Friday, September 19, 2014

PCOS and Birth Control Pills, Part 1: Information about Oral Contraceptives

In previous posts, we have talked about PCOS (Polycystic Ovarian Syndrome). We discussed its definition and symptoms, how it presents, its testing and diagnosis, and its possible causes.

Then we began discussing common treatment protocols for PCOS, and the pros and cons of each. We are discussing treatment options from a size-friendly point of view (meaning no diet talk, no weight loss promotion).

We've already discussed insulin-sensitizing medications like metformin, the TZDs, and inositol. Then we discussed glucose-lowering medications for those who have developed overt diabetes.

Now we are discussing treatments for PCOS, especially those for regulating the menstrual cycle. We talked about progesterone treatments for bringing on a long-overdue period; now we talk about using birth control pills to regulate the menstrual cycle, reduce androgen levels, and control unpleasant PCOS symptoms like hirsutism, acne, and alopecia.
Disclaimer: I am not a medical health-care professional. While the following information is based on my best understanding of the research, always do your own research. This information is not a complete explanation of all the risks and benefits of a particular medication, nor is it medical advice about a health condition or treatment. Consult your healthcare provider before making any decisions about your care plan.
Trigger Warning: Passing mention of the possible weight effects of several medications and of weight loss as a treatment for menstrual irregularity.
Treating for Menstrual Regularity

Many women with PCOS experience irregular periods, often because of progesterone-deficiency. They don't produce enough progesterone to bring on a period and flush out the uterine lining. They tend to be estrogen-dominant, and as a result, that remaining uterine lining is exposed to an excessive level of estrogen for prolonged periods. This can lead to abnormal overgrowth of the uterine lining and eventually, endometrial cancer in some.

Therefore, one of the most important treatment goals in PCOS is to regulate the menstrual cycle. There are two reasons that this is important:
  • to reduce the overgrowth of the endometrium and thereby reduce the chance for endometrial cancer later in life
  • to improve ovulation for the purposes of fertility (if children are desired)
If you've gone a long time without a period, many doctors will choose to use a progesterone medication to "flush out" the uterine lining before trying other medications and treatments to regulate the cycle.

But once the endometrial lining has been "flushed out," the most common medication used by care providers for PCOS is the birth control pill, or The Pill. Oral Contraceptives regulate the menstrual cycle and makes sure your body has a period every month. Most doctors see this as THE treatment of choice for cycle regulation in PCOS.

Remember, although the focus of these post is oral contraceptives, there are alternative treatments out there for regulating menstrual cycles.

These can include lifestyle approaches that are compatible with Health At Every Size® (like moderating carb intake, enhancing nutrition, increasing exercise, avoiding gluten), acupuncture, herbs like vitex/chasteberry, insulin-sensitizing medications like metformin and inositol, and perhaps vitamin D supplementation.

Women with PCOS should also be checked for hypothyroidism. A number of studies have found that women with PCOS have a higher rate of abnormal thyroid function. Some studies suggest that hypothyroidism is associated with menstrual disturbancesinsulin resistance, and infertility. A number of women with PCOS have found that treating even marginal cases of hypothyroidism helped improve menstrual regularity.

Of course, as anyone who has read traditional PCOS medical advice knows, care providers usually strongly promote weight loss for regulating menstrual cycles. They push the idea that "just a 5-10% weight loss" can improve menstrual regularity and fertility, although it remains unclear what type of diet is most optimal, nor that this type of weight loss results in long-term meaningful health effects or sustained weight loss.

It's true that weight loss can be effective in resuming ovulation for some women but remember that studies on this are often extremely small and very short-term. They typically do not show long-term results, nor do they show what happens if weight loss rebounds to more with time (as so often happens). Nor do they acknowledge that weight loss/weight cycling can have risks as well as benefits (see the Weight References section of this blog).

Nor is weight loss effective for regulating the periods or easing PCOS symptoms in everyone; a number of women with PCOS still experience missed periods and significant symptoms even after considerable weight loss. One research meta-analysis noted a distinct lack of high-quality research that examined clinical reproductive outcomes; in other words, it hasn't really been proven that significant weight loss results in more pregnancies and live births. And some research suggests that rapid weight loss or very low calorie diets could even be harmful in obese women undergoing infertility treatment.

The bottom line is that weight loss is another tool that can be considered if you wish, but weight loss is far from the magic bullet that doctors like to pretend it is. For many, it may actually be counter-productive, resulting in far more weight in the long run from rebound. For others, it can lead to eating disorders and unhealthy behaviors. Weight loss for PCOS should not be mandatory, nor should weight loss be a requirement for accessing fertility services or other treatment. 

Remember, there is no one "right" treatment protocol. Each woman must find the right combination of treatments that work best for her circumstances and needs.

For some, this may include oral contraceptives/birth control pills.

Birth Control Pills

Oral Contraceptives are helpful in regulating the menstrual cycle by providing the progesterone each month to prevent endometrial hyperplasia (overgrowth of the uterine lining) and to help bring on your period:
In PCOS, ovulation does not occur regularly, which prevents the rise and fall of progesterone which brings on a woman's period. Instead, the lining is not shed and is exposed to estrogen for a longer period of time causing the uterine lining to grow much thicker then normal. This can cause heavy and erratic bleeding. However, this is not a true period because ovulation has not occurred. Over time, lack of exposure to progesterone may cause endometrial hyperplasia (a fancy word for overgrowth of the uterine lining) which in rare cases can lead to endometrial cancer. Taking the birth control regulates your menstrual cycle by providing the progesterone that your body needs, causing the uterine lining to be shed frequently and reducing the risk of endometrial hyperplasia.
The advantage of The Pill is that it:
  • provides your body with the hormones it needs to have a normal cycle
  • prevents the build-up of uterine lining
  • lowers your chances for endometrial cancer later on, and probably for ovarian cancer too
  • provides contraception until children are desired
  • has an anti-androgenic effect, lessening acne and hirsutism for some
  • may also lessen the severity of symptoms in those who experience difficult and painful periods
The Pill should be taken every day, and at the same time every day, for it to be most effective.

The last few days of the cycle are typically sugar pills (placebos), to enable your period to start afterwards. Even though these have no hormones in them, using sugar pills keeps the habit of taking a daily pill going so there are no inadvertent gaps in coverage. (Not all types of oral contraceptives have a placebo with them, but most do.)

As a contraceptive, the Pill works in the following way:
Hormonal contraceptives (the pill, the patch, and the vaginal ring) all contain a small amount of synthetic estrogen and progestin hormones. These hormones work to inhibit the body's natural cyclical hormones to prevent pregnancy. Pregnancy is prevented by a combination of factors. The hormonal contraceptive usually stops the body from releasing an egg from the ovary. Hormonal contraceptives also change the cervical mucus to make it difficult for the sperm to find an egg. Hormonal contraceptives can also prevent pregnancy by making the lining of the womb inhospitable for implantation.
Our purpose in this post is not to discuss the pros and cons of the Pill as a contraceptive, but instead its utility for regulating the menstrual cycle in women with PCOS, as well as its anti-androgenic benefits.

Some basic information about the Pill's contraceptive properties is given in this post as a introduction to the subject, but it is by no means a complete discussion of the pros and cons of the Pill as contraception. Nor is this intended to be a discussion of potential ethical issues around oral contraceptives.

A thorough discussion of the Pill as contraceptive is a whole different post and not part of the mission of this blog, except in discussing the implications of its use in women with PCOS/women of size.

Our focus here is primarily on the pros and cons of the Pill for menstrual cycle regulation and treatment of PCOS symptoms. Please keep that in mind as you read and comment on the post.

Types of Birth Control Pills

There are many birth control pills to choose from. Unfortunately, a really complete discussion of types of birth control pills is far beyond the scope of this blog, especially since types of birth control pills change over time, but you can read some summaries about them here.

Basically there are two main types of pills:
  • Combination pills, which use a combination of progestin and estrogen
  • Progestin-only pills 
Combination Pills

Combination pills have both progestin and estrogen, and are about 99.9% effective, if used correctly. This drops to around 91% or so if they are used less than perfectly.

There are a number of different versions of combination pills, as written about here:
Combination pills can be differentiated on whether the dose of estrogen progestin stays the same throughout the pill pack (monophasic), if progestin increases once about halfway through the pill pack while the estrogen stays the same (biphasic) or if the levels of estrogen and progestin are different each week of the pill pack. 
Keep in mind that in each of these types of pills, the last week is only a sugar pill, which contains no active hormone. This allows for normal shedding of the uterine lining. 
Monophasic pills can be classified further based on the dosage of estrogen, known as ethinyl estradiol, in the pill. Low dose oral contraceptives contain 20mcg of estrogen plus the progestin. Regular dose contain(s) 30mcg to 35mcg of estrogen plus progestin and high dose contain 50mcg of estrogen plus the progestin.
The first generation of oral contraceptives contained ~150 micrograms (mcg, or ยต) of estrogen (ethinyl estradiol). Starting in the late 1960s, the estrogen dose was strongly reduced in order to improve efficacy and safety and to decrease side effects. Compare the numbers above; it's amazing how much lower the doses tend to be now (20-50 mcg vs. 150 mcg).

Another difference between combo pills can be the type of progestins that are used in the pill. As of now, these are the different types of progestins used in most combined pills; each with its own pros and cons:
  • Desogestrel
  • Norgestrel
  • Levonorgestrel
  • Norethindrone
  • Norethindrone acetate
  • Ethynodiol diacetate
  • Norgestimate
  • Drospirenone
Some of these progestins have strong androgenic effects (Norgestrol, Levonorgestrol, and to a lesser effect, Norethindrone and Norethindrone acetate) so most women with PCOS may be better off with a combined pill that uses other progestins.

Another couple of progestins (cyproterone acetate and dienogest) that have strong anti-androgen effects are available in combined oral contraceptives for use outside of the United States but are not available in the U.S.

Each combination pill has its own benefits and risks, and it is far beyond the scope of this post to discuss the pros and cons of each. Discuss the choice of combo pills in detail with your care provider, and then do your own research on your own as well. You can find discussions of the pros and cons of the various Pill choices here and here.

So, to summarize, combo pills differ in three main ways:
  1. Dose of estrogen used
  2. Types of progestins used 
  3. How the relative dose of progestin/estrogen changes (or doesn't change) during the month
The wide variety of combo pills available offers women many choices to see which suits their needs best. Women who experience uncomfortable side effects on one type of pill may well find that another type suits them better.

A careful and thorough consultation with a care provider is vital to using oral contraceptives wisely. Don't be afraid to get a second opinion.

Progestin-Only Pills

Progestin-only pills (also called the Mini-Pill) do not contain estrogen, unlike combination pills. They are usually prescribed for breastfeeding women (since estrogen can inhibit milk production, especially in the first few months after birth), and sometimes for those who experience nausea with estrogen. As a contraceptive, Mini-Pills work in the following way:
Mini pills work by thickening the cervical mucus so the sperm cannot reach the egg. The hormone in the pills also changes the lining of the uterus, so that implantation of a fertilized egg is much less likely to occur. In some cases, mini pills stop ovulation (the release of an egg). A pill is taken every day.

If mini pills are used consistently and correctly, they are about 95% effective -- somewhat less effective than standard birth control pills.
It is vitally important to take the Mini-Pill at the same time each day for the best efficacy. Any deviation from this timing can substantially reduce its effectiveness. Missing a dose also significantly increases the chances of inadvertent pregnancy and a back-up method should be used.

Because obese women are at higher risk for blood clots and the estrogen in combined pills can increase the risk for clots, some care providers prefer progestin-only oral contraceptives for this group. ACOG suggests considering progestin-only pills or IUDs with hormonal components for obese women, but does not rule out use of combination pills for this group.

While progestin-only oral contraceptives can help treat irregular periods so common with PCOS, they will not help reduce acne or hair growth issues. Therefore, progestin-only mini-pills may be useful for some women with PCOS, while others will prefer combination pills. Still others will choose to avoid oral contraceptives completely and use alternative methods to promote menstrual regularity and reduce androgenic side effects.

Side Effects and Contraindications

Like any medication, the Pill does come with side effects, contraindications, and interactions with other medications that users should be aware of.

Side Effects

The most common side effects are fairly minor:
  • Nausea
  • Weight gain
  • Sore or swollen breasts
  • Spotting between periods (especially with the Mini-Pill)
  • Lighter periods
  • Mood changes
Some women also report an increase in headaches and blood pressure while on The Pill. 

Some side effects are potentially very serious and need immediate medical attention. They can indicate problems such as liver or gallbladder disease, stroke, blood clots, heart disease, or hypertension. You can remember these by the acronym, ACHES:
  • Abdominal pain (stomach pain)
  • Chest pain
  • Headaches (severe)
  • Eye problems (blurred vision)
  • Swelling and/or aching in the legs and thighs
The risk for blood clots with the Pill seems to be greatest in the first year of use.

While the risk for blood clots, heart attacks and strokes with the Pill is higher than in women who do not use the Pill, it's also important to remember that the actual numerical risk is small, and is less than the risk for blood clots during pregnancy.

Low-dose combo pills seem to have less risk than higher-dose pills, and the risk for blood clots seems to disappear once oral contraceptives are stopped.

Some women who experience negative symptoms with one type of The Pill are able to tolerate a different type better, so it can be useful to try switching if you are bothered by side effects. Sometimes just waiting a few months or taking The Pill with meals (or in the evenings) is enough for side effects to lessen.

Side effects with the Mini-Pill tend to be less severe than with combo pills, but the trade-off is that it is somewhat less effective and can worsen depression in those already experiencing depression.

On the other hand, some women find that the Pill just doesn't feel right to them because of side effects. They may need to consider other options instead for regulating their cycles or birth control.

The question of whether the Pill increases a woman's risk for developing diabetes is more difficult to answer. Some studies have found an increase in insulin resistance/decrease in insulin sensitivity in women on oral contraceptives, while other studies have not. Some have found an increased rate of diabetes, while others have found lower blood glucose levels or no increase in diabetes cases.

Since there are so many formulations, a lot depends on the type of oral contraceptive used; high-dose combination pills (30+ mcg of ethinylestradiol) seem to have a more negative effect on insulin sensitivity. Low-dose pills seem to have less effect.

If there is an effect in most women, it probably is a very modest one, especially with low-dose combination pills. However, if you are borderline already, some types of oral contraceptives may increase your susceptibility to diabetes or glucose intolerance.

Some care providers prescribe a combination of low-dose combination oral contraceptives (for their anti-androgenic effects) and metformin (to help counteract any increase in insulin resistance from the oral contraceptives) for women with PCOS who they feel are particularly at risk for diabetes and metabolic syndrome. 


Women who should not take The Pill include:
  • Women over the age of 35 who smoke
  • Women who smoke
  • Women who have a history of blood clots 
  • Women with serious heart or liver disease
  • Women with serious heart valve problems
  • Women who have had breast cancer, uterine cancer or liver cancer
  • Those with brittle, severe, or long-term diabetes with complications
  • Those on prolonged bed rest
  • Those with a history of migraines with auras
  • Those with uncontrolled high blood pressure
  • Those who had cholestatic jaundice of pregnancy or jaundice with previous oral contraceptive pill use
Whether women with certain other conditions should use oral contraceptives is controversial. These conditions include lupus and poorly controlled hypertension.

Non-smoking women over age 35 is another controversial category. Doctors seem to be leaning towards the view that low-dose combination pills are relatively safe in this group, but that counseling should be individualized based on the woman's personal medical history.

Blood clots may be a significant consideration for women with PCOS on the Pill.

Research shows that women with PCOS tend to have a higher risk for blood clots than the rest of the population; the concern is that use of the Pill in women with PCOS might elevate that risk even further.

And in fact, one study showed that women with PCOS on the Pill had about twice the risk for blood clots as other women on the Pill, and an increased risk compared to women with PCOS not taking the Pill.

However, not all studies agree; some studies have found oral contraceptives to be protective against blood clots in women with PCOS.

All women with PCOS who are considering the Pill should discuss the risk for blood clots with their care providers. If you have further risk for clots, such as a first-degree relative who has experienced blood clots or poorly-controlled hypertension, you will need to consider the use of the Pill especially carefully with a care provider.

Interactions with Other Medications

It's important to remember that some medications may interfere with the efficacy of the Pill, including certain antibiotics, anti-fungals, anti-seizure meds, anti-depressants, and others.

In addition, some "natural" remedies like soy and St. John's Wort can also lessen the effectiveness of the Pill. Vomiting and diarrhea may also cause problems with intestinal absorption, as can weight loss surgery procedures like gastric bypass.

Some evidence also suggests that TZDs (insulin-sensitizing medications like Avandia and possibly Actos) can decrease the effectiveness of oral contraceptives. Since some women with PCOS may be treated with TZDs as well as birth control pills, this is an important possibility to discuss with your doctor.

You can read more about medications that may interfere with the efficacy of oral contraceptives here.


Most traditional care providers consider oral contraceptives as one of the best first-line treatments for PCOS.

They help regulate menstrual cycles, prevent endometrial hyperplasia, reduce the risk for endometrial cancer, and probably also decrease the risk for ovarian cancer. In addition, some oral contraceptives have an anti-androgenic effect, so problems such as hirsutism and acne may be lessened while on the Pill. These potential benefits are considerable and should not be shrugged off lightly.

However, it's important to point out that some women with PCOS feel that oral contraceptives are merely a band-aid approach to PCOS and may even be harmful. We will discuss that in more detail in the next post, but be aware that while most care providers consider oral contraceptives to be the treatment of choice for PCOS, some in the PCOS field believe they are counter-productive.

If you choose to use them, oral contraceptives come in a dizzying array of choices (monophasic, biphasic, triphasic, low-dose or regular-dose estrogen, type of progestin used, etc.). There are so many choices available that it is vitally important to consult a care provider who is extremely well-versed in the pros and cons of each to decide which might be the right choice for your situation.

Although the estrogen levels have been significantly decreased over time, there is still an increased risk for blood clots with oral contraceptives. These risks seem to be particularly potent in women who smoke and in those with a family history of blood clots. Other groups have some increase in risk as well, so it's important to consult a care provider who can examine all your individual risk factors when considering whether to try an oral contraceptive.

It is not clear at this time whether oral contraceptives present particularly high clotting risks for women with PCOS. Some research suggests that it does, but not all research agrees. This is an area that needs much more research, given how often oral contraceptives are prescribed for menstrual regulation in women with PCOS.

Remember that while oral contraceptives and/or progesterone treatments can be helpful in PCOS, they are not your only choices for treatment. For some, they can be the best choice; for others, they are not.

Some women with PCOS benefit most from a combination approach (oral contraceptives plus other medications like metformin), while others get the best results from alternative protocols (herbs, lifestyle modifications, alternative medicine). For some, weight loss is helpful (at least temporarily), while others do not gain much benefit from it and may even incur harm from it.

The point is that there are no clear answers as to the "best" protocol for treatment of PCOS. Most women find they need to experiment with several different approaches to find the best combination for their individual needs.

And of course, you always have the right to determine the best treatment protocol for your needs. While a knowledgeable care provider can be truly invaluable in this process, there are no protocols that you "have" to follow just because you have PCOS.

YOU are always the ultimate boss of your own body and your own treatment choices.


References About PCOS
General Information about The Pill
Information about Different Types of The Pill
Information about Side Effects of The Pill

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