Month: September 2020

The combined oral contraceptive pill (OCP), commonly known as ‘the Pill’, is one of the most well-known prescribed medications. Yet, it is something that many women don’t feel fully informed about.

Whenever I speak about sex hormones, the Pill—particularly how it works and what it does in the body—is something that I’m always asked about. And many women are surprised by what they learn. So, while I always encourage discussing any questions or concerns about the hormonal contraceptives you are using (or considering using) with your doctor, I wanted to share some general information on this topic, to help you feel more informed.

The combined OCP contains a combination of two hormones—a type of estrogen and a progestin, which is a synthetic substance similar to progesterone; some types are structurally similar to testosterone. Progestins mimic some of the effects of progesterone, but they’re not identical to the progesterone the body makes and so they aren’t identical in all of their actions.

There are numerous OCP formulations but the classic type has 21 days of active (hormone-containing) pills and 7 days of inactive (or ‘sugar’) pills. When you take the inactive pills, the withdrawal of the supply of hormones leads to a withdrawal bleed—which looks like a period but isn’t actually a menstrual period.

How it works – contraception

The main way that the OCP works to prevent pregnancy is by preventing ovulation from occurring. It also thickens the cervical mucus which helps to prevent sperm from passing through.

When the brain detects the presence of the synthetic hormones supplied by the pill, it gets the message that ovulation has already occurred and that it therefore doesn’t need to communicate with the ovaries to make this happen. When the communication between the brain and the ovaries is suppressed, this shuts down ovarian sex hormone production. Really consider that. This is how the Pill stops an egg being released each month.

Ovulation is the trigger for progesterone production so because ovulation does not occur while a woman is on the OCP, there is no progesterone being produced by the ovaries. While the Pill does contain a progestin, which has some similar effects to progesterone—such as helping to make periods lighter—it doesn’t have all of the same actions and benefits as the progesterone that our body makes. For example, you miss out on progesterone’s anti-anxiety effects.

How it works – symptom management

It would be remiss of me not to mention that the OCP is frequently prescribed for cycle symptom management rather than primarily for contraception. The Pill can suppress cycle-related symptoms because it essentially takes your own sex hormones offline and takes over the job itself. So, it’s important to be aware that the Pill cannot regulate your menstrual cycle or balance your own sex hormones. For many women it suppresses their symptoms and provides regular withdrawal bleeds (which look like periods) while they are taking it, but their symptoms tend to return once they cease it, if they haven’t addressed the underlying problems or imbalances contributing to these.

Please know that I am not suggesting that the Pill should never be taken for this reason. While I do encourage getting to the heart of any health challenge you experience and exploring the lifestyle-based strategies that can be incredibly effective for improving and in many cases resolving cycle-related symptoms, there are instances where the OCP might be the right choice for an individual who is suffering with debilitating symptoms and whose quality of life is greatly impacted by these – while they concomitantly work on what is creating the suffering. The other instance when the OCP can be a helpful option is when the prevention of pregnancy is crucial and those having intercourse are not able to take responsibility for this in other ways. More often than not, there are things that can be done from a dietary and lifestyle perspective to support the body’s own sex hormone balance and ultimately improve/resolve cycle-related symptoms and quality of life. Addressing any underlying issues sooner rather than later can also support other aspects of our health and it means we won’t have to deal with them further down the track when they may have become more complex with time.

It’s also important to mention that for some women, the OCP can actually cause some side effects and symptoms. So, if you choose to use the OCP, the most important thing is to listen to your body and how YOU feel. Each woman can respond differently—some feel great, yet others experience challenging symptoms and find that their body doesn’t respond well to it. Be sure to observe how you feel and whether there are any changes (positive or negative) in your physical symptoms and your mental and emotional wellbeing if or when you make any changes to your use of hormonal contraceptives, such as the OCP.

Some other things to consider

The OCP is known to deplete a number of nutrients so it’s important to be consuming a variety of nutrient-rich whole foods, and particularly getting enough zinc, magnesium, selenium, vitamin C, E and B vitamins. Remember too, that regardless of whether our body is making our sex hormones or these are being supplied by a medication, the liver is still primarily responsible for changing estrogen so that it can be eliminated once it has done its job in the body. So, it’s incredibly important to continue supporting the liver with nourishing food and drink choices.

Some women (not all) experience an exacerbation of acne in the months after coming off the Pill as their hormones and body readjust to moving from relying on synthetic hormones back to the body’s innate production. Zinc is an important nutrient for both the skin and sex hormone balance and the OCP can deplete this, so it can be wise to ensure you are getting enough zinc. In my experience, supplementation is often necessary across this transition to help alleviate symptoms.

Lastly, because the OCP shuts down the communication between the brain and the ovaries, for some individuals it takes time for these communication pathways to become robust again after ceasing the Pill—meaning it may take some time for your natural menstrual cycle to become regular again. For some, this depends on how close to the onset of menstruation (menarche) they were when they first went on the OCP as, if the communication pathways between the brain and the ovaries were not well established—which can take up to five years from menarche—it can take time for that to occur after coming off the Pill. Allowing yourself time to re-establish regular ovulation and to replenish nutrient stores is something to be mindful of, even more so if you are planning to come off the Pill with the view to conceiving in the future. If your period doesn’t return within three months of ceasing the OCP, it’s best to check in with your doctor. If there is nothing wrong and you are told it will just take more time, you might like to consider exploring herbal medicine under the guidance of a qualified practitioner, as there are numerous herbs that can help foster good communication between the brain and ovaries, such as chaste tree or the well-studied combination of licorice and paeonia.

Please note: This information is for educational purposes only and is not a substitute for professional advice. Always discuss the use of hormonal contraceptives with your medical doctor for individualised advice and always read the label and information provided with any medication you are prescribed.

Progesterone is one of our key sex hormones and its name gives some indication of what it does in the body (think ‘pro-gestation’). Yet it plays a key role in so much more than fertility. In fact, progesterone is a substance that every woman needs to know about, regardless of whether pregnancy is on her agenda or not, because of its many biological effects.

Progesterone production that is far from ideal is, unfortunately, very common and it’s likely that you have experienced this at some point in your life—if not right now. When we’re not making optimal amounts of progesterone, this can contribute to a range of challenging symptoms in the lead up to and/or during menstruation. The reason for this is because progesterone helps to counterbalance estrogen. So, when we have poor progesterone production, this can tip the delicate balance of our sex hormones—and our body lets us know about it.

Progesterone has a number of important functions in the body. It supports the body’s fluid balance to prevent you from feeling puffy and swollen, and it helps to hold the lining of the uterus in place so that you don’t experience excessively heavy or prolonged bleeding. Not to mention it has anti-anxiety and antidepressant actions, making it a pretty powerful substance that we don’t want to be lacking.

When progesterone is low, signs and symptoms can include:

• Very heavy periods
• Spotting for a number of days leading up to your period
• Bloating and fluid retention
• PMS—especially anxious feelings and irritability leading up to your period
• You may feel like you can’t get your breath past your heart or like your heart is racing in the lead up to menstruation
• Irregular periods
• Missing periods (and pregnancy is ruled out)
• A short luteal phase, which sometimes shows up as a shorter cycle—there’s not enough progesterone to hold the lining of the uterus in place
• A longer cycle, which means an increased number of days between ovulations.

How your body makes progesterone

During the menstruation years, progesterone is predominantly made by the ovaries in a cyclical manner, and much smaller amounts are made by the adrenal glands across your life. The trigger for ovarian progesterone production is ovulation so if we don’t ovulate, we don’t make it. Once ovulation occurs, a temporary gland called the corpus luteum forms in the ovary where the egg was released from. The corpus luteum produces progesterone from that point (after ovulation) up to just before you get your next period and this phase of the cycle is called the luteal phase.

For ease of understanding, the luteal phase is often referred to as the second half of your cycle (think ‘l’ for last half). However, this isn’t technically correct for every woman as depending on her cycle length, the two phases (the follicular phase and the luteal phase) may not be equal halves—their durations can differ. The luteal phase is ideally about two weeks long and progesterone levels peak at the mid-point of this, so this is why if you are having a blood test for progesterone it is best done about seven days before you get your period (so day 21 if your cycle is 28 days long).

What interferes with great progesterone production?

As you now understand, regular ovulation is essential for a woman to produce enough progesterone during her menstruation years. If you aren’t ovulating or you ovulate infrequently, it’s incredibly important to get to the heart of why this is. Commonly, this can be linked to chronic stress or worry, a frantic pace of life, inadequate rest, not feeling ‘safe’ (whatever this means to an individual) physically or emotionally, not eating enough and/or excessive exercise. These are all forms of stress to the body and increase stress hormone production. Not only can chronic stress lead to anovulatory cycles which means no ovarian progesterone production, but it can also contribute to scenarios where ovulation occurs but progesterone production is suboptimal.

Stress is a major contributing factor to low progesterone because of its link to fertility (because your progesterone levels surge after an egg becomes available). If the body is getting the message that your life is in danger—which is what too many stress hormones communicate—the last thing it wants is for you to potentially conceive at a time it perceives as dangerous, as this could mean the baby might be at risk. So, your body thinks it is doing you a favour by downregulating fertility during times of high stress. Processes that aren’t essential to our survival (such as reproductive function) are not prioritised when the body is putting all of its resources into keeping us alive.

There are also life stages where we are more susceptible to irregular ovulation and low progesterone, such as puberty and perimenopause. These are transition phases and it is normal for ovulation to be less regular during these seasons of our life. While many women experience challenging symptoms during perimenopause, it’s important to know that there are things you can do to support your body and experience a gentler transition. During this time, it’s even more important to take great care of yourself in terms of your nourishment and stress management, as excess stress hormone production—which can be driven by worrying, rushing and feelings of overwhelm, daily alcohol consumption over an extended period of time, restrictive dieting or excessive exercise—can still contribute to anovulatory cycles, irregular periods and low progesterone during this life stage.

That said, irregular ovulation or a lack of ovulation can also sometimes occur with other conditions such as polycystic ovarian syndrome (PCOS) or thyroid dysfunction. If you experience unexplained irregular periods or if your periods have gone missing (and you are not using a type of hormonal contraception that causes this), it’s important to check in with your doctor. For more on hormonal contraception and its influence on progesterone production, you might like to read this blog here on the OCP or this one here on the Mirena.

What about progesterone post-menopause?

Progesterone levels are naturally low post-menopause as ovulation is no longer occurring and women in this life stage don’t have the cyclical sex hormone fluctuations that characterise the menstruation years. The adrenal glands become the primary source of progesterone post-menopausally, and these important glands are also tasked with making our stress hormones. Incorporating strategies to help reduce and manage stress or worry, such as daily breath-focused practices and getting to the heart of what stress really is for an individual so you are able to make fewer stress hormones in the first place, is incredibly supportive for women post-menopause and can truly make a difference in how you feel day-to-day.    

The hormonal IUD—commonly known by the brand name Mirena®—is a small, plastic T-shaped device that is inserted into the uterus. It is considered a long-acting form of contraception as it can remain in place for a number of years. It releases small amounts of a progestin hormone into the uterus. Progestins are synthetic substances that are similar to progesterone, but not identical. They mimic some of the effects of progesterone—such as reducing bleeding—but they don’t have all of the same actions and benefits that progesterone does.

How it works

The progestin-releasing IUD works to prevent pregnancy by thickening the cervical mucus which prevents sperm from passing through, as well as by thinning the uterine lining and physically inhibiting fertilisation due to its placement.

It can suppress ovulation, but this is not its primary contraceptive mechanism. It is still possible to ovulate with this form of contraception; however, some cycles will likely be anovulatory. Anovulatory cycles generally occur more frequently within the first year after the IUD has been placed, likely as this is when the release of the progestin would be at its highest (it gradually reduces over time). Ovulation is the trigger for ovarian progesterone production, so it is still possible to make your own progesterone while using this form of hormonal contraception (in the cycles when you do ovulate).

Besides contraception, the hormonal IUD is often used for the management of very heavy periods and flooding, because the release of the progestin into the uterus acts to thin the lining. For some women, bleeding can cease altogether, or it becomes less frequent. If this occurs, it is still possible to ovulate but not have a period (this scenario does not occur with other types of hormonal contraceptives—typically it is the opposite, where you bleed but don’t ovulate).

Some things to consider

For some women, the hormonal IUD can contribute to challenging side effects. It can commonly cause irregular bleeding and spotting, particularly within the first few months of use, as well as other side effects such as breast tenderness, an exacerbation of acne and/or significant mood changes. Each woman is different, so if you choose to use any type of hormonal contraception, the most important thing is to listen to your body and notice how YOU feel. It can be wise to take note if there are any changes (positive or negative) in your physical symptoms and your mental and emotional wellbeing when using hormonal contraceptives, including the hormonal IUD.

Another consideration with using the hormonal IUD to manage cycle-related symptoms is that it doesn’t resolve why menstruation presented such challenges in the first place. If bleeding is heavy or prolonged, it is most commonly related to an excess of estrogen and/or inadequate progesterone production, which often involves the liver and/or gut not doing their critical estrogen detoxification work efficiently, and prolonged excessive stress hormone production. Because it doesn’t address the root cause/s of the symptoms, the hormone imbalance that created them is not corrected, which potentially increases the risk of other challenges presenting down the track. So, essentially, using a hormonal IUD masks symptoms. Yet this may be immensely beneficial or even necessary for the quality of life for some women. For example, it might mean they can leave the house with confidence if flooding has previously been a problem or get blood iron levels restored after long-term excessive menstrual blood loss, resolving debilitating fatigue. Anytime you mask symptoms, even when this might be necessary or you get positive outcomes from the band-aid, consider addressing the hormonal imbalances that will likely still be occurring, while you have your relief. That way, your use of synthetic hormones can be temporary, rather than you feeling like your life depends on them – a bridge, not an essential. Remember, symptoms can be our body’s way of communicating to us when something needs to change, so when challenging cycle-related symptoms are present I always encourage getting to the heart of the ‘why’.

I’m also commonly asked how a woman knows which stage she is at with her cycle when she has the Mirena® IUD, particularly if she is perimenopausal. Menopause is defined as the 12-month anniversary of your last period (12 consecutive months without menstruating), so because it is fairly common for bleeding to become less frequent or to stop altogether with the Mirena® IUD, this can make it difficult to know exactly when you have reached menopause, as you may still be ovulating but just not bleeding regularly due to the IUD. If it is something you are really wanting to know, sometimes a blood test may be done to check your hormone levels as this can indicate if you are post-menopausal, however please just be aware that your doctor may only be able to order subsidised tests if it is deemed clinically necessary. You can offer to pay for tests to gain more insight if you feel so inclined.

A final note on IUDs

There are different types of IUDs, so the hormonal IUD (Mirena®) discussed above is not to be confused with the copper IUD which is not a hormonal contraceptive. The benefit of the copper IUD is that it doesn’t release any hormones into the body and doesn’t interfere with ovulation; the downside is that it may lead to heavier periods for some women and/or a disruption in your zinc to copper ratio, which can drive zinc deficiency if you aren’t taking steps to ameliorate this.

Please note: This information is for educational purposes only and is not a substitute for professional advice. Always discuss contraception options with your medical doctor for individualised advice.