Functional-medicine doc and hormone expert Aviva Romm, MD, talks to us about the health effects of hormonal contraception — and what to do about it.
Almost two-thirds of American women ages 15 to 44 use some method of contraception, most commonly the oral contraceptive pill.
With so many women using hormonal birth control, we wanted to dig into the issues that can occur with its use, so we talked with women’s health expert Aviva Romm, MD.
“I am not particularly anti-pill,” Romm told us. “However, I strongly feel that for women to make an informed decision, they actually have to hear the whole story, and too often, women are only hearing part of the story. There are much, much more significant risks than women have been led to believe.”
Read on for Romm’s thoughts on the ins and outs of hormonal birth control.
Experience Life | How does hormonal birth control affect overall health?
Aviva Romm | It’s essentially tricking your body into thinking you’re pregnant. And, with pregnancy hormones, we gain weight, we get more emotional, and our sleep gets affected.
A good thing that pregnant women usually say, which we also see initially with birth control, is that their skin gets better. And they don’t get their period for 10 months.
But some of the hidden things that happen in pregnancy also happen with birth control — but with birth control, your body isn’t compensating naturally. For example, you can get really moody, to the point of being depressed.
Also, when you’re pregnant, your body changes how it uses its blood sugar so that you naturally become more insulin resistant. In pregnancy, that happens because your body’s trying to get more blood sugar to the baby so the baby can grow. So instead of the mom’s cells taking up all that sugar, the body is preventing that from happening, so there’ll be more sugar, more energy, and fuel to go to the growing baby. When you’re not pregnant, though, there’s nowhere for that to go, and you just can become flat-out insulin resistant on birth control, and also you can develop high cholesterol.
The other thing that happens naturally in pregnancy, but is forced on birth control, is anticoagulation — your blood coagulates more and you become more at risk for clotting. The reason that happens in pregnancy is because there’s a normal amount of blood loss that happens with birth, and your body’s trying to protect you from hemorrhaging. But when you’re not pregnant and there’s no good reason for it to happen, you just end up with a much higher risk of developing blood clots, which has been one of the most serious consequences that has actually led to deaths in women of all ages on birth control.
Hormonal birth control also makes you more inflammatory. It affects your microbiome. It actually depletes B vitamins pretty significantly. So there’s a lot going on that is not healthy for women and can actually be dangerous.
EL | Are there long-term effects from hormonal birth control?
AR | Absolutely. Once you become insulin resistant, and once you have higher cholesterol, those things may persist when you go off the birth control pill.
Most women that come to me who have been on birth control for a long time find that it can take up to a year after they’ve gone off the pill for their cycles to return to normal — even if they’ve been on birth control for just six months or so. This can be really challenging if they went off of birth control because they wanted to get pregnant. It can definitely delay fertility because of that.
I’ve also had quite a number of women in my practice who had relatively OK skin or maybe had a little bit of acne on their forehead or occasionally cyclically before they went on the pill, and then, within six weeks of coming off the pill, had horrible cystic acne around their chin and jawline. It’s especially problematic with the estrogen-containing birth-control pills.
We also know that women who go on oral contraceptives have a dramatically higher chance of developing an autoimmune condition than women who don’t — about a 30 to 50 percent increase.
For example, you take a birth control pill from when you’re 20 to 26, which is kind of a common age range, and then you go off it, and when you’re 32, you develop an autoimmune condition. You develop Hashimoto’s, or lupus, or rheumatoid arthritis. Most doctors probably don’t actually know the connection between autoimmune disease and birth-control pills, but it’s not a subtle connection. It’s a very clear connection. So some of these longer-term consequences can be completely missed.
EL | Can you talk more about the link between the pill and depression?
AR | There was a JAMA study done that found that women who were prescribed a combination birth-control pill were 23 percent more likely to need an antidepressant. It was a study out of Denmark, and a million women, ages 15 to 34, were followed for 13 years.
For most of those women, it was the first time they ever needed an antidepressant. So it wasn’t like they were depressed before, went on the pill, and then all of a sudden their depression got diagnosed. In the study, it was specifically discussed that this was depression arising from the birth-control pill.
Women who took a progestin-only pill were 34 percent more likely to need an antidepressant, and teenagers were 80 percent more likely.
So women were way more likely to have to go on an antidepressant if they started an oral contraceptive, and that’s just one study. There’s another study that looks at 13 combined studies and found that if you had a personal or family history of mental-health challenges, you were more likely to develop psychiatric side effects, especially with the higher progestin preparation.
EL | How does birth control affect fertility?
AR | The main thing is that it tends to lead toward post-pill amenorrhea. Amenorrhea means not having a period or having periods that are so irregular that you can’t figure out when you’re fertile, so it makes it hard for you to get pregnant. Usually, after about a year or less, that stabilizes. It doesn’t cause infertility, but it can cause fertility challenges for a period of time.
When you get an IUD put in, the day you get it out, you can get pregnant that day, and it doesn’t cause any problems with the pregnancy.
EL | A large percentage of women take hormonal birth control for reasons other than pregnancy — what is your take on this?
AR | The most common reasons are acne, polycystic ovarian syndrome, or very painful endometriosis, and birth control can be effective for that.
With polycystic ovarian syndrome, it can help reduce male hormones. It helps regulate your hormones because you’re getting a predictable dose of the hormones, but you still get all the same rebound side effects. The irony with the polycystic ovarian syndrome is that it is metabolic syndrome. So it’s already a condition of insulin resistance. So even though it can help with the high testosterone, it can actually make the insulin resistance worse, which can ultimately make the condition worse.
With acne, [hormonal birth control is] the one thing that really can help clear it up, and having cystic acne or even significant acne, can be very socially traumatic for women. I understand why women choose to do it, but it’s not really healing from the inside out. Insulin resistance, blood sugar imbalances, hormonal imbalances can, in the long run, make your acne worse, and as I mentioned earlier, I have many women who have not ever had a problem with acne develop severe acne when they’ve gone off hormonal birth control.
With endometriosis, the pain can be really significant and really impact quality of life, but taking hormonal birth control is more symptom control or regulating the hormones than getting to the root of the problem.
EL | Do you have any recommendations of what women could do instead to treat these conditions?
AR | Yeah, there are whole protocols for treating these conditions, and each one is slightly different, but in general, you want to take a root-cause approach.
Basically, what are the underlying common factors that are going on or influencing our health that we can work with? So addressing the health of your microbiome. Making sure that your diet is pretty clean. Having at least one good bowel movement every day. Making sure the liver’s detoxification system is working beautifully so that the body is getting all the nutrients that you need to support detoxification.
EL | What are your top natural alternatives to hormonal contraceptives?
AR | Well, there are a number of approaches. If somebody wants to have a noninvasive approach, then I would suggest a combination of condoms and natural family planning: knowing what your cycle is, knowing when you’re fertile, and then avoiding intercourse or having intercourse with condoms during that time. As long as the condoms are used correctly, natural family planning methods are about 97 percent. So that’s just slightly less effective than hormonal contraception.
You can use diaphragms. The thing with diaphragms, though, is that, one, they’re a little messy. Two, you have to think about keeping it in and remember to take it out. Three, you have to use gels, spermicides, and other things that are also toxic.
The other option is to do an IUD. IUDs are the most popular commonly used form of contraception in the Western world. European women use them all the time. It’s just a little more inconvenient, but it works, and you have to have it properly fitted. You have to go somewhere to put it in. If your weight changes, your body’s size will change even in your vaginal canal, so you have to have it refitted. If you have a baby, you have to have it refitted.
I remember the horrible IUD that came out in the 1970s called the Dalkon Shield, which was configured in a certain way that just basically welcomed bacteria to whip up them and cause really severe intrauterine infections and death. So women of my generation are often very averse to them, but the technology behind them now is really effective.
The problem with the IUD is women are afraid to have them put in, and understandably so, because we’ve all heard the story of a uterine rupture or a migrating IUD. It’s uncomfortable to have it put in. I’ve never had one, but I’ve put many in for women, and no matter how gentle I am, it’s just a little uncomfortable. About 50 percent of women, in that first six months, have irregular bleeding and a lot of cramping. I’ve ended up taking out a lot of the ones I’ve put in, which is pricey, too, because insurance doesn’t always cover the whole thing. So that’s been the biggest barrier to them.
But women who can get through or tolerate those first six months love them. You can get the Mirena, which is the hormonal one, or the copper IUD, and that’s hormonal-free. The copper IUD, it’s meant to last 10 years, and studies show that you can leave it in up to 12 years. Totally safe, totally effective.
EL | How do IUDs work?
AR | Copper IUDs work by creating a local irritation and a local inflammation that essentially chemically changes the lining of the uterus while it’s in so that it makes it inhospitable for you to get pregnant.
The Mirena does the same thing. It just also has a little bit of a local hormonal effect. It’s not a significant systemic hormonal effect, but there is some. The hormonal one you can keep in five years, but seven years has been found by studies to completely confer great birth control.
EL | Anything else you’d like to add about birth control?
AR | It’s a tricky balance, right? I have 21-year-olds who are in college who have horrible endometriosis, and they’re just trying to get through life, and the only thing that’s helped them is the birth-control pill, and if you can get to someone who can really work with you on alternatives, that is amazing, and the things we talked about — cleaning up your diet, working with your microbiomes, supporting your detox — all of these things can be really helpful with any of those gynecologic, inflammatory, or blood-sugar-imbalance conditions that we discussed.
If you do, for some reason, feel that you need to be on an oral contraceptive, it’s really important to make sure your blood sugar is staying in a healthy level. Make sure that your cholesterol’s staying normal. Get on a multivitamin, and make sure you’re getting a B complex and a probiotic. Really be on the lookout for symptoms and side effects. If you’re developing depression, then going on an antidepressant is not the answer. It’s getting off the birth control that is the answer, particularly for women who already have metabolic syndrome, who are already overweight, who smoke, or who have MTHFR, or a blood-clotting problem.