In Our Control (12 page)

One reason that taking the Pill might make you pack on pounds is that
OCs may change the way your body metabolizes carbohydrates. This can have more serious implications than just excess fat: it makes it more difficult for your body to use sugar and increases insulin resistance. When this happens you are at greater risk for type 2 diabetes and cardiovascular problems.

The documented interaction of Pills with diabetes is a very serious concern.
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Hormones can negatively impact this dangerous condition in two ways: estrogen may increase glucose levels and decrease the body’s response, and progestin can cause the body to produce too much insulin. In women who have never had diabetes, either gestationally or otherwise, and who have no family history of the disease, these changes in blood sugar are usually quite small. Women who have diabetes are a different matter, and major international bodies like the World Health Organization suggest that this group may want to consider alternative contraception. If diabetic women choose to stay on the Pill, their doctors should monitor any changes that occur with use.

The Pill may be slightly less effective for women who are overweight when they start taking it.
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In their book
The Pill: Are You Sure It’s For You?
, authors Jane Bennett and Alexandra Pope point out that the threshold at which Pills become less effective is lower than most women realize—you don’t have to be seriously overweight to start having this problem.
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A recent study reported by the American Physiological Society studied how the Pill affects the ability of young women to gain muscle. A group of young women were placed on a ten-week workout regimen. Half of the girls were taking OCs and the other half were not. Scientists conducting the study monitored the workouts and at the end of the trial period measured hormone levels and muscle growth. The two groups gained muscle at different rates, and in different ways. Researchers concluded, “We were surprised at the magnitude of differences in muscle gains between the two groups, with the non-OC women gaining more than 60 percent greater muscle mass than their OC counterpart.”
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It is evident that the Pill interacts with weight, fat, muscle, and metabolism, and women deserve better research and more answers before their concerns on this subject are written off by doctors and health care professionals as misperceptions and self-fulfilling prophecies.

Liver and Gallbladder

As we discussed earlier, the Pill can be hard on the liver, which metabolizes the hormones and sends them in to the bloodstream. Sometimes bigger liver-related problems can develop. Jaundice, a condition in which the skin and the whites of the eyes become yellow, happens when there is a high level of the bile pigment bilirubin in the blood. Its presence generally indicates a problem with the liver or gallbladder. It is thought that estrogen and progestin can have a toxic effect on the liver, causing or exacerbating this condition. If your pills make you turn yellow, it is likely a sign that they aren’t right for your body. The condition goes away once pills are dropped.
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The American Diabetes Association notes that because the Pill can affect blood flow to the liver,
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and this is already a concern for diabetic women, the Pill may also exacerbate existing risks for developing kidney disease.
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This is another good reason for women with diabetes and blood sugar problems to consider alternative contraceptive methods.

The potential of pills to exacerbate gallbladder disease and gallstones has long been documented. This risk has declined with low-dose pills, and is very small,
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although it may be higher on certain pills, like Yasmin and Yaz. If you have had gallstones, or have a family history of gallbladder surgery, take this under consideration when considering hormonal contraception.

Bones

Scientists have studied the relationship between estrogen and bone health for many years. Before the results of the Women’s Health Initiative suggested greater health risks than benefits, postmenopausal women were routinely prescribed hormone and estrogen therapy to build bone mass and prevent fractures, goals the drugs have been proven to accomplish. Because of the effect of HT and ET on older women’s bones, many have theorized that taking oral contraceptives would prove to be a boon for young skeletons, too, creating healthier bodies that would be less prone to break in old age.

Jerilynn C. Prior, a Canadian doctor with years of experience on
women’s reproductive health, argues that the benefits of young women taking estrogen for bone health aren’t so clear. She explains, “A few years ago we showed that premenopausal Canadian women ages 25–45 who had used the Pill had lower bone density levels than women who had never used the Pill.”
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Another study found that women taking the Pill had more trouble achieving peak bone mass when compared with OC-free peers,
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and two studies found that women taking the Pill had 20 percent more fractures then women not using hormonal contraception.
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Significantly, even trials that find higher bone mass with OC use aren’t able to show that it reduces fracture risk.
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With such inconsistent evidence, taking the Pill to build bone mass is not a good idea, especially when less invasive interventions (such as exercise, good nutrition, and taking calcium) are more effective. Concerns that the Pill may actually damage long-term bone health are serious enough to demand more research. As we will see later, particular forms of hormonal contraception, like Depo-Provera, have been shown to be detrimental to bone health, particularly for young women.

Bowels

Crohn’s disease, an inflammatory bowel disorder, may be more common in Pill users. Women who have Crohn’s disease are at an increased risk for blood clots, and if the illness is severe it may mean that pill use is not a good idea. When inflammatory bowel disease happens with OC use, stopping hormones seems to resolve it in most patients.

Menstrual Effects: Period Regulation, Spotting, and Fertility

One reductionary, but clear, way of talking about how OCs work is to say that they suspend a woman’s monthly cycle. Women who go on the Pill often do so because they argue that it “regulates their period.” In fact, women on hormonal contraception don’t menstruate in the sense that other women do. The monthly bleeding, in this case, is more accurately
called a “withdrawal bleed,” and is the result of suddenly removing progestin from the body (which happens when women take the seven “sugar pills” included in birth control packs).

This has many consequences. A woman who goes on hormonal contraception because she is having bad or irregular periods eliminates the possibility that she can help detect what is going on through observing her cycle. Women who aren’t on hormones can chart their cycles, and in many cases figure out what is causing their problem. Victoria, a woman in her early twenties with PCOS, shared her story with me: “I started on the Pill when I was very young. Years later, when I started to worry about hormones, I went off. I was surprised when my periods were irregular—very irregular. I only get one two or three times a year. At this point a doctor diagnosed PCOS. Because I want to have a baby in the next few years, I am very glad to know that I have this problem. Infertility is a symptom of the problem, and now I feel like I can start to do something about it. If I had stayed on the Pill I would never have known.”
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Sometimes hormonal intervention may be a Godsend (for example, if you suffer from endometriosis, a condition that makes monthly bleeds excessively painful and difficult). In many cases, though, other solutions may be just as or more helpful.

Some argue, for example, that the Pill helps reduce iron deficiency anemia. Anemia is indeed a scourge in the developing world, where women struggle with parasites and other dangers that make them particularly prone to the problem. For these women, access to better sanitation and clean drinking water are much more imperative than access to hormones. Women in the United States and other developed nations don’t suffer from the illness at such high rates, and are able to manage it in many cases with simpler solutions (for example, by taking iron supplements). And many women in the West may actually have too much iron in their bodies—a condition which, according to Dr. Susan Rako, a critic of menstrual suppression, can lead to high blood pressure and other cardiovascular problems.
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Whether or not this is true, most American women do not need to take birth control pills to manage anemia.

The Pill is also said to help relieve painful menstrual cramping by cutting
the level of prostaglandins—fatty acids that help control muscle contraction and inflammation—in menstrual fluid.
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The small percentage of women who have such mind-numbing cramps that they are unable to function may indeed find that hormonal birth control is not just a relief, but an answer to prayers. But for women with milder cramps, taking the Pill to curb cramping is less of a medical decision and more of a lifestyle choice. Many find that taking a nonsteroidal, antiinflammatory drug such as ibuprofen can be just as effective against cramps as taking the Pill, since these mild painkillers also reduce prostaglandins.
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Another advantage of the Pill claimed by drug manufacturers is that it helps makes periods more regular. It is striking, then, that one of the top reasons women give for discontinuing pill use when they still need contraception is because of breakthrough bleeding and spotting.
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Breakthrough bleeding and spotting probably happens because the synthetic hormones in pills don’t properly stimulate the endometrium and its blood vessels after bleeding or maintain the endometrium until the end of the active pill cycle. Normal menstrual bleeding involves shedding a relatively thick lining. When you start hormonal contraception, the lining gets thinner, and while the body is adjusting, there can be unscheduled bleeding.

Of course certain gynecological conditions, such as endometriosis, can also cause bleeding, and practical problems like missing pills or having an interaction between the Pill and other medications can also contribute to the problem.

Women who take low dose pills with less than 20 mcg of estrogen are much more likely to have bleeding.
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I developed spotting with two different low dose pills in situations that were years apart. Both times, the problem emerged after several months of use and got more pronounced with time. Bleeding that appears after six months of use may happen because of progressive endometrial atrophy, insensitivity, or resistance of the endometrium to the hormones, and an increase in the body’s metabolism of hormones.

Importantly, bleeding can sometimes be a sign that a pill isn’t working correctly, and backup contraception may be necessary.
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It can also be a sign of a more serious health problem like pelvic inflammatory disease,
spontaneous abortion, or ectopic pregnancy. Make sure that your doctor explores all the possible causes before simply switching your brand. The strategy your doctor uses will depend on when and how your bleeding happens (again, keeping a journal record of problems may make a significant difference in getting proper treatment).

The simplest things a patient can do to minimize the problem are to take her pills at the same time each day, be careful not to miss doses, and avoid lifestyle choices—particularly smoking—that can increase the likelihood of experiencing the problem. If you smoke you are 30 percent more likely to bleed in early cycles of taking the Pill and 84 percent more likely than non-smokers to have the problem after six months of use.
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If you are very young and your menstrual cycles are just getting started, or if you a perimenopausal, you should have a frank conversation with your doctor or health care provider before using OCs to treat your potentially unpredictable periods. Jerilynn Prior, a doctor at the Canadian Centre for Menstrual Cycle and Ovulation Research, explains that the “menstrual cycle can take many years to become established, even though regular periods commonly develop within a year or so of the first period.”
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Young girls often struggle with particularly painful and unpredictable periods. I can recall being woken at night as a girl by splitting cramps and wondering if I would be able to make it through the night without a hospital visit. Because girls (rightly) complain about these pains, doctors sometimes rush to put them on hormonal contraception for “cycle regulation.” Prior doesn’t think this is a very good idea, explaining, “because all forms of hormonal contraception are designed to disturb the brain control of ovulation, and this system needs to grow up in teenagers, we have concerns about anything disrupting that delicate and important process.”
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A friend of mine who is a new doctor and who logs in many hours in a hospital clinic tells me that she believes that “cycle regulation” is often used euphemistically by teenagers and their doctors as a way to get contraception to young women who need it without parental disapproval. Because teen pregnancy is a serious problem, and many teenagers need birth control alternatives, I understand this reasoning, but still think caution is merited.