Birth control pills, patches, IUD, or implant? How to choose hormonal contraception

Margit Kossobudzka: How to choose the best hormonal contraception? There are so many methods and medications...

Dr. Artur Drobniak: Among the methods of hormonal contraception, we have many tools today to prevent pregnancy. It is crucial that the choice of contraception is as individual as possible. It is determined, inter alia, by a woman’s body weight, possible co-morbidities, and the experience with other contraceptives so far. The selection of contraception should always be preceded by a visit to the gynaecologist, examination and taking a detailed medical history.

So what are these options?

The doctor may, for example, recommend hormonal contraception based on one component – a progesterone derivative. It is a method intended mainly for women who are breastfeeding or who have had a thrombotic disease in the past. These women must not use the combined oral contraceptive pill – COCP.

Which is what?

A form in which there are two components in a contraceptive. Not only progesterone, but also oestrogen. Most patients take this type of drugs.

At this point, it is worth mentioning that the COCP drug group is a bit like the antihypertensive drug group. They lead to the same effect, but are composed of different substances. Each substance affects, e.g., blood pressure, adrenal function, and carbohydrate metabolism differently. That is why it is so important to take history before deciding which drug to propose. In the group of two-component hormonal contraceptives, we have pills, patches, or vaginal rings at our disposal.

Another group of good and safe methods of hormonal contraception are the so-called methods of long-term contraception. These include intrauterine devices and subcutaneous implants. These methods are always based on one ingredient – progestogen. They are safer than the combined pill.

And are they more effective? Two seems better than one.

That’s a wrong assumption. First, we know that fewer women get pregnant when using long‑term contraceptive methods than when taking either one-component or two-component pills. Secondly, it is a form of contraception that does not carry the risk of a mistake, e.g., if someone forgets to take a pill, has diarrhoea, vomits, or has an infection...

Many women say that they do not want a contraceptive that they cannot discontinue at any time on their own.

Yes, these are not methods that a woman can quit using by herself, but it is also worth noting that the removal of an intrauterine device is usually painless and takes just a few moments. The removal of an implant takes a bit longer because you need to make a micro-incision to be able to remove it, but it also does not take long, usually several minutes. It is performed under local anaesthesia, so again – it’s painless. My experience shows that patients who have tried a long-term contraceptive method are willing to return to it.

Is it a myth that young women who have not had children should not use IUDs?

The fact is that a woman who has not yet given birth cannot use any IUD. Only those that are specially dedicated to them and completely safe for them.

The devices differ in size, material, and registration by the manufacturer. The size of the uterus of a woman who has never been pregnant is usually a dozen or so percent smaller than that of a woman who has been pregnant before. Therefore, for such women, the IUDs are smaller in order to reduce the risk of side effects during its use. In other words – a woman who has given birth before can use any IUD, and a woman who has never given birth can use only a dedicated one.

It is not always possible to find the right contraceptive at the first attempt. What if the selected form or drug does not suit a woman?

When a woman first starts using hormonal drugs, it is a new situation for her body. Regardless of the choice of the drug, the patient is exposed to adverse events which she has not experienced so far.

The most common symptoms are bleeding when taking the first pack, mild headaches, water retention, and lower leg pain. When the symptoms are mild, sometimes all you need to do is wait a month. Most of them disappear by the second pack. Most likely, it is a reaction of our endocrine system, circulatory system or nervous system to a new situation. The body needs time to adapt.

However, if the patient still feels unwell during the next cycle, it is an indication to change and use another drug with a contraceptive effect. Even if you give a lot of thought to drug selection, sometimes a specific medication will turn out not to be the right choice. There are always genetic factors or individual predispositions that make a woman sensitive to specific medications.

Are there many such women?

There are few of those who do not tolerate any combined contraceptive pills well enough. However, there will always be a few percent of women with such intolerance. These are girls who are offered methods based on one ingredient – gestagen. I can count the number of patients in whom no method of hormonal contraception, including single-component contraception, is tolerated on the fingers of one hand.

Is it possible to control the menstrual cycle through hormonal contraception?

There are known factors that affect the duration of the menstrual cycle, even in women who do not have any menstrual disorders. They include extreme stress, foreign travel, above‑average physical exertion or even changing seasons. In these cases, however, it is impossible to predict how the menstrual cycle will react in each patient. Hormonal contraception, which allows for some targeted control of the monthly cycle, can be of help. However, contraception is not always necessary to shift your period.

In order to extend it, you can also administer progesterone alone in the second phase of the cycle. On the other hand, it is virtually impossible to intentionally shorten the menstrual cycle in a healthy woman.

Isn’t such “tinkering” with cycles dangerous? For example, is it all right if a woman doesn’t have a period two cycles in a row because she decides to extend the use of her medication without taking a break?

This is where the enormous strength of our habit comes into play – the belief that menstruation must occur in a cycle of a woman in reproductive age. From a health point of view, no menstruation even for a period of three months does not pose any threat. There are preparations, also available in Poland, that contain 90 tablets, and the woman has bleeding once every three months.

We already know that exfoliation of the uterine epithelium once every three months will not allow the development of diseases within the endometrium, and blocking the work of the pituitary-ovarian axis will not stop the hormonal activity of the ovary or pituitary gland for good. Taking two packages of the drug one after the other in order not to have a period is not dangerous, it is an option.

What if someone takes pills continuously for a longer period of time?

We definitely should not allow amenorrhoea for a long time, e.g., a year. This can lead to problems with the proper growth of the epithelium after stopping contraception.

There is also a known phenomenon called “post pill amenorrhoea”. It affects a few percent of women on long-term contraception and includes the lack of period after contraceptive discontinuation. It is believed that this may be related to the long-term effects of drugs on the blockade of pituitary gland function. However, such a situation is very rare, harmless and easily reversible. After inducing a woman’s first menstruation, the proper functioning of the pituitary gland and regular menstruation usually return.

Does it make a difference whether the hormones contained in the preparation are of natural or synthetic origin?

Yes, it does. Recently, two preparations that contain natural oestrogen, i.e., oestradiol, have come onto the Polish market. Most of the drugs used contain an artificially synthesised derivative of oestradiol – ethinyloestradiol. However, I must make it clear that this does not mean that this natural oestrogen will be better for every woman. It is no coincidence that ethinyloestradiol is contained in most preparations – it stabilises the epithelium of the uterine cavity better, blocks the pituitary gland more strongly, i.e., it blocks ovulation more effectively than the natural one. Sometimes you need less intensive action, sometimes quite the opposite. Natural oestrogen works great for women over 40 – those who are in between the reproductive period and the menopause. For a 30‑year‑old, it might not be the best choice.

Does a woman using hormonal contraception have to “come to terms with some things”? Many girls feel that the symptoms they experience, such as headaches and breast pain, are the price to pay for hormonal contraception.

There is no such a situation in which a woman has to come to terms with side effects! Contraception should not interfere with the quality of life, we should strive to ensure that it has the opposite effect – it increases satisfaction.

Side effects after taking a medication can be divided into those that are extremely worrying to us, and those that can be given time to simply go away. Breast pain or weight gain by a kilogram or two are not symptoms that will make us immediately tell the patient to stop taking the medication. You need to give your body some time to adapt to the medication. If the symptoms persist and the woman continues to experience discomfort, our next step is changing the drug.

But if the patient has bad, persistent headaches, severe swelling of the legs or chronic profuse bleeding, then we should not wait for her condition to improve. In such a case, you need to act quickly: discontinue the drug immediately and change the preparation.

An adverse effect often felt by many patients using long‑term contraception is decreased libido. Gynaecologists and psychologists have conflicting views on whether it is due to long-term contraception or a long-term relationship with one partner. We will not answer this question until we stop taking the medication for a month and see if the situation has improved.

You mean a slight decrease in libido. And I know women who say they don’t know why they’re taking these drugs because there is no sex. No desire for intercourse.

I have such patients too. In such a situation, it is worth considering taking a break from hormonal contraception or changing the preparation. It is not uncommon that after a one‑month break, patients return to contraception and their sex drive improves.

Can young women be recommended contraception “for skin improvement”?

I’m against it. Yes, contraception is often used to treat various diseases and sometimes skin problems are caused by hormonal disorders. If there is a girl who has very irregular periods, has strong symptoms of androgenisation: dark body hair, oily skin, hair loss and we diagnose, for example, polycystic ovary syndrome, then one of the basic forms of treatment is the use of appropriately selected hormonal contraception. Preferably one that contains an anti‑androgenic substance, which, apart from the contraceptive effect, provides the additional benefit of blocking the secretion of androgens by the ovaries and inhibiting the peripheral action of androgens in the skin. Hormonal contraception is also considered in adolescents who suffer from metrorrhagia iuvenilis, that is when a girl has menstrual bleeding that lasts much longer than a week, is very heavy, leads to severe anaemia, and in extreme cases, even requiring blood transfusion. Although it is a rare disease, hormone therapy is acceptable even for a girl who is, for example, 15 or 16 years old.

You cannot prescribe it before that age?

For the first three years of menstruation, birth control drugs should not be used at all! This is because a naturally functioning hypothalamic‑pituitary‑ovarian axis develops during this period. Properly shaped, it regulates the work of a woman’s reproductive system throughout her life.

What if we are – as you said – in between? How is a woman to know if she has entered menopause if she uses hormonal contraception?

When entering the menopause, despite taking contraceptives, menstrual bleeding most often ceases or becomes significantly lighter. The patient says she used to have five-day long periods and now she only has two days of spotting. Symptoms of the menopausal syndrome may also appear, such as hot flushes, night sweats, irritability, trouble concentrating and remembering. In such a case, it is worth performing laboratory tests, i.e., determining the concentration of the following hormones: FSH, LH, and serum oestradiol. Women who have entered the menopause will have very high levels of FSH and very low levels of oestradiol. Such results will not be observed in any woman with normal menstruation. They are typical for a woman who is in the period of menopause or one whose ovaries do not work for other reasons.

And then what? Should we discontinue contraception?

If a patient is in the menopausal period and has strong symptoms and there are no contraindications to hormone therapy, we naturally switch her to such therapy. At the beginning it is sequential therapy, during which menstruation occurs, and over time, we switch to continuous therapy, when periods are gone. Unfortunately, in Poland there is a huge and unjustified fear of hormone therapy, greater than that of hormonal contraception.

How long can this therapy be used?

It is important to introduce it within five years of the menopause. After this time, the risk of cardiovascular complications increases, but if we apply it early enough, on the contrary – it has a protective effect on the woman’s circulatory system. In addition, it is a great form of osteoporosis prevention. According to most international recommendations, hormone therapy should be used for up to 10 years.

So women over 65 can no longer use it?

The effects of therapy are investigated in patients up to 65 years of age. This does not mean that the drugs become harmful after this age! It means they have not been tested. We have patients in the clinic who, despite turning 65 and justified attempts to discontinue hormone therapy, have extremely strong symptoms of the menopausal syndrome, which do not allow them to function normally. These women choose to keep taking the drugs.

Do endometriosis and myomas affect how we should choose contraception?

In endometriosis, combined hormonal contraception is one of the basic methods of treating and limiting the development of this disease. Especially in women who have severe pain or who still want to have children. For example, the patient has one child, was later operated on for endometriosis, but is considering another pregnancy. In the case of this patient, in the postoperative period, we do not let new endometrial lesions develop, but we introduce therapy including contraception immediately after the surgery.

In the case of myomas, the situation is more complicated. Reports indicate that hormonal contraception may have a good effect here. In most cases, it prevents myomas from growing as fast as they would without drugs. Probably because there is a slight decrease in the blood supply to the uterine muscle and thus to the myoma. In addition, contraceptive therapy reduces the severity of bleeding and other symptoms of myomas.

Don’t myomas “feed” on hormonal contraception?

This is one of the myths – research does not support such a claim. There is also a myth that you get pregnant faster after stopping the pill. It only shows that the woman and her partner are healthy. A woman who gets pregnant quickly after discontinuing contraception would get pregnant quickly without it too. There are so many factors affecting a couple’s fertility that contraception is only a micro factor compared to others.

However, if a woman’s menstrual cycle before using hormonal contraception was disturbed, e.g., irregular, anovulatory, then after stopping contraception, before the body starts repeating old mistakes, it is indeed quite common for women to get pregnant.

Is it true that after stopping contraception one should wait before trying for a baby?

I will definitely fight this myth. There is only one substance with which you should wait because it can accumulate in muscles and adipose tissue. However, 99 percent of drugs only work for 48 hours. We stop taking them and we can try to get pregnant right away. The drug has no effect on the baby.

Some women feel that the body needs to cleanse itself.

Of what? After all, the uterine lining peels off regularly. And the drugs disappear from the body after two days.

And doesn’t the risk of multiple pregnancy increase?

The research here is ambiguous. Some studies indicate that immediately after the discontinuation of hormonal contraception there is a slightly higher percentage of twin pregnancies. Except that this population risk is normally 1.7-2 percent of all pregnancies, and studies have shown that it rises to 2-2.2 percent right after stopping contraception. It is certainly not that twin pregnancies occur twice as often!

Unblocked ovaries feel free and start going crazy?

It is suspected that the standard signal from the pituitary gland after stopping contraception causes a greater “ovarian stimulation”. Hypothetically, this is because more follicles in the ovary are potentially ready for growth.

In each natural cycle of a woman, several or a dozen follicles are recruited, but only one of them grows and bursts. Perhaps when the pituitary gland is activated after a long break, it is more common for two follicles to grow, slightly increasing the risk of a multiple pregnancy.

 

dr Artur Drobniak, MD, obstetrician-gynaecologist, co-founder of Feminature Clinic in Warsaw
Author: Margit Kossobudzka

Illustration: Marta Frej

The text was published in "wysokieobcasy.pl" on 8 May 2021