maintain sufficient nutrient levels may help protect against some of the Pill’s side effects and long-term risks, and make sure to optimize your diet, as well.
#7 Myth or Reality? The Pill Interferes with Bone Growth
Whether the Pill impacts your bone growth and density may not be at the top of your concerns. You may have never even considered this before. But bone growth in our teens impacts whether we achieve our full height, and bone health throughout our lives is critical for preventing osteoporosis—and fractures—either of which can occur at any age, but we’re more at risk for if we’re athletes if we’re experiencing the athletic triad, and also after menopause, and as we age, can have a significant impact on our quality of life, ability to live independently, and our longevity. Fractures, and especially hip fractures, are a leading cause of disability and death for women post-menopause. Bone health is much more important than most women realize in time to prevent the long-term consequences of bone loss.
It has been well-established that the Depo-Provera injection causes a loss of bone mineral density, which is recovered after stopping it. But the Pill’s effect on bone health has been more controversial. In adult premenopausal women, OC appears to have no effect or even to benefit bone health. A review of 13 studies in women over age 30 using varying low-dose COCs reported a positive effect in 9 studies and no effect in 4 studies. This makes sense given the bone-protective effects of estrogen.
However, studies in teens indicate that oral contraceptive use in adolescence can compromise bone mineral acquisition, especially if used in the first few years after their first period. A 2019 meta-analysis of nine studies found that adolescents on combined hormonal contraceptives (COC) had significantly less spinal bone mineral density accrual during a two year period compared with those not using them.
Why the effect in adolescence but not in adulthood? Since estrogen decreases bone turnover, estrogen therapy is actually beneficial for bone health in menopause, when women are gradually losing bone. But the story is different in adolescence when the skeleton is still actively growing. In this stage of development, in order to grow, bone is continually turning over; the fact that estrogen suppresses bone turnover at this age is a bad thing. And not getting optimal bone mineral density in adolescence can increase the risk of osteoporosis and fractures later in life. Nearly half of peak bone mass is acquired in adolescence—usually by age 18.
This suppression of bone growth appears to be a problem with estrogen-containing OC at a wide range of doses. And, unlike with the Depo shot, it’s unclear if these changes are fully reversible. One study found that teens who’d taken OC continued to have smaller gains in spine bone mineral density than teens up even two years after stopping it, compared to those who’d never taken it.
It should be noted that it’s not clear whether the short-term changes in bone mineral density seen in teens on OC actually increase their fracture risk later in life. A 2015 review of 14 observational studies comparing fracture rates in women who had used hormonal contraceptives to non-users found no association between COC use and fracture risk overall; however, subgroups of women with 10 or more prescriptions or those who used COCs for more than 10 years had an increased risk. And, as a 2020 review pointed out, it’s an open question whether that holds for those who began using hormonal contraceptives as teens.
What’s the take away? As women, we need to be more mindful of nutrition, exercise, alcohol intake, and other factors including medications, and even high levels of chronic stress, that might interfere with optimal bone growth and bone density. We also need a great deal more research about the impact of hormonal contraception in teens, a point I highlighted in my recent podcast Did the Pill Ruin My Fertility? – as the only age-group in which the Pill may impact long-term fertility is in teens who started it when they were younger than 16.
#8 Myth or Reality? The Pill Causes Weight Gain and Blood Sugar Problems
When it comes to the Pill, one of the biggest concerns women express is whether it will cause weight gain. A 2016 study that explored the barriers to using hormonal contraceptives among a diverse group of US teens and found this is a concern for them, too. The study found that weight gain was the most common concern they expressed about hormonal contraception. And there’s no doubt that many women do experience some weight gain on the Pill.
Yet, as common as it is for women to report having gained some weight when starting the Pill, studies have failed to reveal significant effects on body weight from the Pill. A 2014 Cochrane review concluded there wasn’t enough data to determine whether the pill causes weight gain or not, but they didn’t see a large effect. A second review of progestin-only contraceptives concluded they were associated with an average weight gain of up to about 4.5 lbs. in the first year, but noted that most of the studies were low quality.
There seems to be somewhat stronger evidence that the contraceptive injections cause weight gain: A 2010 study that followed teens for 4-5 years found that those using birth control injections gained an average of over 13 lbs., compared to average increases of 5 lbs. in the COC group and 6 lbs. in those who didn’t use hormonal contraception or who discontinued it. It should be noted that these reviews didn’t conclude that these methods definitely don’t cause some weight change – the evidence base just isn’t strong enough to say either way.
The main problem with the research on the topic is that very few studies have included a control group of women who are not taking HC, which is important since it’s common for people to naturally gain weight over time, regardless of their contraceptive method. Another weakness is that, in many studies, a large proportion of women have dropped out of the study or discontinued the method by the end of the study. If those women have gone off because of unwanted side effects—like, say, weight gain—then the study would under-estimate the effect on weight. It’s the same “healthy user bias” I mentioned when it comes to mood effects: the people who do stay on the pill tend to be those who don’t experience significant side effects.
And of course, just because we haven’t seen a huge effect on average in studies doesn’t mean individual women don’t experience weight gain due to HC: it’s likely that some women gain weight on the pill, while others may lose weight. As with all side effects, for reasons we don’t yet understand, subsets of users may respond differently. There may be a disconnect between what researchers and women define as ‘substantial weight gain.’ For some women, gaining five pounds might seem significant.
It has been well-established for decades that COCs negatively impact lipid and carbohydrate metabolism. COCs raise serum triglycerides, with an estimated change of 25 mg/dL after six months of use. They increase plasma insulin and glucose levels and reduce insulin sensitivity. For example, in a 2008 study in African-American women, using low-dose OC was associated with increased insulin resistance, glucose intolerance, and elevated triglycerides—all markers of cardiovascular risk. Older formulations of COCs also tended to impact HDL and LDL cholesterol levels, though newer low-dose pills don’t seem to have as much of an effect.
According to most guidelines, these metabolic changes are thought to be not that significant for healthy women. A 2013 study concluded that there is no consistent evidence to suggest that COC use significantly increases the risk of developing diabetes, even in women with a history of gestational diabetes. And while data from specific studies remain scant, to date, COC use has not been thought to worsen glycemic control or increase microvascular risk in women with diabetes. It’s unclear whether for subgroups of women, such as those with polycystic ovarian syndrome, changes in glycemic, insulin, or cholesterol parameters are clinically meaningful, thus the risks and benefits should be explored, and some reasonable periodic assessment of labs (i.e., a lipid panel and a HbA1C) is not unreasonable to request.
#9 Myth or Reality? Taking the Pill Squashes Sex Drive
All of us know experientially that our sex drive increases and decreases with shifts in hormones – whether throughout our menstrual cycles, during pregnancy and postpartum, or in menopause. So it’s not a stretch to wonder about the impact of hormonal contraceptives on libido, and in fact, many women do report changes to their libido when taking the Pill. So what’s the relationship between the Pill and libido?
Currently, official guidelines on contraceptive use do not mention the potential sexual side effects of OC. Yet sexual side effects are a common reason many women go off the Pill. In one prospective study that followed women in committed relationships who went on the Pill, about 1 in 5 reported negative sexual side effects, and nearly half of those discontinued it as a result.
But the research into the OCs’ effect on sexual function is somewhat conflicting and remains controversial. Part of this in my opinion, is that women’s sexual health is understudied in general! A 2016 systematic review concluded that 85% of COC users reported an increase or no change in libido while 15% reported a decrease. However, according to another 2017 review of the research, overall “most studies indicated that women who use OC pills have decreased sexual desire and libido.”
Most studies have been observational, and these can easily be biased by confounding factors. But there have been some randomized controlled trials too: A 2016 Swedish study found that ratings of sexual desire, arousal, and pleasure were significantly reduced in the OC group compared to the placebo group. Another Swedish RCT found a small decrease in sexual interest among pill users, though the difference was quite small.
Also of note when it comes to your sex life: Some studies point to a higher risk of vulvar vestibulitis—which causes pain during penetrative sex – among Pill users, a risk that seems to be higher when OCs are first used at young ages and increases with longer duration of use.
The bottom line is that you know your body; if you start taking any medication that affects your libido, it’s important to weigh the pros, cons, and alternatives, and make the best decision for your medical and personal needs. Some women may be more troubled by decreased libido than others; it’s also important to look at how low libido might impact you in other ways – some women find a profound connection between their sexual and creative energy. As with any side-effects, your medical provider should listen to and believe you when you report one, and should help you to find solutions that work for you.
#10 Myth or Reality? The Pill Affects Mate Selection and Attraction
Research suggesting that the Pill could affect mate selection and long-term satisfaction in romantic relationships first hit the media a few years ago and spread like wild-fire as clickbait across social media as well. The story goes that the type of mate we’re attracted to while on the Pill is different than one we might be attracted to if not under that hormonal influence, ~30:00 there’s some really weird repeat of a sentence here – needs an edit so that it only says what’s here: so that if we meet and marry (or enter a long-term relationship with) a partner while on the Pill, upon discontinuation of the Pill we might wake up and wonder why that person is in our bed, let alone why are you with them at all!
Why might this be the case? Some studies suggest that naturally cycling heterosexual women show differences in their sexual attraction to men across the menstrual cycle. During the ovulatory phase, when estrogen levels are high and we are most fertile, women tend to have a stronger preference for men with more “masculine” features like a strong jawline or deep voice, which tend to be associated with higher testosterone. The same data suggests we are more attracted to ‘bad boy’ types during this phase of our cycle.
The evolutionary psychology theory here is that these characteristics are a “cue” of good genetic quality, which is—evolutionarily-speaking—subconsciously, the most important criteria for women during their fertile phase. On the other hand, during less fertile periods, women may prioritize non-genetics qualities that make a good long-term partner, and evidence that someone might be a committed dad and good provider.
So what happens when women are on the Pill and don’t get this mid-cycle estrogen surge but rather are in a hormonal state that essentially mimics the more steady hormonal conditions of pregnancy for the whole month?
Some small studies have suggested that women using oral contraceptives show weaker preferences for “masculine”-looking men than do women not using oral contraceptives. For example, in one 2013 study, researchers had straight women use a computer program to manipulate the appearance of a male face to create the face of their ideal romantic partner—once before they went on the Pill and then again a few months later. After being on the pill, their ideal male face became significantly less “masculine.” The researchers also compared the facial features of the real-life partners of women who’d started their relationships while on the Pill versus those who weren’t on hormonal contraception when they started their relationship and concluded that the women on the pill had chosen partners with less masculine faces.
There are similar findings when it comes to genetic similarity. Naturally cycling women tend to be more attracted to partners who are genetically dissimilar when it comes to a set of genes involved in immune response—the idea being that mating with someone who is genetically dissimilar maximizes the immunity of your offspring. In a 2008 study, researchers had women smell the used T-shirts of different men and then asked, “Based on this smell, how much would you like this man as a long-term partner?” They found that while women are usually attracted to the scent of men who were genetically different from them, women on the Pill were attracted to the scent of men who are more genetically similar.
An implication of this theory is that if a woman chooses her partner when she’s on the Pill and then eventually goes off it, she may no longer find herself as attracted to him. And indeed, there are plenty of anecdotal reports of women experiencing this.
And there’s some data too: In a 2014 study, researchers surveyed couples and found that women’s sexual satisfaction was highest when their current hormonal contraceptive use matched what it was when they first got together with their partner—in other words, women were most sexually satisfied if they were on the Pill when they first started the relationship and were currently on the Pill or, alternatively, they weren’t on the Pill when they first met and currently weren’t on it. This congruency between past and current contraceptive use didn’t affect women's satisfaction with non-sexual aspects of the relationship or the satisfaction of their male partners.
While these studies have often been covered in the media with sensational headlines like “The Pill Makes Women Pick Bad Mates,” the data is more complicated than that. After all, there’s obviously much more to a successful long-term relationship than whether you think your partner’s scent is super sexy. Another 2012 study found that women who’d met their partner while using OC were less satisfied with the sexual aspects of their relationship. But, on the other hand, those women were more satisfied with the non-sexual aspects of their relationship—their partner's provision of financial resources, faithfulness and loyalty, intelligence, and ambition—had longer relationships, and were less likely to separate.
This theory has been influential – and also controversial. Critics have pointed out that most of the studies showing variation in attraction across the menstrual cycle to begin with have been small and usually relied on women’s self-report of where they are in their cycle. Plus, studies looking at the effect of the Pill have yielded contradictory results: some of these small studies have found that women using oral contraceptives reported stronger preferences for masculine male faces than women not on OC.
And in the last few years, larger, higher quality studies that have directly measured women’s hormone levels have seriously called into question the whole idea. In one 2018 study, the largest at the time to tackle the question, researchers repeatedly tested over 500 women’s salivary hormone levels and concluded there was no evidence that women’s preferences for masculine male faces varied according to their hormonal levels or whether or not they were on the pill. Then, a 2019 study which surveyed over 6,000 heterosexual women again found no evidence that women using oral contraceptives had weaker preferences for male facial masculinity than did women not using oral contraceptives.
What’s the take home? While this is a big, complicated area and the data is still evolving, I think it’s incredibly important for us to make relationship and mate decisions in conscious and highly considered ways that take a great deal of information into account. Attraction is obviously important, as is a partner being able to be a great parent and provider, particularly if you plan to have children, and the qualities associated with this are traits like loyalty, kindness, and stability.
Relationships are complex and go through tremendous – sometimes seismic – shifts over time; more so the longer the relationship. Our needs, desires, expectations – and hormones – all shift over time. Should you find yourself experiencing less satisfaction in your relationship – sure, it’s possible that it’s due to the Pill. It could also be natural evolution and changing over (~36:54 the) time. Should you go off the Pill before or while dating? When getting ‘serious’ with someone? If this research worries you, then possibly so. But I think there’s much more to mate selection and relationship than whether we met our partner on the Pill, and that if the Pill is something you need or want to continue to use, I don’t think the research suggests that you should stop it to vet your potential long-term mate. When it comes to same-sex marriages the data is just not there.
Should You Take the Pill?
I’ve talked about some big myths – and realities. By now you may be wondering, “Should I take the Pill?” “Should I stay on it?” “Should I discontinue taking it? Take a look at the myths and realities that relate to you, and do an audit on whether you have specific risks or are experiencing symptoms?
It’s clear that we need more research and funding towards developing new and truly innovative contraceptive methods that really meet women’s needs for safety, effectiveness, affordability, and convenience. Despite their differences, all HC are basically just versions of the same synthetic hormones we've been using for decades to prevent pregnancy. When it comes to hormonal contraception, there’s no one answer for all women. My goal is to provide the information that helps you make the best choice for your body, your needs, and your lifestyle, not to inspire fear or suggest that women should never use the Pill or other hormonal contraceptives, nor to give them the automatic ‘green light' for everyone.
There’s no doubt that the medical community has long downplayed and dismissed women’s experiences of side-effects, and has even minimized medical research findings. So it’s important not to assume that just because something has been around for a long time it’s completely safe, nor is that simply true because a doctor or other medical provider said it’s safe.
Similarly, not all of the information that’s coming from the women’s hormonal health and wellness space is accurate. While some of it truly does come from citizen scientists trying to shed light on risks, some of it is based on exaggerated claims, limited understanding of the medical literature, and click-bait and fear-mongering to sell books, courses, and supplements. And it’s very hard to sort fact from fiction, expert from exploiter.
I do prescribe HC in my practice when needed for medical reasons or when it’s a woman’s preferred choice for contraception. For many women with hormonal symptoms or gynecologic conditions, they can feel like small miracles. They can be helpful, effective, and convenient. And for women seeking birth control without the work of having to check Basal Body Temperature, cervical mucus, or watch the calendar or an app, the Pill, patch, IUD, or ring may be the easiest option.
So no, it’s not necessary for every woman to avoid or stop using hormonal contraceptives.
There are women, however, for whom certain forms of hormonal contraception, and particularly the Pill, are not recommended, or are even contraindicated for safety reasons. The risks depend on whether the OC is estrogen or progesterone containing. These are especially important to review before you start taking an OC, and also if you’ve been on one, because many doctors neglect to do thorough screening before prescribing them.
Estrogen containing contraceptive pills are not recommending for women with the following risk factors::
- Age ≥35 years and smoking ≥15 cigarettes per day
- Two or more risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)
- Venous thromboembolism (Women with a history of thromboembolism not receiving anticoagulation or women with an acute embolic event)
- Known thrombogenic mutations
- Known ischemic heart disease
- History of stroke
- Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation,
- history of subacute bacterial endocarditis)
- Breast cancer
- Migraine with aura
- Hepatocellular adenoma or malignant hepatoma
Progestin-only containing contraceptive pills are not recommending for women with the following risk factors::
- Known or suspected breast cancer.
- Undiagnosed abnormal uterine bleeding.
- Benign or malignant liver tumors, severe cirrhosis, or acute liver disease.
There are also warning signs to look out for if you're on the pill that all Pill users should be aware of. Seek medical care if you experience:
- Sharp chest pain, coughing of blood, or sudden shortness of breath (indicating a possible clot in the lung)
- Pain in the calf (indicating a possible clot in the leg)
- Crushing chest pain or heaviness in the chest (indicating a possible heart attack)
- Sudden severe headache or vomiting, dizziness or fainting, disturbances of vision or speech, weakness, or numbness in an arm or leg (indicating a possible stroke)
- Sudden partial or complete loss of vision (indicating a possible clot in the eye)
- Breast lumps (indicating possible breast cancer or fibrocystic disease of the breast; ask your doctor or healthcare provider to show you how to examine your breasts)
- Severe pain or tenderness in the stomach area (indicating a possibly ruptured liver tumor)
- Difficulty in sleeping, weakness, lack of energy, fatigue, or change in mood (possibly indicating severe depression)
- Jaundice or a yellowing of the skin or eyeballs, accompanied frequently by fever, fatigue, loss of appetite, dark colored urine, or light colored bowel movements (indicating possible liver problems)
I’m also not a fan of women being put on the Pill for any reason and simply being left on it indefinitely. There really is no zero-consequence pharmaceutical that I can think of and I feel it’s important to periodically reflect on whether the symptoms or condition for which it was started initially is still present, and whether it’s still the best treatment of choice, especially after a year or so of being on it, and certainly every few years.
If you are ready to stop using OC, whether due to side-effects, concerns, or personal preferences, there are non-hormonal contraception alternatives including condoms and the copper IUD, and there are many options for Fertility Awareness methods and apps.
There are also, resources, like my book, Hormone Intelligence, which can guide you on non-pharmaceutical methods of addressing many common concerns from acne to PMS, fibroids to PCOS, endometriosis to menopausal symptoms – all for which hormonal contraceptives, and especially the Pill, are commonly prescribed.
Whatever medication or device we might be considering, or may already be using, it’s important – and even essential – to be thoughtful and knowledgeable about what we are putting into our bodies, to know the risks and benefits generally, and for us individually, to pay attention to side-effects and have a provider who believes you. Know the benefits, know the risks, know your options. That’s the heart of informed consent.