Recommend birth-control pills to me
November 15, 2017 12:26 PM   Subscribe

I have PCOS and they want me to start taking birth-control pills to help regulate things. I also have family and personal history that contraindicates many types of pills. Is there a safe pill for me that does what I want?

Here is what I want and/or want to avoid, keeping in mind that everyone is different and we won't know how it'll work until I try it. I'm going to consult with a gynecologist on this, but before I go, I'd like to get some background on whether what I want exists, so I don't get pushed into something that's not right or that is dangerous for me.
• I don't want to increase my risk of a stroke or clotting problem, so no estrogen.
• I also get migraines with aura, and I'd like to avoid making that worse.
• I have family history of breast and other cancer, too; I don't want to increase it.
• I have anxiety and have had panic attacks; I don't want to exacerbate that.
• I've already gained weight from the PCOS; I don't want to risk weight gain.
• I'm on metformin to help combat that, so it should be compatible with that.
• I would like periods, if I have to have them, to be regulated.
• I would love the option to be able to skip pills to skip periods (so monophasic pills?).
• I want kids sometime in the next 6 years, most likely, so probably no IUD.
• I want the option to stop the medication if need be, so no Implanon or Depo-Provera.
One of the issues with my PCOS has been alternately no periods and then incredibly heavy/long ones, so that to me also contraindicates some types of IUD (e.g., Paragard). Some might then suggest a Mirena, but I'm not sure I want something that long-term, in case it exacerbates any of the other issues. Ideally I think my best option would be a low-dose, progestin- or progestogen-only minipill, so I'm wondering if there are any you've had experience with that you'd recommend. Is there such a thing as a monophasic minipill, so I could eventually skip periods?

All of this stuff is why I've avoided hormonal birth control so far, but the issues the PCOS is causing with my periods are making it necessary to evaluate my options. I'd like to make an informed decision. Thanks for your help!
posted by INTJ to Health & Fitness (20 answers total) 3 users marked this as a favorite
You really need to speak with your doctor and pharmacist about this. You have no idea whether someone answering here has any relevant qualifications. Please don't put your health in our hands. Either trust your doctor, or get a second opinion/another doctor. You have no grounds for trusting that we, too, won't push you into something that's not right or dangerous for you. You have good reason to believe that your doctor is on your side.
posted by Capri at 12:32 PM on November 15, 2017 [2 favorites]

Yep, no worries there. I have an appointment already set. I just want some background information. Thank you!
posted by INTJ at 12:38 PM on November 15, 2017 [1 favorite]

Just as an FYI, the Mirena is quite easy to remove and your fertility will go back to normal within a relatively short window, so I wouldn’t discount it entirely. They also make IUDs that are similarly to the Mirena but even smaller and shorter term (the Skyla and I think another) which could be options to explore.
posted by MadamM at 12:49 PM on November 15, 2017 [8 favorites]

Have you visited an endocrinologist to treat your PCOS? Most ObGYNs lack the necessary knowledge to comprehensively treat PCOS. I have PCOS and hypothyroid and working with an endo really helped me dial in my meds so that my cycles are/were regular (I just had my third baby, so...). I have, in the past, tried low dose progesterone only BCPs and they made me shitshow crazy and for everyone’s safety I had to come off them.
posted by PorcineWithMe at 12:59 PM on November 15, 2017 [6 favorites]

Yeah, I can't imagine going no-estrogen, as progesterone tends to make one Hate All People in a significant way. If there are better endocrine approaches, I'd explore the heck out of them!
posted by acm at 1:07 PM on November 15, 2017

An option to consider and talk to your doctor about is the Nexplanon arm implant. Good for 3 years. Insertion and removal is a breeze. (Birth control and and me don’t mix but if I ever wanted to try it - I’d do that again in a heartbeat.)
posted by Crystalinne at 1:08 PM on November 15, 2017 [2 favorites]

I would consider herbal tinctures or seed cycling, and maybe cinnamon instead of Metformin. There's good evidence for all three although you'll need to see a naturopath who specializes in women's health to get instruction.

Anecdata: I have PCOS, including years of extra-heavy and irregular periods, as well as abdominal weight gain, facial hair and borderline high cholesterol. I've had horrible, gut-wrenching reactions to birth control pills and synthetic progesterone creams (although they are very useful for some!). I started seeing a new doctor last year, and she recommended a two-part herbal tincture for me. I managed to level my cycles out in three months – reversing two decades of "bad blood." Now I don't even take the tincture, and I've maintained normal cycles with only moderate blood loss for over year. My moods stabilized too. Mega win!

Here's the recipe I used. They'll vary a bit. You take 1/2 to 1 tsp, one to three times a day, switching the phases every two weeks (or at the end and midpoint of your cycle).

Phase 1 - black cohosh root, dong quai, bitter fennel, alfalfa
Phase 2 - chaste tree, wild yam, dandelion, sarsaparilla, fenugreek
posted by fritillary at 1:25 PM on November 15, 2017

I am not a doctor, but consider asking your gyn if the nuvaring might work for you. I've been using it for years after many failed attempts taking pills. No weight gain, it has actually reduced my migraines, I use it to skip all but 2 periods a year, and it isn't semi-permanent like an IUD or implant. Anecdotally, I have had issues with cystic ovaries (not diagnosed PCOS) and naturally have AWFUL periods, and the ring has been a lifesaver for me.
posted by tryniti at 1:25 PM on November 15, 2017 [1 favorite]

Cerazette ticks all your boxes.
posted by Violet Hour at 1:37 PM on November 15, 2017

I was on Cerazette with similar requirements and had no side effects
posted by KateViolet at 1:53 PM on November 15, 2017

If you don't want to do Implanon or Depo-Provera or an IUD and don't want estrogen-containing contraception, you're left with progesterone-only contraception. In the U.S., I believe, only one POP is marketed: Norethnidrone. If that drug (or one of the others marketed elsewhere if you're outside the U.S.) suit your purposes, great! If not, you may want to re-examine some of your premises.

I have been told that norethnidrone is my only option because I get migraines with aura, but stroke risks are far lower for modern hormonal birth control and there isn't a consensus that we aura getters can't use estrogen-containing birth control pills. Check out this article which considers the debate and also discusses the use of birth control to reduce the frequency of migraines. I'd say this is worth discussing with your doctors, especially if you have other risk factors for stroke.

Side note: Norethnidrone, which I took to regulate my period, not as contraception, did not make me hate all people. Or even most. I don't know if it helps people with PCOS. I do know it is more liable to fail if you aren't perfectly disciplined about taking it regularly than other kinds of birth control.
posted by reren at 1:56 PM on November 15, 2017

Some people with PCOS have resolved menstruation irregularities with a topical progesterone cream application (often days 14-28 of the cycle, mornings and evenings). (A family history of breast cancer, a PCOS diagnosis, having anxiety, and experiencing panic attacks may mean your estrogen levels are already high, and a progesterone cream can help with balance.)
posted by Iris Gambol at 4:03 PM on November 15, 2017

Like others have said, it sounds like progesterone/progestin-only contraception would match your preferences. You could take progesterone (something like Prometrium) every 3 months (or whenever you want a period, although it is recommended that you shed your endometrial lining at least once every three months to avoid increasing your risk of endometrial cancer). Would recommend taking it before bedtime and not during the day as it can cause drowsiness in some people.
posted by gemutlichkeit at 5:18 PM on November 15, 2017

I have PCOS and I’ve been very happy with my Mirena and will get another when this one expires. My periods are more regular now than they’ve literally ever been and I’ve had a period for 27 years.

I also suggest seeing a reproductive endocrinologist as they’re way more versed in treatment for PCOS than regular gynos.
posted by We'll all float on okay at 6:19 PM on November 15, 2017

The advice to ignore all the posts here and talk to your doctor is excellent, however I would like to offer an opinion regarding your assessment of the IUD as an option. It is, of course, not for everyone, but it's worth having a full picture before dismissing it.

If you have a Mirena and it's not working for you after a few months, it takes all of thirty seconds to take it back out again. Five years is a maximum duration, not a minimum. Once it's out there is no more hormone in your body and you return to full fertility - I was pregnant six weeks after my first was removed. Hell, they advise that if you've had sex the day before it's removed you can get pregnant from that. It's approximately the equivalent progesterone dose of taking three mini pills per week at the start and the systemic hormone dose decreases over time. Your gynaecologist can counsel fully about it, but I would hear them out.

I feel it remains an excellent choice for contraception between and around kids. I had my first Mirena put in maybe five years ago and have had two children and two more IUDs since. It is a far more versatile and flexible option than it is often given credit for.

Minipills are only monophasic.
posted by chiquitita at 7:43 PM on November 15, 2017

To put it another way, if you are limited to progesterone only contraception, the mirena has the lowest possible systemic dose of that class of drugs.
posted by chiquitita at 7:55 PM on November 15, 2017

I have been on a progesterone-only pill for a year and a half now due to endometriosis, with no breaks so no periods ever, and it works just fine for me. I don't hate everyone like I did on a regular pill - well, sexism is running rampant in my grad programme right now, so I am pretty angry a lot of these days, but that's fairly recent - and I don't see any worsened anxiety or depression. My pill is called Visanne in Europe and Dienagest in Japan, not sure about your location. You could respond completely differently, of course.

it is recommended that you shed your endometrial lining at least once every three months to avoid increasing your risk of endometrial cancer)

Can you provide a source for that, gemutlichkeit? Not to be snarky, but you're having me a little worried right now since I was under the impression that mandatory periods were a myth created by doctors who thought women would freak out if they weren't bleeding regularly.
posted by LoonyLovegood at 8:30 PM on November 15, 2017 [1 favorite]

Hello, I'm an NP and CNM (TINMA/IANYNP-CNM/etc.). Respectfully, you've gotten some well-intentioned but inaccurate advice above, which is why, as everyone's said, it's important to check with your prescriber, as you're going to do :)

There are a few important pieces of your medical history that stick out: migraines with aura, PCOS-lack of periods, and depression and anxiety. The reason we prescribe medication to cause "period" (really, a withdrawl bleed) for women with PCOS is because, as mentioned by gemutlichkeit above, is for endometrial protection. When you go more than three months without a bleed, you want to give the lining of the uterus a break from the hormone (estrogen) signaling the uterine lining to build up. If you don't, you're increasing the risk of endometrial cancer down the road. This doesn't apply if there is a different reason for you lack of periods (e.g., you're on the pill so those hormones are overriding your body's natural ones). I see you're already on metformin for your PCOS, but I'd want to know a bit more about this history, especially if you're thinking of getting pregnant in a couple of years--there might be other things recommended for you and to try to help regulate your periods.

Regarding the migraines with aura and estrogen connection: basically, estrogen causes changes to your clotting--broadly, somewhat thickens the blood, which is protection against post-partum hemorrhage--but increases your risk for a blood clot in the leg, lung, or brain. In most women, the risk is negligible; however, for women with migraine with aura (i.e., neurologic involvement), the risk is much higher. Migraines are not 100% understood but when auras occur, there's an increase in brain activity and likely changes to brain chemistry and vascularity--so the risk for having a stroke goes way up. In fact, migraine with aura is a "category 4"--absolute contraindication, no medical justification in prescribing--both nationally and per the WHO. I would honestly not trust any prescriber who offered me combined contraceptives (e.g., combined pill, patch, or ring) if I have migraines with aura. If I were to prescribe them for a patient, I would risk losing my license!

Regarding other methods: Mirenas are great and lots of people love them, but for women who have ovarian cysts, they can actually make them worse, so it may not be the right option for you. Progesterone-only methods are the only safe method for you, as per above; however, they can make depression and anxiety worse for some people, while others don't notice a difference. But for that reason, I would agree that an implant or depo are not good methods for you, as once it's in you're kind of stuck with it, at least for a little while, and plus with those methods you are having a big, systemic dose of hormone. Another option is potentially the copper coil (Paragard); however, it won't give you any control over the frequency of your periods or induce a period as you would need. There may be an option for you to have a copper coil placed and then use Provera tablets to induce a scheduled bleed, but you'll want to talk to your provider about this. (As mentioned above, IUDs can be removed at any time, and your fertility returns immediately, so if you do have one placed, you don't have to worry about being stuck with it for 5 or 10 years). Also, regarding the family history of breast and other cancers, your provider will take a more detailed history about what degree relatives these are, what types of cancers, age of diagnosis, etc. to determine safety of methods. And, depending on how old you are and how long you've been skipping periods, and how heavy they are when you have them, you may be recommended to have some other testing.

I hope this is helpful, and that you can find a provider you feel comfortable talking to and who will work with you to find the right method(s) for you!
posted by stillmoving at 11:28 PM on November 15, 2017 [7 favorites]

In addition to Mirena and Skyla, there are also Kyleena and Liletta for hormonal IUDs. Each one is a little different. (Kyleena and Liletta are smaller, Skyla and Liletta are approved for 3 years use while Mirena and Kyleena are both 5, Mirena releases the most daily hormone , etc). I don’t have any idea about how these differences would affect your situation but it’s good to know all of these options exist and to ask your doc which one is best and why.

Another word to the wise regarding insurance: some insurance (mine, eg) will only cover IUDs that the prescribing office keeps in stock; others will cover it even if you get one that isn’t that office’s regular type. I had to call around to a bunch of offices before I found one that carried Mirena (what I’ve had for the past five years and wanted again). Do be aware that an office may try to steer you toward the type they have in stock, and make sure it’s really the right one for you before you get it inserted.

Kyleena is new enough that some providers don’t know about it yet (mine didn’t when I went in for a consult; I don’t know if he did today when I got the Mirena inserted because I was too busy feeling like I was getting punched in the cervix to bring it up).

Oh yeah, getting an IUD inserted fucking HURTS btw. YMMV, likely to the worse if you haven’t had kids, but for me it’s been the most painful 4 minutes of my life by an order of magnitude at least. 2 minutes for each of two insertions. However the fact that I chose to do it again says it can be the right choice anyhow. If you’re a pain wimp (evidently I am) ask for drugs before. Oh and the removal part was very quick — so if you do try one and it isn’t working for you, it’s ok to get it out (though it does require an appointment to do so).
posted by nat at 12:44 AM on November 16, 2017 [1 favorite]

OB/Gyn here. (IANYOBGYN, etc)

Resounding second to stillmoving's response.

Also, wanted to add that the term "monophasic" just means that there is a fixed amount of estrogen in a combined pill throughout the packet. "Multiphasic" means that each week the amount of hormone is adjusted (supposedly to more closely mimic a regular cycle). No difference in efficacy.

What you and some others are talking about when you say "skipping periods" is taking an extended-cycle contraceptive. You can do this with any hormonal birth control (combined, patch, nuvaring, progesterone-only). Some combined pills are actually packaged this way, but all can be taken this way. I want to n-th the fact that you should have a withdrawl bleed for endometrial protection if taking anything with estrogen--especially with PCOS and doubly so if your BMI is elevated, you are at risk for endometrial hyperplasia which is a cancer pre-cursor. As stillmoving noted, one of the side effects that some people like about the progesterone IUDs is that a significant minority (25% for mirena for example) will not have a period by the end of a year of use, and overall bleeding is decreased by 80%.

Something not many people talk about with progesterone-only pills (aka "mini" pills) is that you must take them at the same time every day for them to be effective. If you do not take them within a 2 hour window of the previous day's dose then you are not protected from pregnancy (if that's your goal) and you will set yourself up for breakthrough bleeding (if cycle control is your goal). So if you know you cannot take pills even with an alarm prompt, or if you have a job which means you constantly switch from day to night shift, etc, then they are not a good option for you. They also have a higher real-world failure rate than combined pills, likely for that reason.

WRT cancer risk I'll quote you the latest from UpToDate (a medical site which aggregates the latest research findings by topic). "Oral contraceptive (OC) use has been associated with an increased risk of certain types of cancer and a decrease in others. However, it appears that the pill is not associated with an overall increased risk of cancer. This was illustrated in the Royal College of General Practitioners' (RCGP) cohort study, which included nearly 50,000 women followed for a mean of 24 years. In pill users compared with nonusers, risks were significantly lower for colorectal, uterine, and ovarian cancer [67]. The incidence of breast cancer was similar in pill users and never users, but there were significant trends of increasing risk of cervical and central nervous system cancer in pill users. Depending upon the data set used, there was either a nonsignificant or significant reduction in overall cancer risk among users compared with nonusers, with an estimated absolute risk reduction between 10 and 45 per 100,000 woman-years." Obviously, these studies have been done in combined pills, so your risk is likely lower for progesterone-only contraception. Also, I don't know your specific family history, so that's something you should discuss with your provider.

WRT PCOS more generally, (and with the caveat that I don't know your starting BMI or other health factors), the single best treatment is weight loss. A 10% weight loss is associated with a regulation of cycles for the majority of people, as well as return of fertility in those attempting pregnancy. The metformin you are already taking can help with this. Metformin also will not interfere with any hormonal contraceptives.

progesterone = hormone which sustains pregnancy (most common progestigen)
Progestigen = the larger class of hormones which bind the progesterone receptor
Progestin = synthetic progesterone
posted by eglenner at 1:50 AM on November 16, 2017 [4 favorites]

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