Any woman who has faced the decision to try hormonal contraceptives knows that doing so comes with a fair amount of warnings and risks. Sometimes these warnings and potential side effects can be exaggerated for the normal, healthy person – just like anything else in healthcare. Other times, some risks may be more important than one might think.
Many of the warnings that stem from oral contraception are indirectly due to their inherent design – a fixed-dose regimen that isn’t able to consider the women’s own specific biology or hormonal cycle. I don’t like a “one-size-fits-all” approach with any type of medication – but it’s difficult to avoid this type of practice, especially when it comes to oral contraceptives. The woman’s body is like a carefully conducted orchestra. When one instrument is off, it could have an effect on the whole performance – just like if a particular hormone or neurotransmitter is off, the whole body could be affected. Hormonal contraceptives interfere with this “orchestra,” – which is why they work so effectively – but also why we see some unwanted issues and side effects. Unfortunately, this predicament leaves many women wondering about the best course of action to take to avoid an unwanted pregnancy or perhaps deal with other issues, like regulating a menstrual cycle or Polycystic Ovarian Syndrome. As a side note, I talk about some other birth control alternatives in this article.
Rest assured that the majority of young, healthy women can safely and effectively take oral contraceptives without many issues. Another piece of good news is that many of the minor side effects we see in the beginning tend to subside with use, as the body has a way of re-regulating and adjusting to new hormones. Hormonal birth control is still a great drug class that offers much benefit to many young women.
However, in recent years, a few large studies have been published that shed some light on hormonal birth control and some of the concerns associated with its use. I’ve broken down some of these studies below. Many of us who have taken the pill before have heard of these issues, but may not know just how important (or unimportant) they really are just how worried we need to be about them.
The Antibiotic/Hormonal Contraceptive Drug Interaction – Mostly Fiction
It has long been purported that taking antibiotics while currently on the pill can decrease the pill’s effectiveness and potentially cause an unwanted pregnancy. The rough idea behind this theory is that antibiotics decrease some of the bacteria necessary for a contraceptive’s metabolism. Years ago, it was commonly advised to use a back-up form of birth control, no matter which antibiotic was prescribed.
New data is showing, however, that the once notorious drug interaction is not as worrisome as need be. A study published in the American Journal of Obstetrics and Gynecology pulled data from multiple sources to evaluate whether using antibiotics with oral contraceptives decreased the effectiveness of the hormones. Parameters such as rates of pregnancy, ovulation suppression, and breakthrough bleeding were evaluated. Based on these parameters, many of the popular antibiotics used today (penicillins; fluoroquinolones such as Levaquin and Cipro; cephalosporins like Keflex; macrolides like Z-pak; and tetracyclines) did not show an interaction with hormonal contraceptives.
One antibiotic that can reduce the effectiveness of birth control is a medication called rifampin. Rifampin interferes with the way the body metabolizes birth control by “ramping it up”, so to speak. Because fewer hormones (birth control) stay around, we see a slight decrease in contraceptive effectiveness with an increase in breakthrough bleeding and menstrual irregularities. Using a back-up method of contraception is recommended in this case. The most common indication that rifampin is used for is tuberculosis, so it is unlikely that other, less serious infections would require this type of antibiotic.
Some particular contraceptives can interact with antifungal and antiretroviral agents, like those used in HIV. No matter which medication is prescribed, check with your doctor or pharmacist to ensure that your therapy works in harmony with each other.
Birth Control with Depression (Fact)
Birth control can worsen depression or cause it to reoccur in women who have experienced depression in the past. Even if you haven’t experienced depression, birth control can cause some emotional instability and make you feel as though your mental clarity is off.
A large Danish study supported these facts. They found that women using hormonal contraception experienced a higher rate of developing depression and subsequently using antidepressants than those who did not use the drugs. This rate was much higher in teenagers, which could be explained by the already unstable hormones caused by puberty.
While this side effect wasn’t widely recognized in the past, many clinicians today are advising women that hormonal birth control can cause depression, whether they have had issues with depression in the past or not. In many situations, this risk will be nominal compared to the benefit as many women will never experience this issue. In others, it could be the deciding factor of whether to continue hormonal birth control or not.
My personal take is this: whether you have had mild to moderate depression in the past or not, don’t let this potential side effect steer you away from birth control if birth control has a proven benefit to you – in which the risks of not taking it are greater than the risks of taking. It is important to know that depression may occur or worsen, and – should this happen – it is best to stop using hormonal birth control and find another option. However, it is also important to simply be aware of, but not ruminate over potential side effects. Depression is a peculiar state in that it is highly subjective and frequently transient. The simple fear of something can trigger a thought or pattern which can then cause a shift in outlook. So, be aware of the side effect, but don’t let it overcome you if hormonal therapy should be an otherwise viable option.
If you have a history of severe depression, and birth control is optional for you, I would advise to look at other alternatives based on the statistics.
Birth Control with Breast Cancer Risk (Fact)
Many who are familiar with women’s healthcare know that birth control has long been associated with a breast cancer risk. Since the 1960s, clinicians and drug manufacturers alike have been attempting to formulate “safer” options – those containing smaller doses of estrogen (the hormone linked to breast cancer) and even non-estrogen, or progestin-only, options.
However, new findings are unfortunately showing that lower-dose options are not as safe as we’d hoped them to be. A study was recently published in the New England Journal of Medicine that followed 1.8 million women taking hormonal contraception over the course of 11 years. The study showed that these women had a 20 percent higher risk of breast cancer – no matter the dose the estrogen – than those who didn’t use hormonal birth control. What’s equally significant is that the study showed harm even with progestin-only pills. It was once believed that estrogen was the sole culprit, however this study shows otherwise.
So, how concerned do we have to be? It is important to remember that – in the grand scheme of hormonal therapy – the risk of developing breast cancer still remains relatively low. However, whether to start hormonal birth control or not should be a process conducted on an individual basis, with the woman’s personal history strongly considered. For instance, if a woman has a family history of breast cancer or has tested positive for breast cancer-related genes, it would be wise to consider this side effect since she is already at a greater risk. For a woman who has no baseline risk of breast cancer, hormonal birth control should still be considered as a safe option.
Take Home
Like anything in medicine, hormonal birth control should be prescribed on an individualized basis, with the woman’s personal history, preferences, and concerns taken into account. It is important to remember that the risk for most side effects associated with birth control increases both with women’s age and length of therapy. I still advocate hormonal birth control, but I believe the greatest benefit is seen with young, healthy women in their 20s who opt to use it for the shortest amount of time possible. I once fell into this category, but after a decade of using birth control, I now feel that I am at a time in my life where the risks and side effects are greater than any benefit once provided.
I hoped this article helped to shed some light on the new information available. Sometimes what’s more important – even more so than facts and statistics – is to find a doctor or provider who appreciates an honest, heartfelt conversation about any of your concerns.
References:
1. Simmons KB, et al. Drug interactions between non-rifamycin antibiotics and hormonal contraception: A systematic review. Am J Obstet Gynecol. 2018;218(1):88–97.
2. Wessle Skovlund C, Steinrud Morch L, Vedel Kessing L, et al. Association of Hormonal Contraception with Depression. JAMA Psychiatry. November 2016.
3. Morch LS, Skovlund CW, Hannaford P, et al. Contemporary Hormonal Contraception and the Risk of Breast Cancer. New England Journal of Medicine. December 2017.
