The desire to control conception is an age old challenge for women. Women's earliest herbal texts dating back as far as the 1400s divulge a variety of methods ranging from an hollowed out citrus peel loaded with herbs to be used as a diaphragm to herbs to be taken to prevent pregnancy. It's no wonder that the advent of the pill indeed seemed to be a wonder drug, and it has provided women with an enormous amount of freedom in birth control since the 1960s.
Today, 4 out of 5 women have been on the pill at some point in their lives, and many are on it for 10 years or more. It's an easy to use and popularly prescribed method to prevent pregnancy and treat hormone imbalances, but do we know the true effects that it is having on our bodies, minds, and overall health?
The Pill has been around since 1960, and with a 91% effectiveness when taken correctly, there’s no doubt that it was a major, hard-won breakthrough for women. For the first time in history, we were in control of our reproduction, which allowed us more autonomy in our ability to work, build careers, and choose whether to stay in relationships, and not be limited by pregnancies they may not want or be ready for. Forget the maternity leave debate – back then, there was no debate. Married or not, you had to quit your job when you got pregnant or hide it until you couldn't anymore.
I don't know if you realize this, but it wasn't even that long ago – just in the early part of the last century – that it was illegal to send any contraceptive information through the US mail. I'm not talking about contraceptives. I'm talking about pamphlets, leaflets, flyers, or medical information about contraception, and it was illegal to the point of being punishable by going to prison, which actually did happen to people like Emma Goldman and other advocates of women's access to contraception.
So on the one hand, a dyed in the wool (or womb may be more accurate – my mom was the first woman in her college to wear slacks to the campus!) feminist, I'm loathe to criticize what has become a mainstay in women's ability to control when we do and don't get pregnant – especially during a time when our reproductive rights are being threatened.
The stigma is still there for women applying to jobs in the question that is not supposed to be asked but sometimes is – “Are you planning to have children any time in the near future?” Further, being ‘on birth control” is considered a sign of responsibility in women – but women are bearing the full burden of contraceptive risk – in fact, many of my young patients in their teens have already been put on the pill by their parents or doctor, whether to prevent pregnancy or to regulate their cycle (the latter being an illusion – it actually blocks ovulation, thus preventing a natural cycle).
The pill comes with a long list of side effects, ranging from mild to severe, that many of us never hear about. In this episode, I discuss depression, weight gain, migraines, blood clots, and cancer, among others. I also talk about potential long-term effects on reproductive health that some women experience even after discontinuing use. I give you the whole story on these side effects, risks, and dangers, along with an overview of my favorite alternative contraceptive methods.
My goal is to share with you what you need to know about the pill so that you can make a truly informed decision if you are on it, or considering it, whether for contraception or other symptoms or conditions
In this article and podcast I discuss:
- What is informed consent?
- Side effects, dangers, and hazards of the pill
- Special concerns for women with depression or migraines
- Hormone imbalance and other post-pill problems
- How autoimmune disease and the pill might be linked
- Misunderstanding alert: the pill and your thyroid
- What if you “need” the pill to treat another condition?
- Warning signs to look out for
- An overview of my favorite alternative contraceptive methods
In medicine there's a concept called informed consent, meaning that your health-care provider is supposed to give you information on the benefits and the risks of the option that he/she is recommending, as well as all the other existing options. While the pill ls not likely to cause serious harm in most women who use it, it is associated with a long list of mild to severe side-effects.
From the insert package from Merck's OCP Desogen, an estrogen and progestin containing form of the pill, we find that the pill can cause: 1. Risk of developing blood clots, 2. Heart attacks and strokes: Smoking and the use of oral contraceptives greatly increase the chances of developing and dying of heart disease. Women with migraine (especially migraine with aura) who take oral contraceptives also may be at a higher risk of stroke. 3. Gallbladder disease Oral contraceptive users probably have a greater risk than non-users of having gallbladder disease, although this risk may be related to pills containing high doses of estrogens. 4. Liver tumors In rare cases, oral contraceptives can cause benign, but dangerous, liver tumors. 5. Cancer of the reproductive organs and breasts Breast cancer has been diagnosed slightly more often in women who use the pill than in women of the same age who do not use the pill. This small increase in the number of breast cancer diagnoses gradually disappears during the 10 years after stopping use of the pill. Some studies have found an increase in the incidence of cancer of the cervix in women who use oral contraceptives. 6. Lipid metabolism and inflammation of the pancreas In patients with inherited defects of lipid metabolism, there have been reports of significant elevations of plasma triglycerides during estrogen therapy. This has led to pancreatitis in some cases.
But did your doctor review these risks with you before handing you the prescription? And really, how many of us actually read that drug package insert? You can't truly have informed consent if you don't have the whole picture. When it comes to oral contraception (aka the birth control pill or the Pill), the truth is that we have not gotten the whole story.
Look, I want to give you the story straight: One of the largest studies to date in the US, The Nurses Health Study, followed thousands of women for over a decade and found no overall increase in mortality in long term pill users vs. “never” pill users, and a massive European study of nearly 50,000 followed over 39 years found that women who'd used the pill actually had rates of death from all causes than ‘never users,' the side effects that shouldn’t be downplayed. There's research data and there are the experiences that real women report – which are too often dismissed.
Along with a complex history of the use of forced sterilization and contraception to control Black Women’s access to health care and social services, all of the risks associated with the Pill are compounded for Black Women. For example, one study found that for African-American women, even taking just a low-dose oral contraceptive, may increase risk of developing heart disease or diabetes, including in women not otherwise medically at risk.
My goal is to share some of the information that you need to know so you can make an informed consent. I understand that for some women, the Pill may feel like the easiest choice for you right now. The Pill continues to allow women control over their reproduction, but to have true control over our reproductive health, we have to know what hormonal contraception can do to our bodies, minds, and health. There's a reason nearly 64% discontinue using the pill due to side effects, and it can increase your risk of serious health problems. I want you to at least know the risks, warning signs – and information on alternatives.
There’s a bitter side to the Pill – know the risks before taking oral contraceptives. @avivaromm
Side Effects and Risks of the Pill
The Pill increases your risk of depression – even if you’ve never had depression before!
Perhaps one of the most compelling arguments against the use of the Pill for most women is depression. A 13-year study of 1 million Danish women found that being on the pill was an independent risk factor for needing an antidepressant. In fact, the study – the largest of its kind to date, published in the Journal of the American Medical Association in 2016 – found about 23% of women (ages 15 to 34) needed to go on an antidepressant medication after starting the pill. And these were not women who had ever had depression before – and it was especially true for teens who were 80% more likely to experience depression if prescribed the combined pill and twice as likely with the progestin-only pill. If you've been on the pill and are struggling with depression, it could be the pill – and if you struggle with depression and are considering the pill – it might not be the best option for you. If you do go on the pill and find yourself moody, emotionally erratic, depressed, anxious, or feeling like you're suddenly ‘manic' or having panic attacks, don't dismiss this – and don't let anyone else, either. It can be a side-effect and deeply affect your quality of life and well-being.
Weight Gain and Metabolic Syndrome
The Pill can cause weight gain, insulin resistance, high blood sugar, and high cholesterol.
The Pill mimics the hormonal state of pregnancy, and with it, causes metabolic changes like elevated blood glucose and insulin resistance. In pregnancy, it’s how your body ensures the baby gets enough fuel for growth and development. These can lead to metabolic syndrome, make you gain weight, albeit the pill has been associated with only modest weight gain according to studies (3-10 pounds, though the latter is not insignificant to most women) – and can cause inflammation. Depending on the hormonal combination you're taking, the Pill can also adversely affect cholesterol leading to high total cholesterol, high LDL (usually called the ‘bad kind’) cholesterol and low HDL (the protective type) cholesterol for the duration of use; as well as high triglycerides. The pill commonly causes minor and sometimes significant elevations in blood pressure.
Therefore it's important to discuss cholesterol and your health with your health care provider before starting the Pill if you plan to take it and if you start to have changes in your cholesterol or blood pressure – don't shrug this off as ‘just a side-effect' or ‘common' – and don't let anyone else convince you of that – it's important to take these side-effects seriously.
Blood Clots and Related Risk of Death
The Pill increases risk of developing blood clots – particularly if you’re a smoker, overweight, or older.
When you take the Pill, your blood coagulates more and you become more at risk for clotting – especially if you’re a smoker, and you’re at a higher risk if you have PCOS or you're overweight. This risk of clotting naturally also goes up in pregnancy, because your body is trying to protect you from hemorrhaging with the normal blood loss that occurs at birth, and in fact, the risk of developing clots for most otherwise health women is higher in pregnancy and six weeks after birth than when on The Pill. However, . if you're not pregnant, The Pill poses an unnecessary risk of developing blood clots, which has been one of the most serious consequences that has actually led to deaths in women of all ages on birth control. Further, the duration of pregnancy and postpartum is limited, whereas most women are on the pill for many consecutive years – leading to extended clotting risk, which is certainly something to consider when selecting contraception or using OCPs for acne or other conditions, if there are effective and safer alternatives.
Again straight from that drug package insert, some sobering data: For women aged 20 to 44 it is estimated that about 1 in 2000 using oral contraceptives will be hospitalized each year because of abnormal clotting. Among non-users in the same age group, about 1 in 20,000 would be hospitalized each year. For oral contraceptive users in general, it has been estimated that in women between the ages of 15 and 34 the risk of death due to a circulatory disorder is about 1 in 12,000 per year, whereas for non-users the rate is about 1 in 50,000 per year. In the age group 35 to 44, the risk is estimated to be about 1 in 2500 per year for oral contraceptive users and about 1 in 10,000 per year for non-users.
Headaches and Migraines
Headache is one of the most common side effects reported with the pill, and is a common reason that women stop taking it. for many women, this side effect goes away, however, after a few months of staying on the pill. Women with a strong personal history or family histpry of headaches appear to be at risk of new headaches related to the pill. The data varies on migraines – some women find they improve, others find they stay the same, and some report worsening of migraines. There is strong evidence of increase risk of ischemic stroke in women with migraines, especially migraines with aura, and OCP use, and thus I do not recommend them for women with migraines. I also recommend women who experience new or increased headaches on the pill to find another birth control method for their best health interests.
Hormonal Imbalances and Post-Pill Period Problems
The Pill’s impact on your hormones doesn’t end when you stop taking it.
While statistically, there is no proven correlation between discontinuing the pill and a lack of return of women's periods, and medical journal articles have discounted this phenomenon altogether, many women report hormonal imbalances after stopping the pill, and some studies do demonstrate that this is a problem. Post-pill amenorrhea – either not having a period or having periods that are so irregular you can’t determine when you’re fertile – is one of the most common symptoms my patients report. Usually, your cycle stabilizes within a year, and this doesn’t cause infertility, but it can cause fertility challenges for a period of time. Stay tuned for an upcoming article on what you can do to restore your hormonal balance and natural cycles after stopping the pill.
Of note, I’ve also worked with numerous women who have developed terrible cystic acne after stopping the Pill – most of whom didn’t have acne prior to starting it – not fun!
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The Pill has been associated with conflicting reports about whether it increases the risks of developing and worsening at least two autoimmune diseases – Inflammatory bowel disease, particularlyUlcerative Colitis, as well as Systemic lupus erythematosus (“lupus”). I caution women with these conditions to avoid the pill to avoid the risk, and it is medically advised that women with new onset symptoms or persistence of existing disease despite proper treatment discontinue taking the Pill. Autoimmune disease is one of the top 10 leading causes of death in women in the US and estrogen has been associated with autoimmune disease risk – this is not a risk to take lightly and more research is needed.
The Pill can increase your risk of certain cancers, including cervical cancer.
Proponents like to tout the decreased risk cofcolorectal, uterine, and ovarian cancers with Pill use, but OCP use has been linked to an increase in some types of cancers, including a modest risk of increase breast cancer and a potentially significant increase in the risk of cervical and central nervous system cancers. And, yes, though it can decrease some forms of cancer, it’s not a recommended ‘preventative strategy’ – there are other healthier ways to reduce cancer risk!
The Pill can put you at risk of a heart attack, particularly if you’re a smoker, overweight, or have other risk factors.
The earlier OCPs were associated with an increased risk of heart attacks and cardiovascular-related deaths, but the subsequent reduction in the estrogen levels found in the Pill has made them safer (but, again, there’s the risk of blood clots). If you’re young, relatively healthy, and a nonsmoker, the cardiovascular risks don’t appear to be high, though they do increase with the use of OCPs. The exception is for older women who smoke, whose risk of heart attack is too high to outweigh the risk of pregnancy. Given the number of women who struggle with their weight, this risk can’t be ignored.
Find out whether the risks of The Pill make it too bitter to swallow with Yale MD & women’s holistic health expert @avivaromm
The Pill and Your Thyroid
The Pill may lower your total thyroid hormone levels.
I would be remiss not to mention a less-common but still worrisome potential side effect of OCPs on the thyroid. The estrogen component of The Pill, like any estrogen taken orally, raises the serum concentrations of thyroxine-binding globulin (TBG), cortisol-binding globulin (CBG), and sex hormone-binding globulin (SHBG). As a result, the serum concentrations of total thyroxine (T4), triiodothyronine (T3), cortisol, estradiol, and testosterone increase. While levels of the active forms of thyroid hormone – free T4 and T3 – do not appear to be significantly changed, the effect of The Pill on thyroid hormone needs to be considered when evaluating thyroid tests.
But I Need The Pill for Hormone Balance…
While OCPs can be temporarily effective for reducing acne in many women, as well as symptoms associated with polycystic ovarian syndrome and endometriosis, the Pill doesn’t get to the Root Causes of these conditions – for example, nutritional insufficiencies or food triggers, high levels of exposure to environmental toxins, gut imbalances like dysbiosis, or slow functioning detoxification. While I understand how debilitating conditions like endometriosis pain and heavy periods or severe menstrual cramps can be, the Pill is not healing you from the inside out. In the long run, the Pill can make acne worse, and I’ve had many women develop severe rebound side effects after going off OCPs.
Women who have PCOS get put on the pill because it helps regulate your cycle, lowers testosterone, and helps with acne. If you miss your period too many times, as can happen with PCOS, it can cause changes in your uterus that put you at a higher risk for uterine cancer. The problem is that PCOS for most women is not just a hormonal problem; it's a problem of insulin resistance. The hormonal changes like high testosterone are happening because of the insulin resistance and the messages given to your ovaries tell them to produce too much testosterone. If you have insulin resistance and you're given birth control, it just makes the insulin resistance worse – it's not addressing the root cause of the problem. It’s tamping down some of the symptoms while worsening the root cause in a very dangerous way. Yet no research has been done on the potential for increased risk of OCP use in women with PCOS though this risk is acknowledged as possible.
Sometimes your symptoms are so severe that you might use the Pill under the supervision of a healthcare professional who can help you bridge a natural and hormonal approach, but keep in mind that the Pill is not an optimal long-term solution.
Once you start to trace your symptoms back to their Root Causes, you can start to see how everything in the body is interconnected and can often start to heal your painful periods and other issues.
Changing to a low inflammatory diet, getting the nutrients your body needs, healing your microbiome, and supporting your body’s detox pathways can all be helpful with the gynecologic, inflammatory, and blood-sugar-imbalance conditions that I have discussed here. Stress can also have a tremendous impact on your cycle, via its effects on the HPA axis and the rest of your stress response system. My latest book is about the adrenals and thyroid, but what many women don’t realize is that these are intricately linked to your reproductive health – as well as your mood, your blood sugar, and how you manage inflammation. Read more in The Adrenal Thyroid Revolution.
For pain associated with endometriosis, read this article for info on how to take a natural approach. For a natural approach to PCOS, you’ll find help here. Herbs and nutritional supplements can also be highly effective in the treatment of heavy and painful menstrual periods.
Reclaim your power. Feel at home in your body. And be the force of nature you really are! Join my Summer Book Club
What Should I Look Out for If I'm on The Pill?
There are warning signs to look out for if you're on the pill. 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)
What Contraceptive Methods Do You Recommend?
One big question I have to ask is, if we're trying to avoid excess environmental hormonal exposure in our food, water, cosmetics, and household products, do we really wanting to be taking them intentionally each day as medication when there are other options available?
I’ll dive deeper into birth control alternatives in another article, but I do want to share some safer alternative to birth control pills. The good news is that plenty of methods work as effectively as the Pill – and don't have the risks and side effects. Please keep in mind that for this article we are only discussing the effectiveness of protection from pregnancy – not from sexually transmitted diseases.
Natural Fertility Awareness
When your hormones are in balance, your cycle is just that – a cycle that is regular, predictable, and reliable. The word menses actually comes from the Latin word for month, as does the word for moon – that is the frequency of our cycle. I use the term “moon time” to describe our cycles sometimes for this reason. When you have a regular cycle, and are able to pay attention to several parameters- your personal cycle calendar, your cervical mucous, and basal body temperature you can combine these findings in was is called natural fertility awareness, or fertility awareness methods. These three methods in combination can lead to up to 99% effectiveness as a method of birth control, however, in reality, for most couples practicing fertility awareness methods, the success rate is closer to 76% . For this method to be effective, you really need to track your cycles and be aware of the fluctuations in your body. I recommend it be combined with condoms for extra security. Withdrawal is not an effective method – so don't rely on this to prevent pregnancy.
Used properly condoms are 98% effective – emphasis added because the real-life success rates are more like 88% – you have to be comfortable buying them and remember to use them. There are also problems with slippage and size, but for the most part if you use them correctly, they do work. A problem with condoms is that the lubricated ones often have ingredients that aren’t optimal for your body. Sustain Natural is a company I’ve worked with in the past, and they make eco-friendly condoms that are free from the carcinogens found in most condoms – and they use Fair Trade rubber. The company was founded by a father-daughter team with roots in natural products (he founded Seventh Generation). Both their condoms and lube are body-friendly, vagina-friendly, and pH-friendly, which means they’re not going to cause you to get yeast infections and pH changes that cause bacterial overgrowth or irritation or dryness.
Condoms are great when you combine them with an understanding of your body's natural rhythms and cycles, which some people call natural family planning. There are a lot of different names and techniques that you can use to learn when you're ovulating (this applies only if you have a generally regular cycle). So during that time you’re fertile – your window of ovulation – you’ll use a condom if you’re not trying to conceive.
Diaphragm or Cervical Cap
Diaphragms and cervical caps are 88% and between 71% and 86% effective respectively. They work best when used in conjunction with spermicides, which I’m not a huge fan of as they’re full of toxic chemicals, and they are a bit inconvenient to remember to put in. It’s also important to remember that if you experience substantial body weight changes you have to be resized. When they do fail, it’s because we forget to put them in, forget to take them out, or don't want to deal with the awkwardness of them. They're not my favorite, but if you can remember to use them correctly and regularly, they do work.
IUD (Intrauterine Device)
Any woman who’s over 30 may have heard horrible things about the IUD because of the Dalkon shield from the 1970s, which caused massive problems for women (infection and death). Surprisingly, today’s IUDs are a generally safe, highly effective, and convenient form of contraception. I know that's probably going to sound really unexpected from me, but they are actually the most widely used form of contraception in the western world.
These little plastic or metal T-shaped devices are inserted through the cervix into the uterus by a midwife, family doctor, or OBGYN during an in-office procedure. It's not very comfortable to have an IUD inserted – especially if you haven’t had a baby – and usually the pain will require a heat pack and some ibuprofen. But the copper IUD, which can be used for up to 12 years and the hormonal IUD 3-7 years, dependng on which you choose, is the most widely used form of birth control in many European countries – we’re talking progressive countries with progressive healthcare policies. You can get a non-hormonal kind or a hormonal kind. They are considered safe for women of any childbearing age, do not increase risk of uterine scarring, and do not increase future fertility risk.
There are two basic types – a non-hormonal kind is made of copper and a plastic one that is impregnated with and secretes a small amount of hormone. IUDs to not cause abortions – they primarily alter the cervical mucus so that you can’t conceive and cause changes in the uterine lining that prevent implantation. The IUD has many advantages – most importantly, if you tolerate it well, you get it inserted and can basically forget about it for 12 years with the copper IUD and 3-7 years with the hormonal form. If you decide you want to get pregnant, you can get it taken out and resume your natural fertile cycle immediately. However, many women do find the cramping too much to tolerate and have them removed. For most women who leave it in, the cramping resolves after 6 to 8 months. Those who do tolerate it tend to love it as a form of birth control. With the hormonal IUD, you do get a small dose of circulating hormone, but it's small compared to oral contraceptives, the NuvaRing, or Depo-Provera, the shot.
(Side note: With the NuvaRing I've seen women have systemic hormone problems and changes. While this form of birth control can be simple and effective to use, it’s along the same spectrum as oral birth control. It’s not quite as extreme, but it definitely carries some of those hormonal changes – and it’s been linked to some high-profile wrongful death lawsuits. Depo-Provera backs a pretty big punch of hormones, and I don't usually recommend it. It also causes bone density changes and all the same blood sugar changes as the pill.)
There are incidents of an IUD migrating or causing a uterine perforation during insertion, but the risks are so small that I wouldn’t advise against using one for those reasons.
These birth control methods are all options in place of oral contraceptives. If you're willing to put the time and energy into using it, my preference is using fertility tracking (cervical mucus changes, calender, and basal temperature in combination), along with condoms. I think that's the safest method for most women for pregnancy prevention, and a highly effective combination, but it does require the most mindfulness. Of all options I’ve mentioned, the oral contraceptive pill in my opinion is the least safe, and the IUD the contraceptive I prescribe the most often who want something more or different than fertility tracking and condoms.