Have you been prescribed birth control pill by your doctor? Not sure if you should take it? Need a second opinion? Deciding on whether taking contraceptive pill or not is very important because it can impact all aspects of your health in the long-term. This decision is deeply personal choice, your choice and it should be made by you. There are many features of the pill you need to consider. Some women do well on the pill, but others experience serious long-term damage. Unfortunately, many doctors hand out prescriptions for contraceptive pills without assessing the patient thoroughly, explaining the correct use, risk, benefits, and possible alternatives. Does benefits outweigh the risks? This is what we will explore below. Hopefully this article will empower you to make a better decision on your reproductive health and have a more productive conversation with your doctor.

History

Two great biologists, John Rock and Gregory Pincus, teamed up to research, develop, then test the first birth control pill in the 1950s. The pill contained the combination of two hormones – estrogen and progesterone. It was tested on poor women in Puerto Rico (without their consent). The first oral contraceptive drug was approved by the Food and Drug Administration in 1960. At first, it was a tool to grant coercive sterilization programs to Native American women and low-income families with the goal of reducing birth rates. In 1968, IUD was introduced to the market as well. In 1969, Barbara Seaman’s book called “The doctor’s case against the pill” was published showing immense amount of research and testimony from doctors and specialists about the negative side effects of The Pill (blood clot, cancer, heart attacks, stroke, death) due to its high content of estrogen. After several years of investigation and escalating lawsuit costs, the doses of hormones were adjusted to a lower level.

What is Hormonal Birth Control Pill?

It is crucial to understand that hormonal contraceptives deliver synthetic (lab-made) hormones into your system. Every cell in your body has receptors to receive these hormones and then elicit changes as your natural hormones do. These synthetic birth control hormones are not identical to those that your body produce. The most common type of birth control is the combination pill which contains estrogen and progestin. Progestin in the synthetic version of natural progesterone that has a different structure and different effects on the body.

• Natural progesterone is a steroid hormone produced by the female reproductive system (corpus luteum). It is linked to the female menstrual cycle, embryo development, and pregnancy. It is the calm, sleep, libido, and bone-enhancing hormone.
• Progestin is the synthetic form of progesterone which was developed for pharmaceutical use. Since it is made in the laboratory, it does not have any of the mentioned benefits of natural progesterone. On the other hand, it delivers various side effects such as blood cloths, heart disease, weakened immune system, yeast infection, disrupted HPA axis, depression, altered liver structure/function, or even cancer.

The monthly supply of the pill comes with 28 pills. Depending on the brand, it usually has 21 active pills (with hormones) and 7 inactive pills (placebo). Bleeding occurs during the placebo days – but it is not a real period, just a withdrawal bleed from the medication.

How does the pill work?

The pill works by shutting down the communication between your brain and the ovaries preventing ovulation.

In normal circumstances, the following process happens. The hypothalamus secretes GnRH (gonadotropin releasing hormone) which signals to the pituitary gland to start to produce LH (luteinizing hormone) and FSH (follicle stimulating hormone). These hormones act on the ovaries to induce ovulation (peaking estrogen, LH surge). During ovulation, an egg is released from the ovaries which moves through the fallopian tube and if it meets with the sperm, it may be fertilized. The empty ovarian follicle called corpus luteum forms a magical endocrine gland which will start to produce progesterone. If the egg is fertilized, progesterone produced by the corpus luteum will maintain the pregnancy, specifically the lining of the womb, until the placenta is formed. If fertilization does not occur, the corpus luteum breaks down leading to less progesterone. When there is not enough progesterone left to promote the growth of uterine lining, the menstrual bleeding starts by shedding the uterine lining.

Under the influence of birth control pill, the brain is tricked by the synthetic hormones preventing the pituitary to release LH and FSH. Without these hormones, the follicle maturation process is blocked. Since there is no hormonal signal sent from the brain to the ovaries to get a chosen follicle ready, no ovulation will occur. No ovulation, no chance to get pregnant. Now, you can imagine if you inhibit a naturally occurring process in your body, other systems will be equally effected, and cellular changes will occur.

How effective the pill?

It is 99% effective preventing pregnancy with correct use. In such a hectic world we live in, it happens that we just forget to take the pill, or we take it few hours later than usual time. In this case, the pill effectiveness decreases to around 91%. Keep in mind, that the pill does not prevent you from getting sexually transmitted infections such as chlamydia.

Who cannot use the birth control pill?

The hormonal birth control delivers synthetic hormones to your body which greatly influences the overall health outcome of the individual. All medications carry risks, and it is truth for the birth control pill as well. The CDC (Center for Disease Control and Prevention) and the WHO (World Health Organization) put together a report called “Medical eligibility criteria for contraceptive use” listing all unacceptable health risks factor. People with these risk factors should NOT use the combination pill.

• Past or current breast cancer
• Breastfeeding – less than 21 days postpartum
• Severe cirrhosis (liver disease)
• Gallbladder disease
• Inflammatory bowel disease
• Malabsorptive bariatric surgery (the pill is a highly nutrient depleting drug)
• History and current deep venous thrombosis (blood clot)
• Age of >35 and smoking >15 cigarettes/day
• Diabetes of >20 years duration or retinopathy, nephropathy, neuropathy
• Headaches with aura
• High blood pressure with Systolic >160 mmHg and Diastolic >100 mmHg
• Vascular disease
• Known thrombogenic mutations (Factor V Leiden genetic mutation)
• Liver tumor (hepatocellular adenoma)
• Multiple risk factors for atherosclerotic cardiovascular disease (older age, smoking, hypertension, high triglyceride, low HDL, high LDL)
• Severely impaired cardiac function
• Positive antiphospholipid antibodies
• Complicated valvular heart disease

Risks Vs. Benefits

There are always risks in taking a medicine, and benefits as well. The question is – does the benefits outweigh the risks? Let’s see.

Benefits that I am sure you know about:

• An effective methods of preventing pregnancy. 99% effectiveness is a lot.
• Decreased amount of bleeding
• Decreased pain during bleeding
• Decreased length of bleeding
• Less skin problems, like acne – not always true.
• You decide when you bleed
• Helps in the management of PCOS due to suppressed androgen production
• Less unwanted hair growth

Risks that might be less popular and not told by most doctors:

• Suppresses your thyroid function
• Risk of forming blood cloths
• Increased risk of liver damage
• Increased risk of infertility after quitting – shrinking the ovaries by 50%
• You have to take it everyday
• Expensive in the long-term
• It disrupts adrenal health
• Increased risk of depression and anxiety
• Increased risk of kidney disease
• Increased risk of breast cancer
• You lose your libido, pain during intercourse and dry vagina
• Leaky gut and gut dysbiosis
• Risk of brain tumor
• Increased risk of getting yeast infection
• Increased cholesterol, blood pressure, and diabetes
• Hair loss
• Dry skin
• Key nutrient depletion (folate, magnesium, vitamin B6, zinc, selenium)
• Can trigger autoimmune disease
• Long-term hormonal imbalances

Do I need a blood test?

I always suggest to have certain blood markers checked to make sure you do not have any undiagnosed disease or predisposing factors. As you have seen earlier, birth control pill comes with serious risks. It may cause thrombosis and damages in your liver in those who are prone to it. Ask your doctor to have some blood markers checked:

• Blood count – It is a group of tests that examine the elements floating in your blood such as red blood cells, white blood cells, platelets, hemoglobin, and hematocrit. It helps to detect several diseases including infections, anemia, clotting problems, even blood cancer. 
• D-dimer – It is a great indication about significant blood clot formation (venous thromboembolism) or breakdown in the blood. Although it does not tell you the location and cause of the clot.
• Bilirubin – Bilirubin is a yellowish compound which participates in normal catabolic pathways (breakdown) red blood cells. This catabolic process is the body’s natural way to clear our waste products such as aged or abnormal red blood cells. Bilirubin is made during normal breakdown of red blood cell, eventually passes through the liver and excreted out of the body. It provides a great indication whether there is a problem with the liver.  High levels of bilirubin may be a sign of cirrhosis, anemia, gallstone, alcoholic liver disease. Normal level is 5 to 17 μmol/l.
• GOT – Glutamate oxaloacetate aminotransferase is an enzyme involved in the metabolism of amino acids. GOT is increased when there is any organ damage in the body. The normal level range is 18-31 U/l in women and 18-33 U/l in men.
• GPT – Glutamate pyruvate aminotransferase is an enzyme produced in the liver showing liver damages. Its level is increased when there is damage made in the liver. The normal value of GPT is 7-30 U/l in women and 10-55 U/l in men.
• GGT – Gamma glutamyl transferase is an enzyme produced in the liver, pancreas and kidney. I it a very reliable parameter to get a clear picture on who healthy is your liver and bile ducts. The normal value is around 8-40 U/l, 9-50 U/l in women.
• Anti–thrombin III – It is a protein made in the liver that blocks abnormal blood clots from forming. It keeps the body in balance between blood clotting and bleeding. If you are deficient in it, you are at risk of having blood clots.
• Protein C – It is responsible for regulating anticoagulation, inflammation, permeability of blood vessel walls. Deficiency in this factor increases the risk of getting blood clots or embolism.
• Micronutrients – vitamin B6, B12, riboflavin, vitamin C, magnesium, zinc, bioavailable copper, vitamin D, selenium. These are key nutrients for the body to function properly, so it is better to check them frequently to avoid complications.

Facts to consider:

• You are ovulating only 1 day per month. The sperm has a limited lifecycle from the moment of ejaculation. It can live just a few minutes (max 20 min) outside the body. However, inside the body, it can live longer depending on the conditions. Inside the vagina, sperms can live only for a few hours, however during ovulation the pH of the vagina becomes less acidic so the conditions are more beneficial for the sperm and can live longer. In the cervix and uterus, most sperm die in 1-2 days, but some might live up to 5 days. What does it mean? It means that you are fertile for 5 days or less per month.
• If you are considering the birth control pill for preventing pregnancy, then keep in mind that most women on birth control pill reported a significant decrease in their sex drive and libido.
• According to a study, 60% of women get on the pill for masking symptoms such as painful period, acne breakouts, missing periods etc.  If you want to take the pill for reasons other than preventing pregnancy then you need to know that the pill is not a cure and symptoms will come back when you decided to go off the pill (sometimes worsen). You need to find why your symptoms occurred in the first place. Is it your thyroid? Your lifestyle? Your diet? Infections? Stress? Finding the root cause of your concerns will give back your health and joy in the long-term. Pill is just a short-term solution with long-term side effects!
• Birth control related death of young women does exist, and it is very much underreported. Each year between 300 and 400 women die in the US due to hormonal contraceptive. Venous thromboembolism is the most common causative of death in those cases. Sadly, these deaths could have been prevented. Using hormonal contraceptive increases the risk of thrombosis by 3 to 9 times, and the risk is even higher in women under age of 30.
• Hormonal contraceptive rewires the brain and interrupts neurotransmitter pathways. The prevalence of moodiness, anxiety and depression is extremely common. Teens on the pill are 80% more likely to be prescribed an anti-depressant. The risk of committing suicide is also increased during the first few years on the pill.

What alternative methods exist?

Hormonal contraceptive methods, including combination/birth control pill, progestin-only pill, IUD, birth control patches, birth control implants are all carry serious risks mentioned in the previous section. Their mechanism is similar – disrupts your endocrine system by shutting down the communication between your brain and the ovaries. There are safer alternatives to hormonal contraception, they are called non-hormonal contraceptives.

Non-hormonal contraceptive methods:

• Sponge and Diaphragm: Both methods are safe and effective. They both work by physically blocking the entrance of the sperm into the uterus during intercourse. Sponge is a small foam device containing spermicide which traps and destroys the sperm. It is inserted into the vagina prior to intercourse. Diaphragm is 94% effective with correct use. Sponge is 88% effective if you have never given birth.
• Phexxi: It is a hormone-free birth control gel which contains lactic acid, citric acid, and potassium bitartrate. This gel is inserted into the vagina via an applicator before intercourse. The gel lowers the pH of your vagina to make it a hostile environment to the sperm. Even though it is a much safer method of contraception, it still has some side effects to be aware of – increased risk of UTI, yeast infection and bacterial vaginosis. It is 93% effective.
• Female Condom: Its mechanism is similar to male condom. It is a soft polymer sheath containing two flexible rings. Before sex, it is inserted into the vagina, and it holds the sperm preventing the sperm entering the vagina. Easy to find it in pharmacies and cheap. It is 95% effective in preventing pregnancy, but some women might have trouble inserting it correctly. It is great option for those who want to be cautious about transmission of STIs.
• Fertility Awareness Method: This is my favorite method of all. It is a non-hormonal and non-invasive approach to birth control. Women are motivated to learn about how their body work and how they can predict their time of ovulation. It involves three methods which could be used together or individually – menstrual cycle charting, basal body temperature, cervical mucus tracking. To get a clear picture about if and when you are ovulating, I recommend to track the first two methods for several months. With correct use, it is 95-99% effective.
• Cycle Tracking App: It is an easy and similar option to FAM. It is based on the concept that you ovulate one egg per month, the egg live for 24 hours, and the sperm live for 5-6 days in the uterus. It means that you are potentially fertile for 6-7 days each month. It you want to totally avoid getting pregnant, this is the time to either use condoms or avoid sex. How does it work? It involves using a fertility app (Daysy fertility monitor) which contains data of millions of cycles. The app learns your cycle and compares your data to the database collected from other users. This mini computer predicts your ovulation day and fertile window. Daysy has a “getting to know you” period to collect enough data from your menstrual cycle, so I would suggest to use other contraceptive methods during the first 3-4 cycles. Every morning, before getting out of bed, you have to take your temperature using Daysy. Basal Body Temperature carries information about hormonal shifts and overall health. During ovulation your temperature drops due to a rise in estrogen, then it continuously rises after ovulation due to progesterone. This is the data leveraged by Daysy to get to know your cycle and predict your fertile period. Daysy fertility monitor is 99.3% effective.

There are many studies and research have been made on hormonal birth control which raises serious concerns on the long-term. Women are not fully informed by their doctors of the possible risk factors these pills hold in the long-term. Hey, there are other safe options involving getting to know your own body such as Fertility Awareness Method. If you are considering taking the pill for other reasons than preventing pregnancy, then you need to change your mindset about your symptoms. Those symptoms are signals from your body telling you that something is not right. Listen to them, instead of masking them. Your body is able to rebalance and heal itself if it has the right tools. Browse through my articles to find answers, and if you need more support, I am here for you.

References:

Obos Birth Control Contributors, December 14, 2013, A brief history of birth control in the U.S.

Hannah Nichol, February 2, 2017, Progesterone and progestin: How do they work?, Medical News Today

The society of obstetricians and Gynaecologist in Canada, 2021, Non-hormonal contraception, Female condom

The society of obstetricians and Gynaecologist in Canada, 2021, Non-hormonal contraception, Sponge  

Dr. Jolene Brighten, Beyond the pill, 2019, page 45-99

Lynn Kennan and Gerard Migeon, March 4, 2019, Birth Control, Blood Clots, and Untimely Death: Time to Reconsider What We Tell Our Teens?, The journal of witherspoon institute.

Medicover, 2021, Laboratory tests before the use of first contraceptive pill