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Confirmed - The Dangers of Birth Control for PMS

The advent of the pill started a sexual revolution because it allowed women to avoid unwanted pregnancies. A lot has been said for and against oral contraceptives since they were introduced. However, there is a valid concern that the hormones in these pills may retrain the normal female hormonal balance. Besides serving their primary role as contraceptives, birth control pills are also used for certain off-label indications. The most common off-label use of oral contraceptives is in the management of PMS. However, skimming PMS with oral contraceptives has its demerits. What are the dangers of using birth control pills for PMS? Does the benefit outweigh the dangers? Read on to find out.
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The Rise of the Pill

Since its introduction, oral contraceptive has been the most popular form of birth control.

Basically, an oral contraceptive or “the Pill” is formulated with certain female sex hormones and/or their synthetic analogs. These are intended to prevent unwanted pregnancies. However, because oral contraceptives contain reproductive hormones, they can also affect the menstrual cycle.

Oral contraceptives can also interfere with any condition dependent on the cyclic production of hormones during the menstrual cycle.

The two most common hormones found in oral contraceptives are estrogen (as estradiol) and progesterone (as progestin).

The simplest formulation of oral contraceptives includes 21 pills containing one or more hormones. These should be taken over a period of 3 weeks (one pill per day). For the last week of the month, the user may take no pills or 7 placebo or sugar pills.

Placebo pills help women settle in the habit of taking one pill per day and, otherwise, they serve no purpose.

While regular oral contraceptives still allow women to see their period, extended cycle oral contraceptive pills can help women go 3 months or 1 year without their periods. Unfortunately, this type of birth control pills also carry higher risks of breakthrough bleeding.

Although oral contraceptives are primarily used to prevent pregnancies, they do have some non-contraceptive benefits responsible for their off-label uses.

Because these pills reduce or eliminate monthly bleeding, women who regularly take them often experience significant improvements in menstrual problems.

One of the most important non-contraceptive benefits of oral contraceptives is the proven improvement of the symptoms of premenstrual syndrome (PMS).

Non-Contraceptive Indications for The Pill
  • PMS
  • Mild to moderate acne
  • Painful menstruation
  • Heavy and prolonged menstruation
  • Anemia caused by excessive menstrual bleeding
  • Pelvic inflammatory disease
  • Polycystic ovary syndrome (PCOS)

In addition, oral contraceptives have been shown to lower the risks of colorectal, endometrial and ovarian cancer.

PMS and the Pill

Oral contraceptives are effective for reducing PMS symptoms because they stop ovulation and change the hormonal fluctuation that happens in the menstrual cycle.

By stopping ovulation, oral contraceptives actually replaces the regular menstrual cycle with another one.

The bleeding experienced during the days without pills (or with placebo, sugar or iron pills) represents withdrawal bleeding and is not a true menstrual flow.

Obviously, the new hormone profile established by oral contraceptives does not negatively interact with neurotransmitters in the central nervous system. Currently, scientists believe that most of the emotional-type symptoms of PMS are the results of the interference of ovarian hormones in the brain.

These hormones can reduce the activities of neurotransmitters such as serotonin, dopamine and glutamate.

These are the same neurotransmitters responsible for the regulation of mood, anxiety and cognitive performance.

Therefore, oral contraceptives do not cure PMS. Rather, they sidestep the problem entirely but at what cost?

Commonly Used Birth Control Pills for PMS
  • Lybrel – the first all-year round oral birth control pill. This oral contraceptive contains no placebo and no pill-free breaks. Therefore, users experience no menstrual flow and, therefore, no PMS
  • Seasonale – contains 12-week worth of estrogen/progestin pills which should be followed by 7 days of no hormone pills. Therefore, users only experience 1 menstrual period every 3 months. This means fewer PMS episodes per year
  • Seasonique – similar to Seasonale but rather than the 7-day period of no pills, it offers 7 days of low dose estrogen pills to fill the gap between each treatment period. Therefore, users still experience only 4 menstrual periods in a year but those periods are short and their menstrual flows are light. This means PMS episodes are few and mild
  • Yaz – contains 28 monthly pills. Out of these, only 24 pills contain hormones while the other 4 are dummy pills. Therefore, users still experience monthly flow but it will be shorter and lighter. The result is less and easier PMS
  • Yasmin – similar to Yaz except that it contains 21 active pills and 7 placebo pills. It can also reduce PMS symptoms

Drug Interactions of Birth Control Pills

Certain medications can affect the efficacy of birth control pills and such drug interactions may cause new complications.

Antipsychotics such as barbiturates and carbamazepine as well as anticonvulsants such as phenytoin can reduce the efficacy of birth control pills and worsen side effects such as breakthrough bleeding.

Rifampicin, an antibiotic, can also interact with contraceptive pills in similar ways.

Antibiotics, especially broad spectrum antibiotics, are known to affect the efficacy and side effects of oral contraceptives.

Broad spectrum antibiotics like ampicillin and tetracycline antibiotics are known for their non-selective destruction of microbes in the gut. They destroy normal gut flora and allow the rise of opportunistic pathogens.

However, by wiping out the normal gut flora, these antibiotics also remove the “good bacteria” responsible for recycling an estrogen metabolite, ethinylestradiol.

The recycling of this hormone by bacteria in the large intestine is important to the maintenance of hormonal balance. Therefore, the combination of broad spectrum antibiotics and birth control pills can throw female sex hormones out of balance and produce some serious adverse effects.

Lastly, herbal products can also interfere with oral contraceptives. The most important interactions involve herbs that affect the liver enzyme family known as cytochrome P450.

St. John’s wort increases the activities of CYP450 and can, therefore, reduce the efficacy of birth control pills.

Adverse Effects of Birth Control Pills

The most common side effects of birth control pills are breakthrough bleeding and the suppression of normal menstrual flow.

Although doctors and drug manufacturers promise that these side effects will disappear within the first 3 months, studies show that they are severe enough to prompt half of new users to stop taking birth control pills within the first year.

Perhaps the suppression of menstrual flow is one reason why birth control pills such as Lybrel were introduced. There is nothing better to do with a side effect drug companies cannot control than to embrace it and advertise it as a benefit of the drug.

However, compared to other side effects, unpredictable bleeding and total absence of menstrual flow are mild.

Discussed below are the major dangers associated with using oral contraceptives either to prevent unwanted pregnancies or to treat PMS.

Deep Vein Thrombosis

The increased risk of deep vein thrombosis or venous thromboembolism is now well established and accepted by the medical community, drug manufacturers and the FDA (Food and Drug Administration). And yet, oral contraceptives are still widely promoted because this risk was unfairly compared to an even higher risk of deep vein thrombosis during pregnancy.

Health experts have argued that the risk of deep vein thrombosis should rather be compared between users and non-users of birth control pills.

A 2013 study published in the journal, Human Reproductive Update, made this comparison and found that women who took birth control pills have double the risks of deep vein thrombosis compared to women who had never used oral contraceptives.

But what is deep vein thrombosis? It is the term used to describe the formation of blood clots in the veins of the legs.

When a clot formed in a deep vein breaks off, it can block blood vessels along the way. The result is gradually worsening pain in the thigh and hips as the clot travels up through the body.

Deep vein thrombosis can cause the affected leg to swell up. It can also lead to permanent disability when it fully blocks a block vessel (think Dr. House). When the clot reaches the lungs, it causes pulmonary embolism; when it reaches the blood vessels of the brain, it causes ischemic stroke.

The risks of deep vein thrombosis, pulmonary embolism and stroke resulting from the use of oral contraceptives are highest among women who smoke, who are over 35 years of age and who are long-term users of these pills.

The risk of thromboembolism varies with different oral contraceptives. The table below summaries this relative risks in ascending order.

Risk of Lethal Blood Clotting with Birth Control Pills

Compared to levonorgestrel (a value of 1), the risk of thromboembolism with common oral contraceptive hormones are

  • Norethisterone – 0.98
  • Norgestimate – 1.19
  • Drospirenone – 1.64
  • Desogestrel – 1.82
  • Gestodene – 1.86
  • Cyproterone – 1.88

Therefore, it seems that this risk worsens with the introduction of newer oral contraceptives.

Drospirenone as an Example

Drospirenone is particularly notorious and well-studied for this risk and it can serve as a good example for the whole drug class.

A 2011 paper published in BMJ provided a summary of FDA studies investigating the risk of deep vein thrombosis for oral contraceptives containing drospirenone.

The FDA findings showed that compared to other oral contraceptives, drospirenone contraceptives (Yaz, Yasmine, Beyaz, Zarah, Ocella etc.) raised the risk of venous thromboembolism by 93% among women who took the pills for 3 months or less.

For those who took these pills for 7 – 12 months, the relative risk rose steeply to 290%.

It is no wonder then that the FDA quickly mandated manufacturers to add warning of this risk to the labels of oral contraceptives containing drospirenone.

Unfortunately, drospirenone is not the only oral contraceptive with this risk and, in all likelihood, it may not even be the one that carries the highest risk of deep vein thrombosis. In addition, deep vein thrombosis is a silent killer and the women who catch its early signs are the lucky ones.

Hyperkalemia

Another side effect known to occur with drospirenone contraceptives is hyperkalemia.

These pills can cause blood potassium levels to shoot up to dangerous levels. Therefore, they are not to be combined with other drugs that increase potassium levels. Such drugs include potassium-sparing diuretics, potassium supplements, heparin, NSAIDs (non-steroidal anti-inflammatory drugs) and drugs that affect the angiotensin and aldosterone systems.

Hyperkalemia can cause heart palpitations, irregular heart beat and sudden death.

Cancer and the Pill

Because oral contraceptives raise the levels of estrogen (and progesterone), their long-term use will likely affect the risks of certain cancers especially those affecting organs in the endocrine system.

Studies confirm that oral contraceptives do indeed influence cancer risks. However, it is not all bad news.

Multiple studies and reviews have confirmed that these pills can reduce the risks of ovarian, endometrial and colorectal cancers. The risk reduction increases the longer the pills are taken and there is good indication to suggest that the protection offered may persist for some years after discontinuing the pills.

However, there is also good evidence to indicate that oral contraceptives can also raise the risks of certain cancers.

There is currently no consensus regarding the degree of cancer risk or its nature. Even then the data suggests that oral contraceptive can increase the risks of cancers of the breast and cervix.

The risk of liver cancer may also be increased among women with some risks of hepatitis B virus infection.

Sexual Changes

Different studies have identified that oral contraceptives can cause different changes in female reproductive health.

Some of these changes involve libido, arousal and vaginal lubrication. Strangely, oral contraceptive use can increase or reduce any of these factors and the exact change varies from one individual to another.

A 2006 study published in The Journal of Sexual Medicine identified that oral contraceptives raised the levels of SHBG (sex hormone binding globulin). Compared to women who had never used the pill, those currently taking oral contraceptives had 4 times the level of SHBG.

SHBG is released in response to the flood of female sex hormones introduced into the body by oral contraceptives.

Unfortunately, it can bind all sex hormones including androgens. Therefore, the reduced level of sex hormones prompted by increased SHBG levels may be responsible for the sexual changes caused by oral contraceptives.

Depression

The estrogen and progestin commonly found in oral contraceptives can lower the level of serotonin in the brain.

These sex hormones increase the level of the enzyme responsible for breaking down serotonin. The result then is depression.

This is a rather ironic outcome given that oral contraceptives are promoted for the off-label use of managing PMS-related emotional symptoms which include depression.

However, health regulatory bodies believe that the doses of estrogen and progestin found in oral contraceptives are low enough not to cause depression. The results of a 2005 study published in the journal, Australian Family Physician, differ from that conclusion.

In that study, researchers found that progestin-only oral contraceptives worsened depression in premenopausal women who were already battling with the condition.

Other Side Effects of Oral Contraceptives
  • Nausea
  • Vomiting
  • High blood pressure
  • Migraine headaches
  • Facial skin discoloration
  • Increased cholesterol level
  • Higher risk of gallstone formation
  • Impairment of muscle gain
  • Lower birth weight of infants
  • Yeast overgrowth and candida infections

Sources


http://www.mayoclinic.com/health/birth-control-pill/WO00098

http://www.health.com/health/gallery/0,,20461504_8,00.html

http://contraception.about.com/od/Benefits/f/PMS-PMDD.htm

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