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  • Contraception - What You Need To Know | with Dr Hazel Batten

    Contraception is something that most women have discussed with their General Practitioner at some stage in life. Many women of reproductive age have used or are currently using a form of contraception, whether it’s for preventing pregnancy, managing period pain, irregularity or heaviness or for improving our skin or hormonal mood swings.

    Contraception has been life changing for women over the past few decades, allowing them to delay their families and focus on their careers and ambitions. However, hormonal contraception can change our body’s natural ability to produce hormones, which can be detrimental.

    The two main female hormones are oestrogen and progesterone. Oestrogen is produced throughout the menstrual cycle. It is beneficial for mood, bones, muscles and metabolism. Progesterone is produced after ovulation and is beneficial for mood, hair, thyroid, bones, skin, metabolism and immune function.

    Here is a review of the different options out there and the pros and cons.

    The Combined Hormonal Contraceptive Pill (COCP) Or "The Pill"

    This is the most commonly prescribed method and is extremely effective (>99%) in preventing pregnancy. COCPs work by stopping the production of ovarian hormones and preventing ovulation. They thicken the cervical mucus preventing the passage of sperm and they thin the womb lining preventing implantation of a fertilised egg (if it were to occur). There are many different types of COCP available. These all vary slightly in terms of their constituent hormone combinations and their potency. Many of the COCPs have 21 active pills and 7 days of non-hormonal sugar pills in which an artificial "period" or pill bleed will occur.

    Some advantages of the COCP are that it stops your natural period so can help with period pain and lighten bleeding. There can be a reduction in the risk of ovarian, uterine and bowel cancer and it can relieve PMS, and improve acne and unwanted hair growth whilst taking it.

    The side effects of the COCP include skin pigmentation, headaches, increased risk of blood clots, breast tenderness, loss of libido, weight fluctuations, nausea, impaired glucose metabolism, high blood pressure, increased risk of heart attack/stroke and breast cancer, headaches/migraines, decreased bone mineral density in adolescence, liver problems, irregular bleeding and malabsorption of vitamins. It can also interfere with certain medications such as anti-seizure meds.

    Post-pill polycystic ovarian syndrome can occur when stopping the COCP. This is a temporary condition, which can last for months. It results in a delay in your period returning. Therefore, if you have an irregularity with your menstrual cycle, it's beneficial to explore and rectify the underlying issue, rather than taking a COCP and having to deal with the problem later down the track when deciding to come off it.

    Different pills contain different oestrogens and progestins. It is beyond the scope of this article to discuss all of these in detail. However, the progestins contained in the COCP are either androgenic or anti-androgenic. The anti-androgenic progestins (e.g. drosperidone), can have temporary benefits in improving PMS, acne and unwanted hair growth over the androgenic forms (e.g levenorgestrel). However, the rebound effect after stopping these anti-androgenic progestins can be worse when eventually ceasing the COCP.

    The Contraceptive Vaginal Ring (Nuvaring)

    This works in the same way as the COCP. The advantages of this are that it is inserted into the vagina and only needs to be changed once a month, so you don't have to remember to take a pill. It has slightly lower doses of oestrogen. There is a lower risk of irregular bleeding, heavy bleeding or painful bleeding. Ovarian and endometrial cancer is reduced. However, it's major side effects include blood clots to legs and lungs, heart attacks, stroke, retinal vessel thrombosis, headaches/migraines, liver problems, major depression and increased risk of breast and liver cancer.

    The Progestogen-only Pill (POP) Or "Mini-Pill"

    These contain synthetic progestins. These are not the same as progesterone which is our body's natural hormone. There are 3 main types available; levenorgesterol (Microlut) and norithesterone (Noriday) have 28 days of hormone pills with no sugar pills. The newer POP drosperidone (Slinda) has 24 hormone pills and 4 days of sugar pills. If used correctly they can be >99% effective at reducing pregnancy. The older Microlut and Noriday need to be taken at the same time each day, if they are taken more than 3 hours late, they won't be effective. Slinda will work correctly if it's less than 24 hours late.

    They work by thickening the cervical mucus preventing the sperms from entering. They thin the lining of the womb preventing implantation and they can also prevent ovulation.

    The benefits of the POP are; that it can be taken when breastfeeding and may be tolerated by some people who don't tolerate synthetic oestrogens in the COCP. Slinda is also anti-androgenic, which can help to improve acne or unwanted hair growth, it may also help with fluid retention and PMS. However, these specific parameters haven't been studied yet.

    Side effects occur because progestins are not progesterone. The side effects of synthetic progestins include an increased risk of breast cancer, irregular bleeding, acne, breast tenderness/enlargement, mood changes, and decreased libido. Headache/migraine, nausea or vomiting, ovarian cysts. These symptoms are generally worse within the first few months of taking the POP and can subside.

    Contraceptive Injections (Depo Provera) And Implants (Implanon)

    The injection contains Medroxyprogesterone acetate which suppresses ovarian function. The dose is so strong that it can cause bone loss due to oestrogen deficiency. It can also cause insulin resistance and weight gain. Usually, periods will cease altogether with the injection. It shouldn't be used in adolescents that are still growing.

    The implant (Implanon) contains Etonogestrel, which can increase the risk of ovarian cysts and mood problems, but it is less androgenic (testosterone-like) than levonorgestrel, so it's less likely to cause acne, hair loss and weight gain. Periods can sometimes be quite irregular on the Implanon.

    The Hormonal Intrauterine Device (IUD) (Mirena and Kyleena)

    These are small plastic devices with a nylon thread attached. They are inserted into the womb via the cervix. They contain the synthetic progestogen levonorgesterol. IUDs are >99% effective in preventing pregnancy. They last for 5 years. They are safe to use when breastfeeding. No medications stop them from working and you don't have to remember to take a pill. They work by thickening the cervical mucus and thinning the womb lining, which often results in periods stopping or becoming a lot lighter. They can be an effective form of contraception for women experiencing heavy menstrual bleeding.

    They are different from other types of hormonal contraception as they do not suppress ovulation and can allow the natural cycling of hormones. The Mirena suppresses ovulation in 85% of cycles in the first year and 15% of cycles after that. The Kyleena has a lower dose of levenorgesterol, so these figures are likely to be even lower with this device. The blood level of levenorgesterol in Mirena is one-tenth of that of COCP users.

    Despite this, there are still associated side effects. When IUDs are first inserted, they can cause cramping which can last a few days. There is a risk of expulsion and a very slight risk of ectopic pregnancy. Spotting or frequent bleeding can be common for 3-6 months. Other side-effects include tender breasts, headaches, acne, hair loss, hirsutism, headaches, yeast infections, weight gain and mood changes. The insertion process can be uncomfortable and there is a small risk of perforation of the uterus.

    Copper IUD (Paraguard)

    This is the only long-acting non-hormonal contraception available. It is a small plastic device wrapped in copper with 2 strings attached. The copper IUD slowly releases copper into the uterus, which produces an inflammatory reaction that is toxic to sperm and eggs, therefore preventing pregnancy. It is >99% effective and can last from 5-10 years depending on which device is inserted.

    Its main advantage over other forms of contraception is that it doesn't contain any hormones, so you get all the benefits of your body's natural hormones. It is incredibly easy to track your menstrual cycle and it permits natural ovulation to occur. Fertility returns to normal as soon as you remove it. It has the highest rate of user satisfaction of any other method and can also be used as emergency contraception.

    Like with the hormonal IUDs, insertion can be uncomfortable, there is a small risk of uterine perforation and expulsion of the device. You may get cramping post-procedure for the first few days. Periods can often be heavy and painful within the first 12 months after insertion. It can be bad for the vaginal microbiome and can increase the risk of bacterial vaginosis.

    The amount of copper released from the copper IUD is very small compared to what we obtain through foods in our diet. Copper excess is more likely to be a problem if you're zinc deficient. Your levels can be checked of these 2 minerals if you are concerned.

    After reviewing all the different methods of contraception, it's important to assess firstly whether contraception is right for you. The methods that have the least impact on the body's own hormones are the IUDs, with copper being the least disruptive as it is non-hormonal.

    If you are searching for the right contraception method for you Dr Hazel Batten can work with you to determine this
    Dr Hazel Batten is an Integrative Doctor with over a decade of clinical experience and a keen interest in women's hormones, PCOS, thyroid conditions and post-partum depletion. 

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