The combined oral contraceptive pill (COCP), also known as “the pill”, is often touted as the answer to fixing hormonal imbalance. It is one of the main treatments for PCOS and many other hormonal conditions in those not wishing to get pregnant. But how much do you really know about the COCP? Only you can decide what is right treatment for you. You may decide that the COCP is the way to go but you should make an informed decision.
How the pill works
We are told that the pill contains oestrogen and progesterone, but it does not. It contains synthetic versions of these hormones. The molecules look similar to regular hormones, but they are slightly different. They don’t fit into our receptors in exactly the same way as our endogenous (naturally-produced) oestrogen and progesterone, and therefore they don’t have exactly the same effects. This is why the COCP inhibits pregnancy, while our endogenous hormones promote it.
The synthetic hormones in the pill work by blocking our hormone receptors, sending a signal to our brain that we don’t need to produce our own oestrogen and progesterone. Essentially, our endogenous hormones are switched off. The pill does not balance our hormones. It inhibits them.
Some COCPs also inhibit androgen production. They can reduce the androgen hormone testosterone by up to 50 per cent, thereby reducing symptoms of PCOS. Furthermore, the COCP ensures that women with PCOS shed their endometrial lining (the lining of the uterus) regularly. This is important for preventing endometrial cancer.
Whilst the pill has desirable effects on PCOS, when you come off the pill, the problems you had before will still be there. No one tells you this. You’ll still have the same sugar-handling problem (insulin resistance). You’ll still have the same tendency toward producing excess androgens. You’ll still have the same tendency toward problems with ovulation. In fact, the pill can make all of these tendencies even worse. The pill actually worsens insulin resistance.
Later, when you come off the pill it is often because you want to get pregnant, but when your problems with ovulation come back, you have problems becoming pregnant. Looking back, you have spent all this time masking the problem with the pill when you could have been fixing the problem other ways. Now, you will probably be told you need fertility drugs. This is not ideal; infertility quickly gets stressful, and stress hormones are also not good for fertility.
Side-effects of the pill
The COCP has a range of side effects that should be considered when making your informed decision on whether it is the right choice for you. To help you with this decision, you may like to consult this table for information on which contraceptives contain what type of synthetic hormones, while reading the information below.
It is now acknowledged that women on the pill have a slightly increased risk of breast and cervical cancer. This risk has been shown to be even higher if you carry the genetic mutation BRCA1. In fact BRAC1 carriers who began using the COCP before age 20 may have up to a 45 per cent greater risk of getting breast cancer than carriers who have never used the pill at all.
The fact that the COCP increases risk of breast cancer is often offset with the fact that it slightly decreases the risk of ovarian cancer. However, it is not recommended that BRAC1 carriers below the age of 25 use the COCP to reduce ovarian cancer risk due to the increased risk of breast cancer.
Women taking the pill have an increased risk of fatal blood clots. This risk is associated with all COCPs, but is highest with those containing cyproterone acetate (found in Diane 35 and Brenda 35, amongst other pills), drospirenone (found in Yasmin and Yaz, amongst others) and desogestrel (Marvelon 28). For this reason, it is not recommended that you take COCPs if you smoke or have an increased risk of blood clots for other reasons.
One reason COCPs cause blood clots is because synthetic oestrogens increase clotting factors in the blood. This has particularly been linked to the most commonly used synthetic oestrogen, ethinyloestradiol, in doses of 50mg or more, but synthetic progesterone has also been implicated too.
Since the pill was first released around 50 years ago, the dose of ethinyloestradiol in most COCPs has been lowered to 30mg or less, to help reduce the risk of blood clots. This was thought to be effective, however, then came the pill called Yaz. Yaz was released in 2006 and contained only 20mg of ethinyloestradiol. It soon emerged that Yaz increases the risk of deadly blood clots more than its predecessors. Not only that, it increases the risk of heart attack, stroke, high cholesterol and gallstones. These effects are thought to be due to the synthetic progesterone, drospirenone. Despite these consequences, Yaz is still being prescribed.
Insulin resistance and diabetes
Research suggests that the COCP can worsen insulin resistance and increase the risk of developing type II diabetes. This is thought to be due to the combined effect of the synthetic oestrogen and progesterone on blood glucose and insulin. The synthetic progesterone, cyproterone acetate, has been associated with an increase in insulin resistance in obese women with polycystic ovarian syndrome (PCOS), but not lean women with PCOS. The synthetic progesterone drospirenone and levonorgestrel (Levlen ED and Microgynon ED, amongst others) have also been linked to insulin resistance in the general population.
Studies have been unable to conclude whether or not COCPs cause weight gain. This is probably because they do for some women and they don’t for others. If you haven’t experienced weight gain on the pill yourself, you probably know at least some women who have. Some women also report cravings and increased appetite. This may be linked to insulin resistance.
Levonorgestrel and norethisterone cause hair loss due to their androgenic effect. This effect is not always reversible.
Decreased sex drive
Many women report lowered sex drive after starting the pill. Sex drive, or libido, is difficult to measure because there are many different factors that contribute to it: emotions, relationships, medications, stress, experiences, beliefs, body image and, of course, physical factors. This may be why scientific studies give conflicting results as to whether the pill decreases libido.
Furthermore, the effect of the pill on libido may differ from woman to woman. It is normal for our hormones, and therefore libido, to fluctuate throughout the month. Most pills deliver the same dose of hormone daily bar when we are on the inactive pills and having a bleed. Therefore we don’t experience heightened libido at certain times, like we did before. This may be one reason women perceive their libido to be lowered on the pill.
Pills that cause a decrease in androgens and an increase in sex-hormone binding globulin (SHGB) are also thought be behind lowered libido. Increased SHBG may persist beyond ceasing the pill, causing lowered libido to linger.
Our endogenous oestrogen has antidepressant effects due to it’s ability to affect neurotransmitters and the nervous system. Our endogenous progesterone makes us feel calm and helps prevents anxiety. Synthetic hormones suppress our endogenous hormones, which may leave us more susceptible to changes in mood. Again, this may differ from woman to woman and not all studies show links between the pill and depression, yet the reality is that many women on the pill report changes in mood and an increase in depression.
The pill can deplete B vitamins, vitamin C, zinc, magnesium and selenium. All of these nutrients are important for mental wellbeing and general health. If you do decide to take the pill it is important to take a high quality multivitamin containing these nutrients, as well as adopting a well-balanced, nutritious diet.
The synthetic estrogen in the pill promotes the overgrowth of a yeast normally found in our gut, Candida albicans. This is what causes yeast infections. Yeast infections tend to be recurring whilst on the pill, especially if we have a high sugar, high carbohydrate diet. But it’s not only the uncomfortable symptoms of having a yeast infection that we are dealing with whilst on the pill: the Candida overgrowth is a sign that we are losing a war in our gut.
Levels of protective, beneficial bacteria are declining, and it is not only Candida that is taking their place. Other nasty bacteria can overgrow causing a myriad of gut problems and worsening hormonal health.
How to make a choice
The pill has it’s downsides but still is a valid and useful form of contraception for many. You may decide that it is the best choice for you right now, but before you make that decision take a look at the alternative methods of contraception available and their pros and cons.
If you choose not to take the pill and you still need help with hormonal conditions see your naturopath.
Editorial note: we’ve written a book on how to solve PCOS, the PCOS Solution. You can find it here.