By April Segal, PharmD, APh, BCPS, Remedy Pharmacy Owner
There is no question that birth control pills have had a remarkable impact on women’s lives. They enhanced our opportunities to control childbearing and careers, allowed us to plan fertility independently of partners, changed family roles, gender relations, and premarital sexual practices. The emergence of the women's rights movement of the 1960s and 1970s was significantly related to the availability of the pill and the control over fertility it enabled (1).
So it is understandable that the pill is very popular. In 2018, 65% of U.S. women aged 15–49 were using a contraceptive method. By the end of their reproductive years, more than 80% of US women will have used oral contraceptives (OCs), for an average of about 5 years (2).
As a pharmacist I have seen another trend as to why we see so many patients on OCs. They tend to be prescribed now as a ‘catch-all’ for health conditions that are related to irregular cycles (ex. PCOS, Endometriosis), women who have more severe premenstrual symptoms (ex. PMDD). While I am happy to have OCs as a tool for these women, what I hate to see is underlying conditions not being fully addressed before jumping right to covering them up with OCs. I agree with Lara Briden, ND, who refers to a woman’s period at the 5th vital sign. If you are not cycling regularly, then it is something that should be investigated and treated, not covered up by synthetic hormones.
For women on OCs, for contraception OR other health benefits, there is an art and a science to selecting the correct pill for the woman. In this article, we will help you understand what factors there are to consider.
Breaking Down The Pill
Most birth control pills have 2 components - estrogen and progesterone. The type of progesterone and estrogen in the pill is not the same that naturally occurs in a woman’s cycle.
Estrogen Component - Dose Matters
Almost all pills contain the same type of estrogen - Ethinyl estradiol (EE), the only difference between different types of the pill is the concentration of EE in a pill. (There is one birth control that contains a bioidentical estrogen, Called Zoely, but it is not available in the US) In general, the less EE in a pill the better because it is the EE that is responsible for the increased risk of blood clots when taking birth control pills. The reason some women might require more EE is when they have spotting on days that they shouldn't. The lowest concentration of EE that pills have is 10 mcg (Lo Loestrin) and the highest is 50 mcg, however, these high doses are used more to help with women who have excessive uterine bleeding than for use for contraception. The general rule of thumb is the lower the EE the better. Estrogen is known to decrease low-density lipoprotein (LDL) and increase high-density lipoprotein (HDL), triglycerides, cholesterol, and SHBG. This last point is an important matter for those who feel they have a lack of libido on OCs. The higher your SHBG is, the lower your free testosterone is and that can be correlated to a lower sex drive in some women.
Progestogen - Type Matters
The progesterone component, unlike the estrogen, can vary in the type of progesterone used. There are about 12 different types and they all have slightly different effects, typically related to how “androgenic” they are. Androgenic means having androgen effects, or testosterone-like effects (think of sex-drive, facial hair growth, increased muscle mass and acne). The overall effect of all OCs are antiandrogenic, regardless of the type of progestin used, however. This can be good in reducing acne and facial hair growth as those are often not desirable but it can also lead to other symptoms related to androgen deficiency:
- lethargy (tiredness)
- loss of muscle mass and strength
- loss of libido
- lack of motivation
- low wellbeing
- lowered mood
If you think you are experiencing these symptoms you might want to consider going off hormonal OCs or considering a hormonal OC that has one of the below progestogens that are listed in the ‘High Androgenic Activity’ categories below.
Androgenic Activity of Progestogen in OCs
Norethindrone, Norethindrone acetate
Ethynodiol, Norgestimate, Desogestrel, Drospirenone, Dienogest
Besides for the estrogen dose and the progestogen components, there are a few more considerations when picking the best pill for you:
- Multiphasic vs Monophasic - Meaning do the “active” pill strengths fluctuate vs being monophasic where the strength of the EE and progestogen stay constant. In my experience there is not much benefit in the multiphasic and it can end up being more of a nuisance than anything.
- Continuous or Breakthrough Bleeds - Continuous use means skipping any inactive pills and taking a hormone pill every day and thus skipping the breakthrough bleed. Many women confuse a breakthrough bleed with a period, which it is not. When OCs were first approved the concept of the breakthrough bleed was to mimic a women’s period, but there is absolutely no medical need or advantage of having this breakthrough bleed. The only possible benefit is for a woman to be reassured that she is not pregnant (you will not have a breakthrough bleed on inactive pills if you are pregnant).
Side Effects of the Pill
Serious Risks: Blood clots are the most well known and severe side effect of OCs. That being said the risk is still very low, but increases in women who are obese, smoke or who are over the age of 35. OCs protect against ovarian, endometrial, and colorectal cancers, but do temporarily increase breast and cervical cancer (during use and up to two to five years after discontinuation).
Mood and Libido: Decreased libido and depressed mood are commonly reported by women on OCs. If you must use a hormonal OC, the best thing to do is use one with the lowest dose of EE (as explained above) and one with more androgenic effects. Also make sure to address nutrient deficiencies that can be caused by OCs.
OCs have been shown to lower the level of six nutrients - riboflavin, pyridoxine, folic acid, vitamin B12, ascorbic acid, and zinc. The reason why OCs cause this deficiency is not well understood but it seems to be related to an alteration in absorption, metabolism or binging of these nutrients. Typically the longer a woman is on OC’s the more severe these nutrient deficiencies can become. We always recommend OC Companion for women on hormonal contraceptives to help replenish these nutrients. This thoughtful formula also includes dandelion root and DIM to help support the liver in metabolizing the hormones as well as Beta Carotene to promote a healthy cervix, gamma-linolenic acid (GLA) to support healthy breast tissue, and a low dose of probiotic to help support a healthy vaginal microbiome.
Just how these nutrient depletions might affect you is hard to say but it is certainly true that if you are deficient in any of these nutrients, you will not be operating optimally at a cellular level and that can cause downstream effects. If you are curious about your micronutrient status we also offer full micronutrient panels, which can show you your individual levels of these nutrients.
Non-Hormonal Contraception Options
Many women come to me asking about non-hormonal contraception options. There is of course the standard barrier options - condoms, and cervical caps. There is one IUD that is non-hormone-based, it uses copper instead which interferes with sperm transport, fertilization, and prevention of implantation. Another method I am a big fan of is the Fertility Awareness Method (FAM), which involves knowing your fertile window and avoiding intercourse on those days. It is not for everyone, but when it is used it is definitely the most natural contraceptive technique. The Daysy device can be helpful for women who want to try FAM. Lastly, a new medication was just approved called Phexxi, which instead of using hormones, maintains a vaginal pH in an acidic range and decreases sperm motility. The only downside is that it is an on-demand birth control, meaning that you do have to use it just prior to intercourse.
Hopefully this information can help you select the right birth control for you. OCs are not perfect but they provide a level of freedom that it is hard to imagine not having. If you choose to use OCs remember the above tips to help minimize the side effects and nutrient depletions. In California Pharmacists have authority to prescribe OCs for our patients. If you are interested in booking a Birth Control Consultation with one of our pharmacists to obtain a prescription or otherwise optimize the OC that you are on, book an appointment here.
- Tyrer L. Introduction of the pill and its impact. Contraception. 1999 Jan;59(1 Suppl):11S-16S. doi: 10.1016/s0010-7824(98)00131-0. PMID: 10342090.
- Daniels K and Abma JC, Current contraceptive status among women aged 15–49: United States, 2017–2019, NCHS Data Brief, 2020, No. 388, https://www.cdc.gov/nchs/data/databriefs/db388-H.pdf.