Tuesday, June 14, 2011

Summer of the Pill

It’s summertime, and as we shed our winter layers thoughts turn not only to love and sex, but also regulating menstrual cycles, understanding premenstrual syndrome, and potential population variation in the pharmacokinetics of hormonal contraception. Or is that just me, as a ladybusiness anthropologist?

If my inbox is a clue I am not the only person who wants good information on hormonal contraception. Many women are on the pill, and they use it for many reasons, only one of them contraception. Remembering to take the pill or get a new prescription, deciding on the relative impact of the current side effects versus new ones one might get from switching, wondering if it’s really doing its job, wondering if it’s increasing or decreasing breast cancer risk… these questions are like a buzzing in the back of the head at all times for many reproductively-aged women and their partners. And they want the buzzing to stop.

Let me see if I can help. Let’s make the summer of 2011 the Summer of the Pill. Every week I will cover a different topic or answer a different question on the subject of hormonal contraception, in addition to my usual posts.

Want to suggest a topic or ask a question? Comment on this post, email me, or @ me on Twitter.

The first post should appear by this Friday.


  1. I've got one! I asked my doc once if I could skip the placebo week and continue with the real pills for 6 wks straight. (Who wants to be on the rag on a cruise?!) That was fine, but then I got a FAKE EXTRA PERIOD during the like 5th week of real pills, thereby totally freaking me out and causing me to need (psychologically, if not in reality - who knows?) backup for like another whole month.

    The question I'd like to ask is about when you are and aren't fertile in a general sense. It's hard to find an answer to this question that says more than "take the pills exactly as prescribed."

    I'd also be interested to hear about going OFF the pill and what happens as your fertility returns.

    Also why the hell I have to go pick them up every month. Give me a damn year's supply! Hell! Give me a two-year supply! What do you think, I'm selling them on the black market? /rant

  2. JMT, you've practically given me fodder for the whole summer, thank you! I will make sure and cover:

    -how fertility works/how the pill works
    -the implications of skipping the placebo week (or taking those Seasonale ones where you only get 4 periods a year)
    -resuming cycling after the pill
    -the politics of contraceptive prescriptions (maybe I can get someone to guest post on that one, that will take some research!)

    Thanks again, great questions!

  3. I would also love to hear more about the changes that happen after ceasing hormonal contraceptives. I was on the pill from age 15 to age 25, and stopped taking it about 18 months ago.

    When I stopped taking the pill, I experienced this terrible nausea whenever my stomach was empty -- friends who have been pregnant say it sounded like morning sickness! Definitely not fun, especially because even though I was off the pill, I was still trying to avoid pregnancy. I also have completely unpredictable cycles now, even though it's been 18+ months since I stopped taking the pill. I try not to worry about that after reading your great post on "irregular" cycles (and how they are not usually a sign of a health problem), but it's certainly inconvenient.

  4. I am trying to regulate this new cystic acne on my jawline that has happened since I turned 29/30 and have had to go off of Yaz/Loestrin (both of which kept my acne at bay). I am now on Ortho Tri Cyclen, but still getting the acne. Any suggestions? I don't know how much is related to my baby-making-age hormones and how much is related to the pill I am taking?

    Thanks, Doc! ;)

  5. Since women stop ovulating when they go on the pill, are we expected to have viable eggs and remain fertile for longer than we otherwise would? Or do we mature and then resorb the eggs, so that we're still going to run out at the same time as we would have otherwise?

    Related to this, what's the current consensus on whether competition/selection for the "best" eggs earlier in reproductive life accounts for the increase in chromosomal abnormalities later?

  6. I'm so glad you posted this, because as I type I have been having discussions with my doc on whether or not to discontinue the use of my birth control pill. I get headaches. A lot... and bad ones at that. My doc was saying that I should seriously consider going off the pill completely (and immediately) and opting for one with just progesterone or perhaps using an IUD. Honestly, I'd rather not using anything, but what's the alternative? I'm feeling a little cornered and am thinking of opting for an IUD instead of the pill. I'm interested to hear your take on this.

    Thank you!

  7. Wow, more wonderful questions. Yes, I will definitely talk about side effects, egg viability, and I will even see what I can do to learn about acne. And I will definitely write about non-pill alternatives like IUDs.

  8. I too have headaches and I'm meant to be going off the pill. Seriously if I go off that pill I'll get pregnant again. Thats harder to swallow than a few headaches. How serious is the headache/pill issue?

  9. I don't take seasonale, but take the pill and probably have 3-4 periods a year (whenever I feel like it or whenever they break through randomly). I've been on it 10 years now. When I started I was extremely irregular, and heavy for 3-4 weeks straight. When an OBGYN told me I could take the pill and "skip" that placebo week they didn't realize how amazing that was. I wonder how necessary even having a period at all is. I don't personally have intentions of pregnancy (childless by choice) but do worry about the long term effects of being on it for so long.

  10. I have heard that the pill makes you attracted to potential partners that you otherwise wouldn't naturally have been attracted towards. For some reason, whatever I read about this made me think that it was better not to take the pill, so that I would be attracted to those people who were the best fit for me (...as dictated by evolution, perhaps?). Have you heard anything about this? I can't remember where I read it... nor do I remember all of the details.

  11. Well Rowena, the headache thing is hugely variable -- some people get zero headaches, for others the pill makes the headaches go away, and for still others the pill causes headaches. So you will have to decide where you fit in, the severity of your symptoms, and whether it is worth trying to switch pills or try an alternative to the pill.

    Frautech, I will definitely make sure I cover what we know about long-term effects -- particularly breast cancer, because that's the one most people have studied. And Stephanie, I believe the issue is not that the pill makes you attracted to the wrong people, just that it blunts your attraction to the people who genetically might be the best fit. But I will have to read up on this and make sure I cover it as well!

  12. Oh yes! That sounds right! So interesting... Thanks Dr. Clancy!

  13. Great idea!
    1)I am very curious about the pathways and mechanisms that lead the pill to cause its side effects. What do we know about progesterone and estrogen receptors in the body and brain? And how they might lead to things like weight fluctuations, mood swings, cognitive changes, breast swelling…?
    2) Do people become less "responsive," to these side effects over time? And if so, does it have to do with up or down regulation of hormone receptors?
    3) On a personal note, I felt that I was not warned at all about risks and side effects associated with the pill. It was prescribed nonchalantly when I was a teenager. In retrospect, if I had known about the changes it would wreak on my body, I would never have taken it! Do you think there is a culture of nonchalance surrounding the pill? Is it not seen as a serious drug/treatment and what are the implications of this?

  14. I second something covering the minimized side effects of hormonal contraception. I've never taken "The Pill" - I'm terrible about taking daily medication - but I've been on "The Patch" and "The Ring." Both gave me ridiculous, constant migraines, digestive problems and horrible mood swings. It also killed my sex drive. My OBGYN assured me they would go away (they didn't in 6 months), and the hubby and I had to revert to condoms and abstinence during the middle of my cycle of all things. At this point, because of my body's wicked reaction, my OBGYN won't even consider the hormonal IUD.

    Someone else mentioned fertility, and that's always interested me. A girlfriend went off The Pill and it took her almost a year to get pregnant. I'm extremely fertile, apparently, and I was pregnant the very next cycle. I have zero science to back this up, of course, but I've noticed friends who have horrible side effects get pregnant sooner after stopping than friends who have almost no reaction.

  15. i spent a large portion of my adult life not taking the pill, as it was a choice my ex-h and i made. i've been on it for the last 5 years, and i hate it. the weight gain sucks (with the exception of added cleavage), and i find myself "weepy" right before my time. i have a consult next week about getting the paraguard IUD, and know i'm a good candidate. i'm so sick of messing with my natural hormone levels.

  16. I have another question. I've heard that there's some evidence (although I'm not sure how strong it is) that there is a correlation between having fewer menstrual cycles and reduced risk of breast cancer. (One of my friends, a biologist, used to argue that every non-reproducing woman should go on the pill for this reason.) I noticed that after using the pill for a couple of years, my cycle length was significantly shorter than it had been once I stopped - it used to be a very regular 28 days and now is about 25 (but still regular). So I feel like any periods I "saved" by being on the pill are being made up involuntarily. Is this common? If so, is there an established lifetime homeostasis mechanism of some kind?

  17. Becky, you ask some wonderful mechanistic questions, and I hope to try to get at at least some of them over the course of the summer. As for your last one, from some focus groups I ran in the spring it seems like patients' experiences of this are very mixed -- some encounter the nonchalance you describe, others have doctors who meticulously discuss everything.

    Anonywriter, I am surprised your doc said the symptoms would go away -- I'm not sure why they would! And I think your idea about fertility and different experiences of side effects are very interesting, and definitely testable!

    a -- yes, while there are plenty of women who absolutely love the pill and think it is perfect for them, there are a lot of women who are uncomfortable messing with their hormones. I hope you have a productive conversation with your doc, whatever you decide!

    Hi Anon, there is a link, and some good papers on it. But there is a big difference between fewer cycles due to exercise and/or many pregnancies, and fewer cycles because one is on the pill. The evidence for the former kind reducing breast cancer risk is strong. But the evidence for the latter, that the pill could reduce breast cancer risk, is actually mixed. I hope to cover this in a separate post because I need to do some research to make sense of what I have read so I can present it clearly!

  18. Could you please comment on the effects of hormonal contraception on sex drive? This is my main side effect of taking the pill and I was told by a doctor that it is extremely common but that they rarely try an alternative, and that I should just live with it. Is there an alternative method of birth control that might be better? Reading the other comments, there seem to be various side effects to the pill that can seriously affect quality of life but are dismissed by many doctors.