Alternatives to the Pill

by Lili Cote de Bejarano, MD, MPH

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The Pill has become a popular contraceptive method and is currently used by over 11 million women in the United States. According to a recent report of the Guttmacher Institute, teenagers and women in their 20s prefer to use the Pill over other contraceptive methods. [1] “The Pill” actually refers to synthetic female hormones in pill form. Other ways to deliver contraceptive hormones have been marketed such as shots, vaginal rings, patches, implants, and intrauterine devices (IUDs). Over 100 million women worldwide use contraceptive hormones in one of these forms. [2] Regardless of the method of delivery, hormonal contraceptives have similar effects on women’s bodies. The Pill is sometimes prescribed for medical conditions such as acne, irregular cycles, menstrual pain, painful periods, endometriosis, and other gynecological conditions. For most of these conditions, the Pill is only treating the woman’s symptoms, while her underlying medical problem—the cause of the symptoms—remains unaddressed and undiagnosed.

WHY DO WE NEED ALTERNATIVES TO THE PILL?

Hormonal contraceptives, including the Pill, have been associated with a number of health problems, social problems, and ethical problems.

Health Problems: The Pill was developed in the mid-1950s to reduce pregnancy rates. In the original trials of the Pill in Puerto Rico, three women died, but this deadly effect of the Pill was ignored. [3] In the late 1960s, many people became greatly agitated regarding deaths and illnesses caused by the Pill; this led to the development of lower-dose combined oral contraceptives and the mini-pill. Even with these lower doses, studies continue to be published indicating that the Pill causes women’s deaths every year. These studies typically conclude that the Pill’s benefits for women greatly outweigh its hazards. [4] Various studies have linked hormonal contraceptives to a wide variety of life-threatening conditions, including heart disease, stroke, blood clots, liver cancer, a variety of female cancers, and depression. [5] Other illnesses such as migraine, moodiness, and weight gain have also been associated with the use of hormonal contraceptives. Synthetic hormones can impair the normal function of the cervix, even years after discontinuing the Pill, causing temporary and sometimes permanent infertility. [6] Recent research has highlighted another action of the Pill. It suppresses androgens in a woman’s body, resulting in suppression of her sexual desire (libido). This effect has been shown to persist after the Pill is discontinued, and may be permanent. [7]

Social Problems: The Pill also appears to have serious social effects. The time period in which society became saturated with the Pill coincides with a huge increase in divorce rates and other major changes in patterns of sexual relationships, collectively known as the “sexual revolution.” Thus use of the Pill appears to have very serious negative consequences for marriage, family development, and the quality of child rearing. [8] Also, more than half of the women who request abortions report that they were using a contraceptive in the month they got pregnant, [9] which indicates a strong connection between contraception and abortion.

Ethical Problems: Pregnancy and childbirth do occur among women using the Pill, which shows that it does not always prevent ovulation or fertilization. The effectiveness of the Pill (in preventing observable pregnancy) is achieved in part by destruction of new human lives prior to implantation in the womb. [10] For many women this is a very serious ethical concern.

The serious health, social, and ethical concerns associated with Pill use must be weighed carefully in any decision for its use, whether for birth control or for medical conditions such as premenstrual syndrome (PMS), acne, or endometriosis. Fortunately, effective alternative treatments are available.

NOTE: While this pamphlet will introduce some of these alternatives and will describe some common medical conditions, it is not meant to be a diagnosis or treatment tool, and should not replace the advice of a physician. Rather, its intent is to inform and assist women in speaking to health care professionals.

IRREGULAR CYCLES

This refers to abnormal quantity, frequency, duration, or regularity of vaginal bleeding in the absence of medical illness or pregnancy. In most cases this is related to changes in hormonal levels. Normally in each cycle, a woman’s ovary releases an ovum (egg). If the ovary does not release the ovum, hormone levels change, causing unexpected bleeding. This problem is common near the beginning and the end of a woman’s reproductive life, in athletes, obese women and in women using mini-pills or contraceptive injections. [11]

WHAT DOES THE PILL DO FOR IT?

Oral contraceptives suppress normal menstrual bleeding. Some a woman takes the placebos, she has “withdrawal bleeding,” a reaction to a change in hormones. This bleeding is typically not as heavy or as long as menstrual bleeding. Some varieties of the Pill include no placebos, and so there is irregular bleeding or none at all. Also, new contraceptive pills have been developed to decrease the number of menstrual cycles to four in a year with no normal monthly bleeding.

ALTERNATIVES

The first task should be to identify and correct the underlying condition causing the irregular bleeding. If there is an imbalance of hormones, a healthy diet, healthy weight, stress reduction, sufficient sleep and rest, and moderate exercise are lifestyle changes that could help improve hormonal balance. For example, a woman who has lost a significant amount of weight and now has an extremely low body fat percentage may need to gain five or ten pounds for her cycle to resume. A teenager involved in regular strenuous exercise, such as team sports, may want to wait until the season is over and her exercise level has decreased to see if menstruation comes back on its own. For severe bleeding due to hormonal imbalance, supplemental estradiol and/or progesterone may be needed. [12]

ACNE

Acne is a common localized skin inflammation resulting from over-activity of the oil glands and hair follicles under the stimulation of hormones called androgens (principally testosterone). Bacteria, feeding on excess oil under the skin, produce irritating substances, causing the inflammation.

WHAT DOES THE PILL DO FOR IT?

The Pill causes a decrease of free testosterone. This in turn can reduce the outbreak of acne since in some cases it is testosterone that causes the oil glands to be overactive. [13]

ALTERNATIVES

Treatment will depend on the severity of the acne. Alternatives range from non-prescription topical antimicrobials, such as Benzoyl Peroxide, to prescription treatments such as topical retinoids, adapalene, topical antibiotics, and oral antibiotics such as minocycline, amoxicillin, or trimetropin-sulfamethoxazole. [14] A medication called Spironolactone, originally developed for the treatment of high blood pressure, has been used for the treatment of acne for its ability to block testosterone. Brewer’s yeast is a rich source of chromium, which is believed to improve acne, [15] and, for severe cases, the last resort is Accutane, a potent form of vitamin A. [16]

PAINFUL PERIODS (dysmenorrhea)

Painful cramps accompanying menstruation may result from a recognizable disease, or may occur in a woman who is otherwise healthy. The pain is due to inflammation and spastic contractions of the uterus caused by prostaglandins.

WHAT DOES THE PILL DO FOR IT?

Oral contraceptives can relieve menstrual pain by reducing prostaglandin levels.

ALTERNATIVES

If some disease process is the cause of menstrual pain, it is important to identify it and treat it appropriately. Masking the symptoms without appropriate diagnostic work could lead to more severe illness later on.

For menstrual pain occurring when no disease is diagnosed,

there are a wide variety of treatments. Non Steroidal Anti-Inflammatory Drugs (NSAIDs) are the first-choice, if not contraindicated. [17] Vitamin B1 (thiamine) is shown to be an effective treatment for dysmenorrhea, taken at 100 mg daily. [18] Some studies suggest that magnesium can relieve the pain related to dysmenorrhea. [18] Some natural alternatives are aerobic exercise, dietary changes such as decreasing intake of animal fats, and use of omega 3-6 fatty acids and evening primrose oil. [12]

ENDOMETRIOSIS

Endometriosis is a condition in which bits of tissue similar to the lining of the uterus (endometrium) grow in other parts of the body. This tissue may continue to react to the hormones produced during a woman’s monthly cycle and can cause severe pain, especially during menstruation, as well as infertility, heavy menstrual bleeding, and pain during intercourse, urination, and bowel movements.

WHAT DOES THE PILL DO FOR IT?

The hormones in the Pill replace the hormones produced in a normal monthly cycle and cause much less change in the tissue of the womb, apparently including such tissue located in other parts of the body. Treatment with the Pill relieves endometriosis-associated pain in 75-80% of patients, but recurrence upon discontinuation of therapy is common. Generally the Pill is considered less effective than other hormonal treatments and Danazol. There is no evidence that the use of the Pill for endometriosis improves fertility. [19]

ALTERNATIVES

NSAIDs may alleviate the symptoms. Hormonal treatment with Danazol or Lupron may also relieve pelvic pain associated with endometriosis. [12] Autoimmune therapies have shown some promise. [20] Ultimately, however, the treatment for endometriosis is surgical removal of the displaced tissue. [21]

POLYCYSTIC OVARIAN SYNDROME (PCOS)

PCOS is a disease involving great overdevelopment of cysts in the ovaries. It is associated with high levels of testosterone (a hormone which is present in all women, but in lower levels than men), anovulation (the absence of ovulation), and high insulin levels or insulin resistance. Some symptoms include excess facial and body hair (a condition called hirsutism), acne, obesity, irregular menstrual cycles, and infertility.

WHAT DOES THE PILL DO FOR IT?

The Pill causes suppression of androgen secretion by the ovaries and an increase in the level of circulating sex hormone binding globulin. [22] This reduces the amount of available testosterone and can relieve the symptoms. Progestins in hormonal contraceptives may increase insulin resistance.

ALTERNATIVES

Weight loss and exercise are important lifestyle changes in the treatment of PCOS. Weight loss and the use of insulin-sensitizing agents have been beneficial in improving the frequency of ovulation in women with PCOS. [22] Metformin (a drug used to treat diabetes) induces ovulation in many insulin-resistant and obese women with PCOS. [23] For hirsutism, Spironolactone may be used, [24] as well as certain topical treatments.

PREMENSTRUAL SYNDROME (PMS)

PMS refers to a group of symptoms often occurring during the luteal phase of the menstrual cycle (the 10-16 days between ovulation and menstruation). Symptoms can include headaches/migraines, irritability, food cravings, breast tenderness, weight gain, anxiety, diarrhea, feelings of being overwhelmed, and sadness. PMS is also associated with a worsening of preexisting medical conditions including asthma, arthritis, skin disorders, gastrointestinal disorders, and psychiatric disorders such as anxiety and substance abuse.

WHAT DOES THE PILL DO FOR IT?

Oral contraceptives replace the normal fertility/menstrual cycle with a very different cycle controlled by synthetic hormones. Some symptoms of PMS may be relieved with this treatment, but others may be worsened.

ALTERNATIVES

A wide variety of vitamin, mineral, and herbal treatments have been suggested for PMS. Vitamin B6 (Pyridoxine) has been recommended in the treatment of PMS. [25] Magnesium may help with reduction in water retention and improvement in mood. It is known that magnesium has anti-prostaglandin effects. [26] A high intake of calcium and vitamin D may reduce symptoms of PMS. [27] Calcium and vitamin D may also reduce the risk of osteoporosis and some cancers. Tryptophan used during the late luteal phase of the menstrual cycle is therapeutic in patients with premenstrual mood disorder. [28] Evening primrose oil may relieve breast tenderness. [29]

BIRTH CONTROL/CONTRACEPTION

“Birth control” is any means used to prevent sexual intercourse from resulting in childbirth, including contraception, abortion, and sterilization. Contraception is any means intended to prevent sexual intercourse from resulting in conception or pregnancy. The term “contraception,” however is often used to refer to methods, such as the Pill and the IUD, which sometimes fail to prevent conception and owe much of their effectiveness to destruction of human life after conception. [30]

HOW DOES THE PILL WORK AS A CONTRACEPTIVE?

The Pill inhibits, but does not always prevent ovulation. The Pill also reduces the likelihood of conception by thickening the cervical mucus, which inhibits sperm movement. In addition, the Pill decreases the thickness and quality of the lining of the womb so that if fertilization/conception occurs, the newly conceived human being, in the form of an embryo, is much less likely to implant in the womb. By this means, the Pill causes abortions.

ALTERNATIVES

Common alternatives to the Pill, such as condoms, spermicidal substances, cervical caps, withdrawal, or sterilization, are associated with many health, social, and/or ethical problems.

There are, however, methods of family planning, commonly called “Natural Family Planning,” or “NFP,” which are medically safe and which, by all available evidence, have none of the associated social or ethical problems mentioned above. [31] Unlike birth control, NFP does not separate sexual intercourse from procreation. Also, modern methods of NFP (developed since 1950) are as effective as the Pill. NFP involves the woman becoming aware of her personal signs of fertility. On the days on which she is fertile (about 100 hours per monthly cycle), she and her husband decide whether they wish to achieve or postpone pregnancy at that time. This level of communication reportedly has a strong positive effect on their relationship. An incidental benefit of NFP is that it is nearly cost-free.

WHERE CAN I FIND MORE INFORMATION ABOUT ALTERNATIVES TO THE PILL?

Many women have found that physicians who have chosen not to prescribe hormonal birth control and instead have familiarized themselves with Natural Family Planning (NFP) are very knowledgeable in the diagnosis and treatment of medical issues involving the menstrual cycle. A database, searchable by state and zip code, of these physicians can be found at OneMoreSoul.com. This database also lists a number of organizations that promote NFP and many of the teachers of NFP in the United States. NFP teachers help women learn a method of NFP. This can be helpful for women, not only as a family planning method, but also for understanding the workings of their reproductive system. For more information about NFP instruction available in your community, contact one of the following organizations:

References

1. Facts on contraceptive use. Guttmacher Institute. Retrieved on Mar 20, 2008 from www.guttmacher.org.

2. World Contraceptive Use 2001 wall chart. United Nations Population Division, 2002.

3. Grant E. The Bitter Pill: How Safe Is the “Perfect Contraceptive”? 1985; 19.

4. Estimates of mortality from contraceptive use. Retrieved on Apr 7, 2008 from http://www.pdr.net/druginformation/DocumentSearchn_Local.aspx?documentId=90403950&drugname=Lybrel%20Tablets.

5. Kahlenborn C. Breast Cancer, Its Link to Abortion and the Birth Control Pill. 2000.

6. Hume K. Effects of contraceptive medication on the cervix. The Biology of the Cervix. Retrieved on Apr 11, 2008 from http://www.billings-ovulation method.org/omrrca/bulletin/vol25/no2/effects.shtml.

7. Panzer C, et al. Impact of oral contraceptives on sex hormone-binding globulin and androgen levels: a retrospective study in women with sexual dysfunction. J Sex Med 2006 Jan; 3(1):104-113.

8. Laumann EO, Michael, RT (eds). Sex Love and Health in America: Private Choices and Public Policies. 2001; 46-49.

9. Jones RK, et al. Contraceptive use among US women having abortions in 2000-2001. Perspect Sex Repro H. 2002; 34(6):294-303.

10. Larimore W, Stanford J. Postfertilization effects of oral contraceptives and their relationship to informed consent. Arch Fam Med. 2000; 9:126-133.

11. Benson & Pernoll’s Handbook of Obstetrics & Gynecology. 2001; 735-738.

12. Davenport M. Rethinking Reproductive Medicine. 2003.

13. Arowojolu AO, et al. Combined oral contraceptive pills for treatment of acne. Cochrane Database of Syst Rev. 2004.

14. Turowski CB, James WD. The efficacy and safety of amoxicillin, trimethoprim-sulfamethoxazole, and spironolactone for treatment-resistant acne vulgaris. Adv Dermatol. 2007; 23:155-163.

15. Trickey R. Women, Hormones, and the Menstrual Cycle: Herbal and Medical Solutions from Adolescence to Menopause. 2004.

16. Retrieved on Apr 18, 2008 from http://www.pdr.net/druginformation/DocumentSearchn_Local.aspx?documentId=69200150&drugname=Accutane%20Capsules.

17. Marjoribanks J. Nonsteroidal anti-inflammatory drugs for primary dysmenorrhoea. Cochrane Database of Syst Rev. 2003; Issue 4.

18. Dennehy C. The use of herbs and dietary supplements in gynecology: an evidence-based review. J Midwifery Wom Heal. 2006; 51(6):402-409.

19. Vercellini P, et al. Cyproterone acetate versus a continuous monophasic oral contraceptive in the treatment of recurrent pelvic pain after conservative surgery for symptomatic endometriosis. Fertil Steril. 2002; 77:52-61.

20. Nothnick WB. Treating endometriosis as an autoimmune disease. Fertil Steril. 2001 Aug; 76(2):223-231.

21. Hilgers T. The Medical and Surgical Practice of Napro-Technology. 2004 Jul; 404.

22. Schroeder B. Practice guidelines: ACOG releases guidelines on diagnosis and management of polycystic ovary syndrome. Am Fam Physician. 2003 Apr; 67(7).

23. Stadtmauer L, Oehninger S. Management of infertility in women with polycystic ovary syndrome: a practical guide. Treatments in Endocrinology. 2005; 4(5):279-292.

24. Farquhar C, et al. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev. 2003; Issue 4.

25. Kashanian M, et al. Pyridoxine (vitamin B6) therapy for pre-menstrual syndrome. Int J Gynecol Obstet. 2007 Jan; 96(1):43-44.

26. Stevenson C, Ernst E. Complementary/alternative therapies for premenstrual syndrome: a systematic review of randomized controlled trials. Am J Obstet Gynecol. 2001; 185:227-235.

27. Bertone-Johnson, ER, et al. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005; 165:1246-1252.

28. Steinberg S, et al. A placebo-controlled clinical trial of l-tryptophan in premenstrual dysphoria. Biol Psychiat. 1999; 45(3):313-320.

29. PDR for non-prescription drugs, dietary supplements, and herbs: the definitive guide to OTC medications. (Physicians Desk Reference, 29th ed) 2008, 425.

30. Stanford J. Mechanism of action of intrauterine devices: update and estimation of postfertilization effects. Am J Obstet Gynecol. 2002 Dec; 187(6).

31. Wilson M. Love and Fertility. 2005; 85.

Alternatives to the Pill

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