S1 E16: The Impact & Side Effects of Hormonal Birth Control


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Amanda: Hey, this is Amanda, women’s health dietitian.
Emily: And I’m Emily, nutritional therapy practitioner.
Amanda: And this is the Are You Menstrual? podcast where we help you navigate the confusing world of women’s hormones and teach you how to have healthy periods.
Emily: Each week we will be diving into a different topic on women’s health and sharing our perspective using nutrition, female physiology, and metabolic health.
Amanda: Our goal is to help you wade through conflicting health information and empower you on your healing journey.
Emily: We hope you enjoy it.

Emily: So far on the podcast, we have discussed a wide variety of topics spanning women’s health and hormones, from mineral balance and metabolic health to PCOS and menopause. But one area that we have yet to cover is birth control, which we realize is hugely important to most women in their childbearing years. A whopping 80% of women will take the pill at some point in their lifetime. And for that reason, we didn’t want to go any longer on the show without speaking about it. So in this episode, we’re going to be covering what you need to know about hormonal birth control, specifically, including the different types, how hormonal birth control works to prevent pregnancy, and the specific impact each type can have on the female body. 

Amanda: And this is something that’s had a huge impact on myself, personally—it’s, hormonal birth control, particularly the pills are really big part of my hormone healing journey. It’s what kind of sparked my whole interest in this world, because I came off the pill and was just a complete mess, didn’t get my period, my hair was falling out, had acne, I was diagnosed with PCOS…and it, no one could help me. So it really is, kind of sparked my entire interest in switching my career path to women’s health. And it’s a huge part of the majority of the clients that I work with. Like, most women that I work with have been on some type of hormonal birth control. And I don’t want anyone to ever feel bad about taking whatever form of birth control it is that has worked for you in the past or even that you might be taking right now. I took the pill for seven years. And then I had a copper IUD for seven years. And I don’t regret it. Sometimes I do. Sometimes I’m like, I wish I didn’t do that, because it took me a really long time to get rid of estrogen dominance. But I think you kind of have to do the best you can with what you have. And that’s why we like to talk about topics like this. And we’re going to have another podcast on fertility awareness method with my friend Nina. 

You know, it’s, hormonal birth control is important to have access to—it helps us avoid pregnancy. Like for me, I was in college, and it let me finish college, start my career without having a baby, which was important to me at that time. So I’ve definitely since adapted and successfully use the fertility awareness method as my form of birth control. We’ll talk about that more in the next episode. The goal of today is really to just go into how different types of hormonal birth control work, because I don’t think this is made clear. When we talk to our doctor, I definitely had a very big lack of informed consent. And then possible side effects, because I think one of the big reasons I came off the pill was because I was dealing with feeling like I was like more depressed than normal. I didn’t feel like myself, and I couldn’t figure out where it was coming from. And I dealt with it for way too long. So it’s one of those things where it’s like, it’s important to know what the side effects are, because it just could mean that that’s not the best form of birth control for you right now.

Emily: So we are going to talk about the different types. But before that, let’s just kind of cover how hormonal birth control in general works to prevent pregnancy. And it does that by putting synthetic hormones into the body, which are very different from our natural hormones, to shut down your natural hormone production and stop ovulation. So just as a small recap, ovulation is when one of our ovaries releases an egg. And it’s the only time during our cycle that we can get pregnant with the exception of the five days leading up to this. So those five days with the ovulation day are known as your fertile days. And that’s because sperm can survive that long in the female body. So anytime from you know, five days pre-ovulation all the way up until the day you ovulate, you are potentially fertile, which means if you have sex that day, or on one of those days, you can get pregnant. So that’s just kind of a summary of how ovulation works.

But when you’re on the pill, you have no sex hormones of your own. So all of those beautiful, helpful hormones that lead up to ovulation are not there. And instead you have steroid drugs given to you as a kind of “hormone replacement”…so let me kind of repeat that. Okay, so because I really want you to understand what the pill does. Basically, the pill shuts down your body’s natural process of producing hormones, and replaces those helpful hormones with contraceptive drugs that do not actually have the same molecular structures or provide the same benefits as real hormones. These hormones trick your body into thinking it’s already pregnant. And I think it’s really important to say that Dr. Laura Briden, who I am a big fan of, she puts it as kind of like a “chemical menopause” that your body is going through when you’re on the birth control pill or any form of hormonal birth control. Most forms we’ll, we’ll talk about the different forms in a bit. Certain types of hormonal birth control don’t actually directly suppress ovulation, but they do tend to indirectly suppress it. And as I said, we’ll get into kind of the different nuances of all the types in a second.

Amanda: So why do we want to avoid suppressing ovulation? That’s really how we make progesterone. Right? Ovulation is the star of our menstrual cycle. You don’t technically need to bleed every month. I disagree with that. A lot of people say that, you don’t need to bleed every month, but you do need to ovulate. But I do think you need to bleed because it’s the only way you can get rid of iron. Right. And if you don’t know the concerns with iron, definitely check out our copper and iron episode. But you don’t, you’re not going to have those hormonal shifts that keep us, you know, healthy, thriving, feeling good. Progesterone is really what balances out that estrogen and it’s very metabolically supportive. So when we’re not getting that chance to ovulate and make progesterone to balance out estrogen and feel good and have good moods, good energy, good recovery, then we’re in this place where we’re not quite as balanced. We can be a lot more symptomatic. 

Ovulation is really key. I do think it’s important for long term health for women. You want to be making your own hormones for as long as you can, and you want to ovulate. When we don’t, that’s not how our bodies are designed to live, and when we use hormonal birth control to prevent pregnancy like that’s one thing. I think when you’re using it for symptoms and certain conditions that that’s not the best way—that’s not what it’s designed for. It’s designed to stop ovulation so that women can’t get pregnant. Most women are not using it for that, you’re, they’re using it for other menstrual issues, period pain, heavy periods, PCOS, acne, amenorrhea. You’re often the…endometriosis, another big one, you’re told to take the pill. And the thing to know if you’ve been prescribed the pill or any other form of hormonal birth control for one or more of these hormonal issues is that that birth control isn’t going to fix those problems. Right? It’s a bandaid, and when it’s removed, and you stop taking that form of birth control, all those symptoms are going to come back, which is what my experience was.

Emily: Right, and I actually had a very similar experience, Amanda, so I never was given the pill for preventing pregnancy, it was always about other things. For example, the first time I was on the pill, I was 16 years old. I had terrible acne. And I was put on Accutane. So the pill was a way to prevent pregnancy. So I guess I was using the pill to prevent pregnancy. Even though I wasn’t sexually active. You have to do that in order to take Accutane, and I’m sure many women who have had to take Accutane are very familiar with this or wanted to take Accutane because that was a big reason for getting on the pill. And I didn’t know any better at 16. So of course, I just did what my doctor told me to do.

But then the second time I was on the pill was in my early 20s. I think I was probably 22. And I walked into the OB office, she was a completely new OBGYN that I had never seen before. And she literally, I remember being in the room with her for maybe five minutes, she took one look at like my acne, I showed her that hirsutism I was dealing with, so like the unwanted hair growth, and without asking me about anything else, without asking me about my diet, without asking me about my health history, like nothing. It was literally just like she looked at me. She prescribed the pill. And so I kind of had, I didn’t feel right about that, like leaving her office like I, but I didn’t know how to advocate for myself. So of course I just, you know, filled the subscription or the prescription and went on my way.

And it’s funny now because I was on the pill for about a week. And I was having terrible digestion. I think for that entire first week that I was on it, I didn’t have one bowel movement. And that was, yeah, it was very strange for me. I was like, this is different. This is very off for my body. Like I feel very weird. And so I told my mom who I was living with at the time, I was like, I’m just gonna stop taking this because it’s, it’s not helping me. It’s hurting me. And I literally said that within the week that I started taking it and my mom got so angry at me. She was like Emily, you’re so stubborn. You just need to listen to your doctor. You keep going back and forth on what you want. And I was just, but I knew my intuition was telling me this is not helping. This is causing more problems. 

Looking back, because I was having PCOS symptoms I was prescribed the pill, but I even knew the second I started taking it. This is not the answer. And I didn’t even really know, I didn’t have any experience and knowing that hormonal birth control would increase my risk for inflammation, especially in the gut, which is what happened, hypothyroidism, which is what I was diagnosed with a couple years later, nutrient depletion, and insulin resistance. And these were all things that I didn’t realize I was already struggling with that were just going to be exacerbated by the pill. That’s just kind of one example of how you have to get to the root cause of what is making your symptoms happen. And things like PCOS and endometriosis, these hormonal conditions, it’s often the sluggish metabolism and the thyroid, like we’ve talked about many, many times before.

Hormonal birth control is not going to help these issues. And in a lot of cases, they end up hurting them. Which is why I just think, you know, we’re doing this whole episode just about being informed and knowing your options. What exactly is hormonal birth control? And what are your options. That’s what we’re going to talk about next. But just to kind of keep it simple for you, hormonal birth control is any form of birth control that uses synthetic hormones to prevent pregnancy. This is typically referring to things like tablets, patches, and injections, but let’s talk about the different types specifically. 

Amanda: So the pill I think, is the most common, and well actually, technically, I think the IUD is now, which is wild, but it used to be the pill was definitely the most common but all types of pills are going to—minus the mini pill—all types of pills are going to work by directly suppressing ovulation. You can definitely get some side effects from that. We’re going to go through some of the biggest ones once we kind of go through the different types of hormonal birth control. But when we think…the pill, that’s kind of like your classic, you suppress ovulation, so you’re not cycling, if you’re, when you’re bleeding, it’s a, it’s just like a withdrawal bleed. It’s not because you ovulated—a true period can only happen when we ovulate.

Emily: Another option is going to be the NuvaRing, which some of you are probably familiar with. So this is going to contain estrogen plus progestin, and that’s the synthetic form of progesterone. Similar to the pill, but it does have a higher blood clot risk, which we will talk about later on in the episode.

Amanda: And then the contraceptive patch, that has synthetic forms of estrogen and progesterone, and it has a pretty high risk for blood clots as well.

Emily: The mini pill or the progestin only pill does not directly suppress ovulation. It works by thinning the uterine lining and impairing cervical fluid to prevent pregnancy. So this indirectly suppresses ovulation in most women. But again, there are many, many side effects to the progestin only pill, and that includes things like irregular menstrual bleeding, acne, breast tenderness, decreased sex drive, depression, headaches, nausea and ovarian cysts. Yikes.

Amanda: And the other types of pills, like the combined pill, that’s, like, it has synthetic estrogen and progestin…that one does directly suppress ovulation. But, so I think that can be a little bit confusing, but most people on the mini pill progestin only ones are not ovulating. The arm implants are another pretty common one, these are actually progestin only as well, and they can also cause weight gain and excessive bleeding, which is why a lot of women get them removed. I do tend to see a lot of headaches with those as well.

Emily: Then there’s also the injection, it’s commonly known as Depo-Provera. So this is a high dose of progestin and the high dose suppresses our natural hormone production completely. So we’ve actually seen the worst side effects from clients who’ve used this form of birth control—weight and unstoppable weight gain, awful migraines, nausea, and a complete loss of their cycle. This also has an increased breast cancer risk.

Amanda: Yeah, I think the, the Depo shot is probably the most severe form of symptoms that I’ve seen from people as, as, as a result of getting that, like, no period for years. And, and like in, you know how they can they only last for like so long, a lot of people will still have some level of hormones long after. It’s just interesting how much of that can linger. And I think that is why it has such a strong impact on symptoms. Mirena or the Skyla IUD…these are devices that are inserted into the uterus that give off a small amount of progestin, so the synthetic form of progesterone—very, very different. I think I was even talking to someone the other day, and I was talking about taking progesterone, they’re like, oh, like the pill. And I’m like negative, not even close. Like the progesterone in the pill is acts more like an androgen in the body. They’re actually very, very different. And so it can sound like oh, I’m taking progesterone—you’re not, it’s, it’s not even close to that. And if you look at the chemical structures they’re actually very different.

The Mirena or the Skyla, these do work similarly to other progestin only methods, they have similar side effects. They can be pretty symptomatic, but they do prevent pregnancy pretty well. I think there’s some of the most effective ones, minus the copper IUD…that’s actually like the most effective, but we’ll talk about in a different episode because that’s not hormonal. They do still indirectly suppress ovulation, but they’re mainly preventing pregnancy by thinning the uterine lining and impairing cervical fluid. It’s interesting because a lot of women like after they’ve had their Mirena for a year, they do tend to ovulate more frequently. So the Mirena is probably the best form of hormonal birth control, where you’re still going to be able to ovulate. The only issue I have with this for a lot of people is that they’re not cycling, like they’re not bleeding. When you’re not bleeding, you have no way to get rid of that excess iron. And that can lead to a lot of symptoms as well. So once people have this for a year, typically about 85% of the women will ovulate about three quarters of the year, it’s a lot more frequent ovulation than you’re going to get from any other birth control methods. Some people have very strong reactions to it, some people do great. So I think the best birth control method is the one that, you know, works for you.

Emily: You know, we’ve just listed in pretty much all of the options for hormonal birth control. And it can be very daunting to figure out which one is best for you. And I think it’s very personal to each woman and just talking to your doctor. We do want to cover the not so great effects of these options, because that’s something that, like Amanda said, you don’t hear too much from your doctor. I definitely never did. We might sound kind of like Debbie downers in this episode on these options. I will say that since the Mirena doesn’t completely suppress ovulation, and you do end up ovulating more frequently afterwards, it is the one that we believe could be the best option for many women. That said it has been linked to depression and may reduce your ability to handle stress. The one thing that concerns many with this IUD, like Amanda said, is that they no longer get a period. Remember, the period that you get on the pill is what’s known as a pill bleed. So it’s not an actual period. So that’s not really a huge concern. For me, the big one is the depression risk for this one.

Amanda: Yeah, and it’s like I have a few clients that do choose the Mirena, works for them, it’s the only form of birth control that they feel okay on, maybe they’ve had difficulty preventing pregnancies in the past. So it’s like, that’s their chosen method, which is fine. They don’t get a cycle, like they’re not bleeding ever though. So they do, they donate blood a few times a year. And that is a great way to get rid of some of that excess iron. So that’s definitely an option. But it’s funny, because I’ll have some people that are the exact opposite. Like they as soon as they get the Mirena put in they feel terrible. So you have to experiment and see what works. I think there’s pros and cons of many different types. I think some of the benefits of all the forms, whether it’s pill, patch, injection, IUD, is that they do give women the right to birth control and to prevent pregnancy, especially like when you’re at a young age. And I do think that that’s important to have that option.

I think there’s other ways that I wish we were taught, and we, I wish we learned about our cycle and how our body works at a much younger age. I feel like I didn’t learn this stuff till I was like 22. I think I could have, if we were taught from a young age how the body works, it’s not, I don’t think it would be impossible to prevent pregnancies without hormonal use. We can suppress often stressful symptoms of certain conditions like endometriosis, or adenomyosis. Like some, for some women that have endo, birth control, like the pill is the only thing that’s allowing them to stay sane and minimize a lot of those symptoms. It doesn’t work for everyone. And there are, there’s some research that shows there’s a reduced risk of like colorectal, ovarian and uterine cancers. There’s definitely some benefits to hormonal birth control. But there’s some downsides as well.

Emily: Yeah, I was just gonna add, I know someone very close to me actually, who started taking birth control pill when she was very young, because she had undiagnosed endometriosis. But it was it was in the form of painful, painful periods. She was literally incapacitated for several days every month, she could not go to school, could not do anything productive…birth control actually really helped to take that pain away and basically shut off her hormones. She wasn’t cycling, she wasn’t having a period, so she didn’t have to deal with that. And it did serve her very well in that regard. But the downside was that she started actually getting really bad migraines after that and she’s been dealing with migraines ever since. It’s really unfortunate that you almost have to pick and choose, like, what would I prefer, right? The, the debilitating migraines or the debilitating period pain once a month? It is pretty upsetting. I feel like there should be better options, especially for people with endometriosis. And, and there are, we might have to do an episode on endometriosis in the in the future, because it’s a whole thing in and of itself. There’s a lot of women struggling with those with those symptoms of endo.

But let’s talk about the cons really quickly. So the cons, as we said, is going to be that it stops ovulation and prevents your body from cycling. So as Amanda mentioned, this is very essential for keeping us young and vibrant and healthy overall, because of that wonderful cascade of hormones that keep our body functioning correctly. You don’t make any of these hormones on your own. So when you’re on hormonal birth control, that’s not what’s happening in your body anymore. And that’s a problem because our hormones are protective of our health. And just as an example of this…I know we like to demonize estrogen a lot in the wellness space because of estrogen dominance, which a lot of women are dealing with where that estrogen is higher in relation to the progesterone. It’s actually important to know that estrogen is a really good health-promoting hormone. So it’s actually a happiness hormone because it stimulates your mood and your libido. And is important for pleasure as well as bone, muscle, brain, heart, and even skin health. So again, we like to, I feel like talk about the negative sides of too much estrogen a lot. But it’s really a good hormone to have in your body. You don’t want to be bottomed out on estrogen for sure. Progesterone on the opposite side, obviously, you want these balanced out, because progesterone is a calming hormone. And missing out on this one means possible interruptions in things like sleep, muscle building, not having enough of it can cause an increase in inflammation as well. So those are two cons is that you, you don’t ovulate and you don’t make these incredibly healthy hormones.

Amanda: And then of course, you know, the hormones in the pill are synthetic, so they’re not the same form as the hormones that we’re going to make in our bodies naturally. And this means that they can negatively impact our long-term health, such as an increased risk to stroke and blood clots and as well as certain cancers, which we’re going to talk about a bit more. But specifically, like, while some, it can prevent some cancers, it’s also been shown to promote more breast cancer, cervical, liver and uterine cancers. So luckily, I mean that the risk does reduce when you stop taking that form of birth control, it’s still something to keep in mind, you know, and it’s something to be aware of.

And I would say the other kind of con is a lot of birth controls have iron in them, especially on like the sugar pill days when you see the reddish pills, those are iron, and if it has Fe in the name, and you know, it’s gonna have iron in it. And a lot of those can have up to 75 milligrams of iron. So it’s, that’s significant. I think that’s why a lot of women have digestive issues. And I have some clients that they forgot to take a pill. So then they doubled up and then they’re like, in stomach pain all day, and like super bloated and crampy. And I’m like, probably because your pills have 75 milligrams of iron. And the iron accumulation is huge, especially if you have PCOS or endometriosis like those are, that’s a major concern and something that I would make sure if you are deciding to use the pill, and you have any sort of like, any sort of symptoms, like if you went on the pill for something like PCOS, acne, endometriosis, headaches, whatever, make sure your pill doesn’t have iron in it at least. So I would say that’s kind of like the other con. And then of course, if you’re not bleeding, then you have no way that you’re getting rid of iron, and women absorb a lot more iron than men. Because we typically bleed every month, it’s a way easier for you to accumulate iron in your body when you’re on the pill.

Emily: That’s so interesting. I actually, that was one thing that I did not know about the birth control pill was the iron thing. I knew obviously, if you aren’t having a period, I definitely knew that that was, that could be unhealthy or potentially dangerous because of the iron buildup. But I did not think about the birth control pill having iron itself so…

Amanda: And not all of them do, but a good portion ,I think some of the most popular ones do.

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Emily: Okay, so moving on, we do you want to cover in more depth the side effects. I know obviously we mentioned quite a few of them in the first half of the episode, but we just want to make sure that you know exactly what you’re putting in your body and how it may affect you, so that if you are currently on the pill or another form of hormonal birth control or considering getting on, you are not going to be totally blindsided by any of these things that could happen. Because I feel like you have to make the best decision for yourself, but as long as you know the risks and the way that you might potentially feel, that’s gonna help you make the best decision and just kind of go into it with more knowledge and education so that you can be informed and make an informed consent.

Amanda: And not think you’re crazy. I think, that’s like, literally all my doctors thought I was insane. And I was like, I can’t be the only one dealing with this. And the whole reason that I even figured it out was because I went online and I looked. I was like googling and looked things up and a ton of other women felt the same way. And then I dove into the whole, what does the pill do to your body? I didn’t even know that it suppresses ovulation. I felt so dumb, but I didn’t know, I just was taking it because I’m like, well, I don’t want to get pregnant. This is, seems like my only option. IUDs weren’t really big then. I had to beg to get the copper IUD. They were like, no, because I hadn’t had a kid yet. So they’re like, it’s not gonna fit. And I’m like, I don’t think that’s how it works. This isn’t to make anyone feel bad. This is just to, so that if you do decide to take something that you understand, like, oh, that maybe this, maybe I should try a different type. Because I started to notice this. And this actually is a side effect of taking hormonal birth control. It’s not meant to like, you know, freak anyone out.

Emily: Right, that’s, thank you. You said that way more eloquently than I was trying to. But yeah, so let’s just get into a few of them. The first one is definitely relevant to my story was the abdominal cramps and the bloating. So many women take the pill for PMS symptoms, which is ironic, because it turns out that one of the side effects of hormonal birth control is cramps. So if you’re someone who gets on the pill or anything else and starts experiencing these cramps, the bloating, and the digestive problems, which we’ll talk about in a bit, it can definitely be your, your form of birth control.

Amanda: Yeah, and I think one of the, it’s not funny, but like, it’s kind of funny, but like having a low libido from hormonal birth control, it’s like, but I’m taking, a lot of women are taking it so that they can have sex and not worry that they’re gonna get pregnant. But low libido is really common. Same thing, I think it has a lot to do with, hormonal birth control can decrease the size of the clitoris—it doesn’t make sense in my brain to take something that’s gonna make your sex life worse and your sex drive lower. The pill has been shown to decrease the size of your clitoris. And that’s why some people, when they start taking it, they actually have a harder time achieving orgasm. A study showed that after six months of oral contraceptive use, the frequency of sexual intercourse and orgasms were significantly reduced. Both the IUD and pill reduce the clitoris size. And I’m pretty sure if someone told me this, when I first went on it, I wouldn’t have done it.

Emily: Yeah, and I also said, think about this one in terms of, let’s just imagine a world in which we had birth control for men. And if a man walked into a doctor’s office looking for birth control, and then was told this side effect that he might have, you know, a, a reduction in penis size or, or just like a, you know, a reduction in libido. I feel like every single man, 100% of men would walk out of there saying no thanks. But of course, with women, it’s almost like well, that’s the burden we take, right? Like we have to prevent pregnancy. So that’s what we’re going to agree to. And I just, I don’t know, I just think that’s really unfair.

Amanda: Well, they did try to make a pill for men.

Emily: And didn’t it fail?

Amanda: I think it was 10% of the study group experienced depression, so they decided that it was unethical.

Emily: Oh see, okay, and this one is gonna anger a lot of you because our next side effect we’re talking about is depression, which I

Amanda Montalvo

Amanda Montalvo is a women's health dietitian who helps women find the root cause of hormone imbalances and regain healthy menstrual cycles.

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