Back to gynecology...
- Jeanette Thomas
- May 22, 2024
- 7 min read
The magic number is 3, and the word of the day is consistent:
Go ahead and pull up "The Magic Number" from 3 feet High and Rising by De La Soul while you read this. You should probably listen to the entire album. You're welcome, and my apologies to the group. Copyright De La Soul, 1989. Image from substackcdn.com
For today, we’re going to pretend that pregnancy prevention is a side effect of using hormonal birth control medications, not the primary purpose. Because sometimes it is. And that’s more than okay.
Because these medications can be extremely helpful for women who have heavy, irregular and/or painful periods. Endometriosis? Gotcha. Fibroids? worth a shot. The magic number is 3, and the word of the day is consistent. Don’t come back and tell me that this isn’t working for you until you have trialed it with 3 months of consistent use.
Maybe you just don’t want to get a period, this month, or really ever? Who does? -- unless they have been playing pregnancy roulette.
With progesterone only methods (the shot, the rod, the minipill, one type of the IUDs), the lining of the uterus gets very thin. These don’t always keep women from ovulating, or releasing an egg each month, but there is very little lining there for a period. Most women have irregular bleeding or spotting while the lining is getting thin (the magic 3 months), then have very light periods or none at all. YAY! It also takes time, so you can’t come into the gyno office and expect to shut down your period immediately. Expect the light bleeding and spotting, and then you can be pleasantly surprised if you don’t have it.
More good news:
most women can use these without worry for rare, but potentially severe, side effects. If you stop and start them, the 3 months of possible bleeding and spotting start over again.
They are all safe with breast feeding
For women with seizure disorders, they don’t interfere with seizure medications and can actually make seizures less likely (I care more about this now than I used to)
We wouldn’t start them if we know you are pregnant, but most are unlikely to cause birth defects. (We’ll discuss IUD’s later).
If you can’t get to the gyno office, or just want to try it on your own, you now can with the over-the-counter progesterone only pills, or mini-pill. Remember the word of the day, and that this means at the same time every day.
The down sides:
That irregular bleeding and spotting in the first 3 months can be annoying. Again, you are playing the long game for cycle control, not stopping your period for your beach vacation next week. For most women, the total amount of blood lost is less than if you were having your period, but the unpredictability is GRRRRR.
The Depo-Provera shot can have some other side effects that range from irritating to deal breakers:
weight gain
increase in acne or depression symptoms if you are prone to these
mild hair loss—you don’t go bald, but you may notice more on your brush or your pillow
You do have to get a shot every 3 months.
Yes, it is a shot. with a needle.
Some studies have shown loss in bone density while women are on the shot. This appears to reverse when they stop using it. It’s important to get enough calcium and weight bearing exercise for all of us, especially if you’re on the shot. As a young adult, you’re building peak bone mass. As a middle-aged woman, you’re already losing bone mass.
There may be a delay in your ability to get pregnant after stopping the shot. This can be a few months, or up to a year. For most healthy women, we wouldn’t start an infertility evaluation until a year after you stop birth control anyway.
How many blogs have both Schoolhouse Rock AND De La Soul references when discussing hormones? Guessing that Venn diagram is pretty small.
The rod (Nexplanon):
The irregular bleeding and spotting may not always get better after 3 months.
It is a simple procedure in the clinic to insert and remove it. You do have to have this done in the clinic when it expires or you’ve decided it’s not for you.
The arm is cleaned and marked
A numbing medicine is injected. With a needle.
The skin is elevated, and the rod is placed by a little device It’s kind of cool.
Your arm is bandaged, and you go on your way.
It works for up to 3 years. The likelihood of pregnancy with the rod is almost zero, unless you had an undetected pregnancy when it was inserted. You can get pregnant any time you want after it is removed, or have a new one inserted if it is working well for you. To remove:
We feel for the rod and hold it in place.
Inject numbing medicine at one end of the rod.
Make a small cut (2 to 3 mm) in the skin near the end. Yes, these steps involve a needle and a small scalpel/knife.
Push the end of the rod to the opening, grasp it and pull it out.
Bandage the area and go on with your day.
You can see and feel the rod on the inside of the upper arm if you know what you’re looking for.
If placed correctly, it almost never moves. I’ve seen an infection, but they are incredibly rare.
The mini-pill is now available over the counter (see previous post from March 5, 2024)
Same breakthrough bleeding and spotting. Expect more of this if you don’t take it at the SAME TIME Every. Single. Day.
This is true if you are out late, hung over, traveling, busy, camping...you get the idea.
Many women on the pill (either mini-pill or combination pill) set an alarm on their phones to remind them it’s time to take it. Find a time that works for you and stick with it. Some pair it with another activity that they do at the same time every day, like brushing their teeth.
Progesterone only pill Pros:
You can choose when to stop and start it, if it isn’t working for you. You don’t need a clinic appointment for either.
You can use it continuously, so that you don’t get your period.
Progesterone only pill Cons:
you don’t get the counseling that you would with a clinic appointment on options, side effects, etc. Questions are answered by the package insert (who reads those?) or the internet. Doctors are good for something.
Bleeding and spotting as above. It’s the most finicky of the progesterone options.
Progesterone IUD’s (intrauterine devices) are the longest acting of these hormonal methods, and most likely to shut down your periods and symptoms.
They release a small amount of progesterone inside the uterus, so have fewer whole body (systemic) side effects.
They do require an office visit both to place the IUD and to remove it.
Progesterone IUD’s are effective for 3 to 8 years. Timing depends on the amount of hormone that they contain. They can be removed at any time.
Progesterone IUD’s are a fantastic bridge for perimenopausal women who are having heavy and/or irregular periods. This is true for women who don’t otherwise need birth control.
Yes, you can use a progesterone IUD even if you have had your tubes tied, have never had a pregnancy, are a nun, or only have sex with women, or all of the above.
They are a “set it and forget it” option.
If women are doing well with a progesterone IUD, and would be due for replacement in their late 40’s or early 50’s, it is fine to leave it in until the mid-50's to help that menopausal transition. Since spontaneous pregnancies are incredibly rare in this age group, this should also be fine for women using the IUD for contraception.
The progesterone in the IUD isn’t likely enough to help with hot flashes and night sweats (systemic perimenopausal symptoms)-- however the Mirena IUD (which has the highest dose of progesterone) can be used to protect the uterus if estrogen is needed for hormone replacement (HRT). And maybe the IUD alone will help with the systemic symptoms; all medication options for hot flashes and night sweats have a high placebo effect when studied in double blind trials.
In English: The most reliable way to study a medication is a setup where patients are chosen randomly to receive the study medication or a pill that has no medication. When neither the researcher nor the patient knows which option she has, it is called a randomized, double blind controlled trial. In many studies for hot flashes and night sweats, improvement in symptoms is seen with both treatment and thinking that you are taking the treatment. None of the treatments relieve symptoms as much as estrogen.
Never underestimate the benefit of a benign placebo.
Tune in for our next episode for details on IUD insertion and removal, risks and benefits. Since these are virtually the same for progesterone and copper IUD’s, I’ll talk about them together.
There were some bad IUD’s in the 1970’s. We don’t use them anymore. Having an IUD inserted isn’t meant to be scary. It’s an effective way to put the lowest dose of the hormone exactly where it is needed.
In the meantime, if you want to read ahead, try this link:
AND—I love reliable journalism. I read the NYT online most days. However, I disagree with some of the assertions in last week’s article about women not quitting the pill en masse.
First of all, as the article states, they really aren’t. You have to read the piece, not just the headline.
Secondly, the claim about weight gain links to the world’s most boring table from the CDC. If you actually read this table (which I have) there isn’t strong evidence that the combination pill leads to weight gain. Depo Provera, as I said above, different story.
The comments on the article echo one of her core statements: not having side effects is dull and uninteresting. (My favorite was: “good news is no news...like a Kansas newspaper running a headline: ‘No Tornado Today’” A.L Hern.
Having side effects or associated events, particularly tragic ones, make for click bait and likes. And association doesn’t mean causation. Some women have horrible periods, use the pill or an IUD, and then have trouble getting pregnant. It doesn’t mean that the treatment caused the infertility. It could be that the cause of the pain led to infertility. Or they could be unrelated.
A lot of the comments also point to distrust of medicine and doctors in general. Nobody wants you to have adverse reactions. Your doctor included. Nobody wants you to have complications, or suffer. Your doctor included. What motivation do we have to lie to you or withhold information?
Nothing is risk free.
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