The "Pill” is often used to treat female health problems ranging from painful or irregular periods, acne, PCOS, peri-menopause, hormone imbalance, and of course prevention of unintended pregnancy.
It is so universally accepted that most women never stop to ask: 1. How does the pill work and 2. What impact is it having on my own hormone production? Chances are if you have ever stopped to ask this question to your doctor, you come off looking like a crazy person in need of some “hormone balancing”.
But I think they are valid question that we as women should be asking. Why don't men take contraceptive pills? There are certainly medications that can inhibit testosterone and sperm production. However, I am not too sure if low sex drive and depression as side effects would convince any man..
So is the pill actually treating these female conditions AND is its impact on our health as harmless as it seems?
This is what I asked myself about 5 years ago, after being on it for over 10 years. You might be surprised by what I learnt to these two questions.
The oral contraceptive pill is the most commonly used form of contraception amongst females of reproductive age. In the case of combined oral contraceptive pills (COC), they contain a synthetic progestin (eg. levonorgestrel, dienogest, drospirenone) and a synthetic oestrogen (ethinyloestradiol). In the case of the mini pill, or progesterone only pill, it contains just that a progestin like levonorgestrel or norethisterone.
The plethora of different COC pills (eg. Yasmin, Laila, Levlen, Yaz) usually reflects the different progestin combination with ethinyloestradiol. These different progestins have different properties and hence some are chosen for more specific purposes. Eg. cyproterone has greater anti-androgenic properties meaning that it suppresses androgen production more strongly and is often used in conditions associated with greater androgen production like acne, PCOS.
How does the pill work?
Before I answer this question let’s do a little dive (apologise it turned out to be a "not so little" dive. Feel free to skip ahead to the summary) into the complex world of female hormone secretion that occurs during the ovarian cycle.
So that we are all on the same page let’s simplify some terminology and get some perspective happening.
The hypothalamus = Think of this guy as the big brother to the soon to be introduced pituitary gland. Located in the brain, he is the controller. His primary goal is to maintain homeostasis in the body. He gets messages and feedback from hormones and the nervous system and speaks to the pituitary gland. The function of the hypothalamus is to secrete releasing hormones and inhibiting hormones that stimulate or inhibit production of hormones in the anterior pituitary. P.S. The only thing making him male is me.
The anterior pituitary = is also located up stairs in the brain and is responsible for secreting hormones that communicate to other endocrine = hormone producing glands that regulate a wide variety of body functions, including the release of sex hormones from the ovaries.
Now that we have some basic understanding of the who’s who in this hormone regulating world let's have a look at the complex interaction of hormones at play during our cycle.
Use this visual to guide you.
- On day 1 of the cycle (this corresponds with the first day of menstruation), rising levels of Gonadotropin Releasing Hormone (GnRH) from the hypothalamus stimulates an increase in the production of Luteinising Hormone (LH) and Follicle Stimulating Hormone (FSH) by the anterior pituitary.
- FSH and LH stimulate follicle growth and maturation in the ovaries and oestrogen secretion. As the follicles enlarge they produce more oestrogen within the ovaries.
- The rising oestrogen levels in blood exert a negative feedback (that is an inhibitory effect) on the anterior pituitary, inhibiting the release of FSH and LH, while simultaneously, prodding it to synthesise and accumulate FSH and LH. Within the ovary, oestrogen output continues to rise.
- Although the initial rise in oestrogen inhibits the hypothalamic-pituitary axis, high oestrogen levels have the opposite effect. Once oestrogen reaches a “critical” blood level it exerts positive feedback on the brain.
- The high oestrogen levels sets a cascade of events into place. There is a burst like release of accumulated LH (and to a lesser extent FSH) by the anterior pituitary about mid cycle (ovulation).
- This LH triggers ovulation at or around day 14. Whatever the mechanism blood stops flowing through the protruding part of the follicle wall and within 5 minutes, that region of the follicle wall bulges out, thins and then ruptures. Shortly after ovulation, oestrogen levels decline (probably reflecting the damage to the dominant oestrogen secreting follicle during ovulation)
- The LH surge also transforms the ruptured follicle into the corpus luteum, and stimulates this newly formed endocrine gland to produce progesterone and oestrogen almost immediately after it is formed.
- Rising progesterone and oestrogen blood levels exert a powerful negative feedback effect on the anterior pituitary release of FSH and LH. The corpus luteum also releases inhibin (a hormone) which enhances this inhibitory effect. Declining levels of FSH and LH inhibit the development of new follicles and prevent additional LH surges that might cause additional eggs to be ovulated.
- As LH levels fall, the stimulus for luteal activity ends, and the corpus luteum breaks down. As goes the corpus luteum so do the levels of oestrogen and progesterone.
- This sharp drop at the end of the cycle (days 26 to 28) end their blockade of FSH and LH, and the cycle starts again.
Pretty full on right?! And guess what? That’s only half the story. These hormones also exert their effects on the uterus lining (endometrium) and affect a whole host of other bodily functions.
In case your getting caught up in the numbers and the days, a normal menstrual cycle length is anywhere from 28 to 35 days and is compromised of 3 main phases.
1. Follicular phase. This starts on the first day of bleeding and can last for 7 to 21 days
2. Ovulation. This lasts for 1 day. Yep 1 day!!!
3. Luteal phase. Which should last exactly 14 days.
Ok so to go back and answer the original question which in case you had forgotten was how does the pill work, well quite simple, it inhibits all of the above.
The pill delivers a constant does of oestrogen and progesterone like compounds into the blood for usually 21 days thereby sending a message to the pituitary to inhibit the release of FSH and LH. The inhibition of these hormones prevents the development of follicles and the mid-cycle surge of LH and ovulation. Hence, there is no egg to be fertilised ergo preventing pregnancy from occurring.
That means, often women take a decade or more of synthetic hormones all to prevent this one day a month from occurring. Now I am not saying that the pill isn't a good idea at times for some people. I am all for giving people informed consent and letting them decide what is best for their life. I am just alluding to the idea that there may also be other options.
The pill bleeds that occurs when you stop the active pills are not the same as natural menstruation. The abrupt withdrawal of the synthetic oestrogen and mostly the withdrawal from the progestin induces a withdrawal bleed. They have been coordinated into a 28 day pattern to seem natural however they could just as easily be every 55 days (or any arbitrary number) if formulated that way.
The intricate cyclical mechanism described above, simple does not occur when you are on the on the pill. Let me repeat, if you are taking hormonal contraception and it is doing its job then you don’t ovulate and you don't have a natural period.
Why might this be a problem?
The big overarching problem to me is that the pill makes our natural, biological menstrual rhythm obsolete. Human biology organises it’s structures to achieve rhythm (eg. heart beat, circadian rhythm, etc). The natural hormonal signals, that are mapped to our monthly cycle rhythm, are critical to female health. If we lose this rhythm we lose normalised function. Period (punt intended).
Other problems include:
- The hormones contained in the pill are similar but not the same as your own hormones produced inside your body. Hence, their effects are not the same either. For example, ostradiol is a natural oestrogen whereas ethinyloestradiol is a synthetic oestrogen. Progestins are a group of molecules similar to pregesterone but are not the same as natural progesterone.
- Our sex hormones don’t just effect our period and fertility. The affect other important areas in our body.
- Mood: oestrogen has a mood boosting effect through it’s influence on serotonin, oxytocin and dopamine release. Progesterone acts as your natural anti-anxiety hormone via it’s effects on stimulating GABA
- Metabolism: Oestradiol positively affects how insulin works in our body and therefore helps us to convert food into energy. Progesterone influences thyroid function and increases metabolic rate.
- Healthy bones: oestrogen stimulates bone formation and prevents its breakdown
- When you stop the pill your natural cyclical production and communication between your brain and ovaries needs to be established. This can happen quickly and effortlessly for some and more often than not women feel better, have improved mood, less headaches and find it easier to lose weight.
- However, for others this can take some time and the length of time depends on so many other factors including: your hormonal status before you went on the pill, how long you have been on it, your nutritional status, liver health, gut health and more.
- During this time you are not getting the effects from the synthetic hormones nor your own natural hormones. This can leave a gal feeling pretty shitty. Symptoms can include:
- Think a flare in sebum production resulting in working skin (sometimes enough to make you question if coming off it is worth it)
- A surge in androgens (think testosterone) which if you had PCOS beforehand this can flare symptoms up
- No ovulation and hence non of the positive effects of oestrogen and progesterone
- Painful PMS symptoms
- If you were placed on the pill for a medical reason, and the underlying causes were never addressed, then this medical condition is likely to recur once stopping.
- Not only does the pill suppress ovulation, it also suppresses testosterone production. As you may already be aware of, testosterone isn’t only important for males, it is also important for females - think libido, mood, bone health, and energy.
- In addition, the pill increases thyroid and sex hormone binding globulin, which bind to the available thyroid hormone and testosterone in the blood rendering them unable to do their jobs. Unfortunately, SHBG remains elevated even after stopping the pill and may never return to normal levels :(
What's a gal to do if she has come off the pill and still has no period?
- Try not to panic, it can take some time. However, also don't be complacent. Whilst it might seem like a nice idea to not have a period for a year, the reality is, that your period and your ability to ovulate each month is a sign of not just good fertility but also good health. Remember these hormones don't just benefit fertility but also a host of other things in your body.
- Ask yourself, what were your periods like before you went on the contraceptive pill? If you never had a regular or proper period before you went on the pill, then the likelihood of the pill being the cause of your lack of period now is low. You will need to work with a doctor or practitioner to establish the underlying cause of your irregular or absent periods.
- If on the other hand you had normal periods, you may be experiencing a type of post pill ammenhorea or post pill PCOS. Both of these conditions are rarely treated unless fertility is the goal, which in my opinion is simply not good enough. Regardless of whether having a baby is our priority, all women should have the right to optimal hormone balance, don't you think?
I hope this provides you with “the other side of the story” so that you can make an informed decision and appropriate action for your own health.
Reestablishing a healthy monthly hormonal flow can do wonders to your physical and mental health. If you need help getting your post pill period back, then please reach out.