Episode #126:Research Recap: Journal Article Review on PCOS Contraception

Hi, and welcome back to the PCOS Repair podcast, where today I’m really excited to be reviewing another research article. I think that it’s been exciting over the last several years how much more research is being done and published about PCOS specifically. I’m always excited to share that with you here on the podcast. I hope you find that it’s helpful. First of all, this one is an interesting one because birth control pills have been a mainstay treatment in helping women have regular cycles. From a medical standpoint, physicians are taught in medical school that unless someone is trying to get pregnant with PCOS, birth control is a really good option to give them. In this particular research article, it’s looking at the fact that because women with PCOS, because it’s a lifelong disorder, they’re going to probably want to be on the medication, the birth control, for a long period of time, and whether or not that is a appropriate treatment modality because there are risks associated with birth control. This article wanted to look at specifically the concerns of diabetes and hypertension and cardiac risk factors in regards to PCOS and birth control. I think this is a really interesting article that we’re going to dive into today.

Before we dive into the article, I just want to remind our frame of reference. There is our own personal health and how we care for our health, and that’s our lifestyle. Then whenever we have a medical problem or a problem with our health or a symptom that we feel, then that’s when we go to our physician to get help with it. When we go to a traditional medical physician, the tools that they have are procedures and medications and monitoring. When it comes to PCOS, their tools are limited because This is a disorder that really it stems in our genetics that is amplified or softened by the environment that we expose ourselves to. Then there are medications and so forth and things that the medical doctors can do to help with those symptoms that arise from our PCOS, given the environment that we’re in. My hope is that we can make so much more positive progress by adjusting our lifestyle to dampen the negative effects and to amplify our health, then we can get assistance from medical treatments. That does not mean that medical treatments are not helpful. By any stretch of the imagination, that’s not what I’m trying to say here, But I think that as we dive into the pros and cons of birth control, I want to preface this particular episode by saying that while there are risks with not having a period for long periods of time where birth control may be a really beneficial thing certain people, and not all people are interested in adjusting their lifestyle.

It’s not their top priority at the moment. And so that may be something that they find really helpful in managing their life the way they want to. Absolutely no judgment there about that. But if you’re wanting to take a natural approach, birth control is definitely not necessary. It is a conversation that you’re going to want to have with your physician about when and if and how and do you need it and so forth, because like I said, there can be risks in going too long without having a period. But birth control can also cause some hormonal disruption, as we’ll see in this article as well as there’s other articles that talk about that. It’s not a clear-cut decision. And so knowing that you can do so much for your PCOS with your lifestyle, but then also being armed with the information of if you do choose or for whatever reason need to be on birth control, you understand the pros and of that as well. I think information is just important. We don’t need to be scared by it, but the better we understand it, the more informed we can make our decisions, and the more informed that we can have a conversation with our health care providers when we go to see them and so forth.

So that’s why I’m excited to bring you this article today. This article is from the Journal of Endocrinology and Metabolism, and it is titled An Update on Contraception in Polycystic Ovarian Ovarian syndrome. It was published in 2021. At the time of this recording of the podcast, it is a relatively recent journal article. Okay, so a couple of things. First of all, it’s important to just remember that polycystic ovarian syndrome is a very, very common reproductive and endocrine and metabolic disorder characterized by hyperandrogenism, as well as irregular periods and ovulation and having various symptoms systems that arise from those root causes of the endocrine and the metabolic and the cycle disturbances that can lead to infertility and so forth. One of the main treatments for women who are not planning to become pregnant is to be put on a combination contraceptive. As a reminder, a combined oral contraceptive is a combination of a low dose estrogen with a progestin. These started back in the ’60s, and they contained high doses as an estrogen. Then this was over time, lower to lower amounts. We have to be a little bit aware of where our research is coming from when we’re reviewing some of these, because historical amounts of combination birth control compared to current amounts in combination birth control do vary.

So knowing that that’s a thing and then doing your research on what years things change so that you’re aware of comparing apples to apples, or at least that your doctor is. If your doctor says something and you’re like, It doesn’t quite sound like something else you’ve read, just be aware there are some discrepancies there and make sure that both of you are talking about the same era of medications. One of the historically high risk factors for estrogen-containing birth control is DVTs or some thromboembolism. Those ones were why it wasn’t good to take birth control if you’re a smoker or have a history or a family history of clots or clotting. That still remains something that can be contraindicated for certain medications and that should be evaluated by your healthcare provider prior to giving you a prescription of birth control. But birth control has become so commonplace that sometimes these in-depth histories miss something. So make sure that if you have any concern of a clot or a family history of clot, that you at least discuss it with your healthcare provider. But the combination medications, they usually come with either two types of estrogen.

The most common type is an EE, which is a modified synthetic form of estradiol. So it’s a synthetic, it’s not bioidentical. Then there’s a couple that contain a estradiol valerate, which is an E2V. You may see that abbreviation, which is a more natural form of the estradiol. That one’s not as common. Most of the ones you’re going to see are the EE form. Then there’s numerous forms of progestin, and they’ve had several different generations of development as well. Let’s talk about the mechanism of action. This is an interesting thing of how these work, because in the last couple of weeks, we’ve had some discussion on the podcast about how the cycle naturally works. This is how the mechanism of action, so basically, this is how your combination birth control would work in your cycle. You’ll see here when I go over, a research article is sharing that it dampens certain parts of your cycle. When you go off of it, I believe, this is not in the research article, but I believe that’s why some women with PCOS struggle to regain these aspects of their cycle, is that the birth control train the body to react this way.

In the article here, the mechanism of action is that the progestin component of the combined oral contraceptive directly inhibits the secretion of the gonadotropin-releasing hormone, and this suppresses the luteinizing hormone, so your LH. So the peak doesn’t happen. So it just stays at a base level. And so ovulation doesn’t happen because that LH peak is required for ovulation. So the absence of this LH peak causes a decrease in ovarian sensitivity to FSH, your follicular stimulating hormone, which leads to a reduction in estradiol production. So then another thing that the progestins do is they prevent the sperm penetration in the implantation because they increase the viscosity of the cervical mucus, and they decrease the tubal mobility, and they thin the endometrial lining. So by thinning the endometrial lining, specifically, you’re really impeding the ability for an embryo to implant and for pregnant emergency to occur. The estradiol component of the combined contraceptives affect the progesterone by suppressing the FSH search. So that first half of your cycle where estrogen is your primary player, it’s the The estradiol component of your combined oral contraceptive is suppressing that FSH surge that does not select a dominant follicle and finish maturing it to prepare for ovulation.

So your ovaries are not preparing a follicle each month, or they’re decreasing the amount that they would do that, which also improves the menstrual cycle for women that are having problematic periods or cycles because it helps to prevent that breakthrough bleeding because it maintains needs an endometrial proliferation. Basically, the endometrial lining stays more consistent, so there’s less breakthrough bleeding with the combination oral contraceptives. What about combined oral contraceptives in the use of women with PCOS, specifically? The article states very clearly that lifestyle modifications are the number one modality of treatment and should be the number one consideration when it comes to PCOS. But in addition to those, combined oral contraceptives represent the first line treatment in most women with PCOS if fertility is not desired in order to regulate the menstrual cycle and improve clinical signs of hyperandrogenism. Basically, when a female goes to their doctor, my opinion, this is not from the article, but when a female goes to her doctor because she’s having irregular periods and she does not want to get pregnant, birth control would be the first line after lifestyle suggestions in order to treat her PCOS symptoms. Now, caveat here, too, that I want to point out is that medical professionals are not trained in lifestyle modifications.

So they may say you may want to live a more healthy lifestyle that may improve your PCOS, but they’re not really trained to give much advice beyond the fact that lifestyle would be their number one recommendation. And so that becomes frustrating because then their next recommendation they have available for you, but their first recommendation, they don’t have a lot of advice for you on how to actually implement that. And that’s why I started the podcast and what I do here at Nourish to Healthy. Okay, so The non-contraceptive benefits of combined oral contraceptives is that they can reduce heavy bleeding, they can improve symptoms of endometriosis and pelvic inflammatory disease. Now, I want to point out, though, here, just because I’m lumping this in with this article that’s talking about contraceptives for PCOS. Endometriosis and pelvic inflammatory disease are not related to PCOS. They are an additional finding, they are an additional problem. Sometimes they go hand in hand, but Just because you have PCOS doesn’t mean that you have endometriosis or vice versa. They are two separate things. A lot of women, they think that their pelvic pain is because of PCOS. Heavy periods can lead to cramping, sure.

But other than that, PCOS is typically not super painful. You can have a cyst on the ovaries that’s really painful. That’s not a PCOS cyst. That’s actually a true cyst, not ovaries that look cystic because of the multiple partially matured follicles. There’s a lot of lumping these things all in together. They actually are separate things and should be addressed separately. But the consideration of whether or not to go on an oral contraceptive, if you have PCOS, you’re having irregular periods, and you have endometriosis, would change your consideration potentially if this is a good treatment for you. Also, it can help with women who really suffer with PMS or a more advanced form of PCOS called premenstrual dysphoric disorder. So having really, really, really, really moody or horrible days leading up to when your period should start. Also, it was interesting that the research article did note that women using combined oral contraceptives, their risk of both endometrial and ovarian cancer was reduced by nearly 30%. Now, that’s a complicated statistic. There’s a lot of things that go into that, but these are all reasons why your doctor may talk to you about these. These are specific questions that you may want to bring up to your health care provider of how that works or if that was something that would be of concern to you or of benefit to you.

There still are several concerns and contraindications that go along with the use of combined oral contraceptives. Again, combined being both estrogen and progestin. The biggest one is, of course, a venous thrombosis. This is going to be some clot that can lead to a DVT or a stroke or something like that. They can be quite serious if left unaddressed. Those are one of the top concerns still and why a thorough history should be taken before prescribing any birth control medication. There has been risk of increased MI or stroke. Again, those are I believe in relation to the increased clotting risks. But there also is some counter information that estrogen can actually be beneficial to heart health. These are all conversations that you would want to have with your doctor. They’re really going to come down to probably family history in the conversation about those. But it’s important to know that these have been marked clearly as adverse effects related in research articles and throughout research, proven to be associated with birth control, especially long term use of it. Also, another side effect that was noted, especially in women with PCOS, was that the hyperandrogenism, which is found…

The excess that we have with PCOS, contributes to the insulin resistance through various pathways, which we talked about in the last several episodes, that improving that hyperandrogenism may provide some metabolic improvement. So potentially the effects of combined oral contraceptives may improve the metabolic pathways. However, in reality and in observational studies, this hasn’t necessarily shown to be true, but these are just some things that they theoretically make sense. And so these may be points that your physician points out to you. There’s not a lot of research pointing one direction or another. I think one of the really, this is my personal opinion here, not the research articles, but I think one consideration that is very difficult to always weed out when we’re looking at these articles is that women who have maintained a healthy weight and a healthy lifestyle with PCOS symptoms, like they’re still having some symptoms, Their situation and their health profile and how they react to certain medications is going to be vastly different to someone who is struggling with their weight or has been overweight for a long period of time or who is on the verge of diabetes or who has not adopted certain lifestyle factors to help manage their PCOS.

That same person that has not adopted lifestyle measures to manage their PCOS, if they were to spend a couple months adopting lifestyle modifications, their way of reacting to the medication would likely be quite different as well. A lot of research articles will actually be put in the parentheses. This study was done on women that were under or over a certain BMI, just to try to give a clear a picture on exactly what demographic we’re talking about to help people better understand and make more informed choices of which ones and which advice may or may not pertain to them. It’s a little bit of a cloudy picture is what I’m trying to say there. Then in addition to all of that, there has been a lot of indication that combined oral contraceptives do increase appetite, therefore increasing weight gain over prolonged periods of use. Maybe if you used it for six months, you may not notice that, but over a long period of time, adding a couple of pounds a year may be associated with oral contraceptives, combined with oral contraceptive use. They’ve also been known to potentially cause an increase in blood pressure. Then studies have also indicated in the general population that, not specifically to PCOS, so general population, have suggested that combined oral contraceptives might occasionally be associated with mood alterations, particularly in younger patients and particularly in the form of depression.

Those are our combined oral contraceptives, combination of estrogen and progestin. Next, we have the progestin-only contraceptive. Now, there was an article about this a few weeks ago, I think last month on the podcast where we talked about synthetic progesterone contraceptives. This goes over some of this as well, but looking at these. We have a couple of different forms of progestin-only contraceptives. We have the pills. This is primarily the mini pill. It can be used. It’s used sometimes to induce a period. That can be a very effective way to do that. It’s also not  a bad idea for women who are going long periods of time without having a period to help reduce against endometrial cancer. Ideally, they’re able to get their lifestyle modifications to help regulate that cycle, so they’re having a period often enough to reduce that risk. But if they’re not, the mini pill or a progestin-only pill can be a good way of inducing a period to shed that uterine lining and start fresh. Then we have the Depo Medroxyprogesterone Acetate. This is basically the Depo shot, and this is the one that is actually marked to be avoided with women who have diabetes.

This is one where, frankly, my personal opinion, I would stay away from the Depo shot if it’s at all possible. According to a prospective case-controlled study, a 30 month of the DEPO, basically this is abbreviated DMPA because it’s the DEMPA-methodroxine, a progesterone acetate, so DMP usage. Let me backup and read that to you again. According to a prospective case-controlled study, 30 months of DMPA usage in healthy young women significantly increased body weight, which was entirely attributed to increased fat mass and ino central pattern. Basically, they’re saying that this one was highly associated with weight gain, and that weight gain was not muscle, it was confirmed fat weight gain. That study was pretty clearly marked. It also, and this is concerning, to have weight gain and showed decreased bone mineral density. Not one that I would recommend. Then we have the etonogestrel which is basically the implant. That one’s sometimes implanted in the back of the arm. Studies in healthy women using this one seem to not have reported any adverse effects from a metabolic standpoint. However, a small study of patients with PCOS suggested insulin resistance with a six-month duration of the implant usage.

I would not recommend this one for PCOS. I think a lot of the progestin-only ones tend to be a little problematic for women with PCOS, especially those to the shot and the implant. Next, we move on to the intrauterine contraceptive devices. These are progestin only. They’re long-releasing, over time-releasing IUDs, and they are different durations. This one only talks about the five-year duration, I believe. There are multiple durations of those, but they all fall basically into the same class. The interesting thing with these is that they were able to reverse endometrial hyperplasia. For women who have very, very thick endometrial linings and do have irregular periods, they are the ones that we are concerned about being at higher risk of endometrial cancer. This helped to reduce that hyperplasia, which reduces their risk. It also was helpful in reducing heavy bleeding and in treatment of endometriosis in associated pelvic pain. Those are patients where potentially there could be a really beneficial use. In an observational prospective-controlled study, including non-obese patients with PCOS, six months of an IUD use improved the hyperandrogenemia but increased the weight circumference and fasting plasma glucose measurements, whereas it decreased LDL and total cholesterol concentrations compared to the baseline.

So obviously, there isn’t a clear cut. There are benefits and there are drawbacks. I bring you this article today so that as When you consider your options, as your physician talks to you about different options, or as you see different physicians over time that bring up different options, you are better equipped to have these conversations with them and ask questions so that later on when you go home, you’re not googling things and then wishing you would ask the questions, but going in with better understanding of the topic and ready to ask specific questions. I will also link this article in the show notes on the episode web page. If you go to the episode web page, you’ll find it there. That way, if you ever wanted to discuss a specific article with your healthcare provider, if you had a specific question, you would have the article in order to do so. All right, so that brings us to the conclusion of that research article review for this week, and I hope you found that helpful. Now, I know many of you are coming off of birth control, have been on birth control for a long period of time.

There may be some frustration that you didn’t have some of this information previously. Information is constantly rising, and we’re all learning as we go. I encourage you to feel all those feelings that come up as you hear all this information today. At the same time, give yourself some grace if there was something that you would have done differently in the past or wish you had known in the past. We are learning as we go, and unfortunately, hindsight can be 2020. But if you are struggling after coming off of birth control, there are a lot of episodes to help you with that. On the PCOS Repair podcast. Feel free to reach out to me on Instagram @nourish2healthy. I’d be happy to point you in the direction of other episodes that can help you as you transition back towards trying to have healthy and natural cycles. Then there are those of you who are considering birth control for other reasons, whether your symptoms are fairly controlled, except that you’re still having irregular periods or your periods are too heavy or do not currently want to get pregnant. There’s a lot of reasons why you may want to consider contraceptives, and hopefully that today and that article review is helpful for you.

With that, I’ll say goodbye for this week, and until next time, bye for now.