Coming off hormonal birth control

Women have fought long and hard for contraception, so that all of us could have control over our reproductive health. Birth control has always been a major part of this fight because it is an important tool in allowing us agency over our health and bodies as well as providing protection from unwanted pregnancy.

However the problem with hormonal birth control (HBC) is that it is prescribed for women for all sorts of hormonal health issues that are completely unrelated to contraception including period pain, heavy periods, no periods, irregular periods and acne which masks those issues, and it can have significant side-effects.

It takes 12 years for a woman to mature her HPA axis – the communication pathway between the brain, the pituitary and the ovaries. So if you start your period at 14, it will take until you’re 26 to have established a healthy, normal, ovulation cycle. it is no wonder then, that many women who have been on the pill since their teens and stop in their 30s to try for a baby, have fertility issues.

The medical approach to period problems shuts ovulation with contraceptives such as the Pill, implants, injections and Nuvaring.

As ovulation stops, so the production of DHEA, oestrogen, progesterone shuts down as well. It causes the ovaries to shrink by almost 50%, to the same size that they shrink to at menopause. When HBC is discontinued, the ovaries previously suppressed with synthetic hormones fail to return to healthy function, often leading to irregular periods, heavy bleeding and acne.

In the meantime the hormonal imbalances cause troubling and potentially serious side effects such as depression, weight gain, microbiome disturbance, and loss of libido.

Emerging research is also suggesting long term impacts on insulin resistance, fat mass, diabetes and bone mass.

Sandra supports women in coming off hormonal birth control to minimise unwanted side effects such as rebound acne, irregular periods or no periods. Additionally she provides support for weight loss and hair growth

Sandra’s approach is tailored to each woman. Hormonal birth control does not fix period problems, only masks them and the support is customised depending on the health issues before starting hormonal birth control.

Our natural hormones Estrogen, progesterone an DHEA are required to make a healthy brain, bones, muscles and metabolism.

• Estradiol (the main oestrogen) plays a key role in insulin signalling
• Estradiol and progesterone influence the release of neurotransmitters – serotonin, dopamine, GABA – to keep mood stable
• Progesterone converts to alloprogesterone and interacts with the brain and nervous system.

The steroids in HBC are not the same as our natural hormones.

Oestrogen:

• Natural oestrogen is replaced by Ethinyl estradiol which worsens insulin sensitivity, causing insulin resistance and weight gain.

Natural progesterone is replaced with a variety of progestins:

• Levonorgestrel causes abortions – it is used in the Plan B abortion pill
• Many synthetic progestins have a similar structure to testosterone, and are androgens i.e. they work as testosterone

Natural progesterone is a calming hormone which converts to allopregnenalone, which is a strong modulator of the GABA receptors in the brain. It is hormonal valium. Progestins don’t convert to allopregnenalone and so don’t support mood or brain function. Levonorgestrel dramatically reduces progesterone and therefore allopregnenalone, and does the opposite, reducing GABA receptors, leading to anxiety

Synthetic Progestins

Progestins have an androgen index, indicating how close their effects are to testosterone. Androgenicity is described as the progestin’s affinity for and binding to the androgen receptor, and it’s effect on the sex hormone binding globulin (SHBG). SHBG binds testosterone and estrogen making the sex hormones unavailable for use at the receptors.

Levonorgestrel and dl-norgestrel have a high affinity for sex hormone binding globulin and decrease free sex hormone binding globulin levels by binding it and displacing testosterone, consequently increasing free testosterone levels. (PMID: 15802398)

High androgen index:

• Causes acne, weight gain, anxiety and hair loss (can be devastating)
• Older progestins are made from testosterone
• Progestins include: Levonorgestrel, Norgestrel, Medroxyprogesterone
• Included in: Levelen, emergency contraception, Mirena, Depo-provera

Medium androgen index:

• Norethindrone, Desogesterel, Etonogestrel
• Included in: Loestrin, Implanon, Nova ring

Low androgen index:

• suppress DHEA, higher risk of fatal blood clots, depression and anxiety, loss of libido
• Drospirenone – derived from a diuretic drug – anti-androgen – reduces acne but causes more depression, anxiety and clot risk than the high androgen progestins
• Cyprotenone – Yaz and Yasmin, Brenda

Mirena coil

• Intrauterine Levonorgestrel releasing IUD
• Works locally in the uterus, prevents fertile mucus, impairs sperm and thins the uterine lining.
• Blood levels of progestins are at 10% compared to Levonorgestrel pill, but this is still enough to cause androgen side-effects in some women such as acne and hair loss.
• Allows normal estradiol and some ovulation .

• Altered microbiome of gut [PMID: 26658991]
• Altered microbiome of vagina IPMID: 24993504] – yeast infections, thus, UTI
• Altered brain structure IPMID: 25832993]
• Altered sleep architecture IPMID: 17383933]
• Reduced bone density IPMID: PMID 20004271]
• Gallbladder disease IPMID: 21502354]
• Increased risk of cervical dysplasia IPMID: 18513406]
• Increased risk of autoimmune disease IPMID: 19333988]
• Zinc deficiency IPMID: 19501214]
• 3-fold higher risk of breast cancer [PMID: 25085875]
• Digestive bloating
• Recurrent bladder infections
• Thrush
• Vaginal dryness

A real period is about the healthy functioning of the ovaries and the healthy production of oestradiol and progesterone. A pill bleed suppresses those hormones and instead is a bleed from the withdrawal of the drugs. So the timing of the pill bleed is about the dosing of the drug.

There is no medical reason to bleed monthly on HBC. Hence HBC does not regulate periods. It stops periods altogether, and a bleed only occurs when HBC is paused which causes a drug deficiency.

Once HBC is stopped, the most common symptoms are:

• Irregular or skipped periods
• Heavy menstrual bleeding
• Ovulation pain and menstrual cramps
• Acne breakouts
• Bloating
• Mood swings

Sandra’s approach to coming off the pill consists of consecutive stages, and ideally should begin 2-3 months before HBC is stopped:

Individualised support, with 4 distinct strategies, depending on how periods were before HBC started:

• PLAN A: normal periods
• PLAN B: irregular periods
• PLAN C: acne
• PLAN D: heavy bleeding and/or period pain

Nutrition

• Individualised recommendations for appropriate nutrition, including avoiding sugar and dairy increasing healthy fats, protein, fibre and phytonutrients.
• Full blood tests including: liver function, thyroid metabolism, iron levels, vitamin D, vitamin B12, folate, cholesterol, zinc levels.

Supplements

• Individualise supplementation of all the nutrients that HBC depletes including:
• B vitamins: loss of B vitamins can lead to depression, which then leads women to be prescribed anti-depressant medication (if you would like support with coming off anti-depressants then please see here).
• Magnesium
• Zinc
• Vitamin D, which declines once off HBC, and is required for ovulation
• Support the hypothalamic pituitary ovarian axis with glandulars to revive the ovaries, restore ovary-brain communication and support fertility.

Tests

• 3 months after coming off HBC, testing for oestradiol, progesterone and testosterone to make any further adjustments.
• Some women may need cortisol tests.

How long it takes for periods to resume and normalise depends on which HBC was taken, how long it was taken for, what it was taken for originally and your age.

• Stopping the Pill should allow the ovaries to return to their normal size within 3 months, and AMH levels to normalise within a year. Which means that conception can be delayed for over a year.
• It can take up to 18 months for cycles to return after Depo-Provera discontinuation
• IUD can allow a quick return of fertility, but progestin-based IUDs can take longer.

The wonderful news is that supportive nutrition, supplements and lifestyle changes can restore ovarian function and get you back to your natural flow.

Book a discovery call to see if this approach is right for you.