My Dear Daughter,

I never thought I would be sharing the story of Maribell with you one day. It feels like just the other day that we were playing pretend kitchen and cooking dinner with your tiny toy pots and pans that were barely big enough for my adult hands. You used to cook elaborate dinners and served me on your dining table all the time. Many times, we sat on the floor and ate those dinners. I had to delightfully pretend to eat them and enjoy just to see that sparkle in your eyes. The joy in your eyes would make us happy. The hand me down kitchen sets was enough to bring the simple pleasures of life. Life was that simple. These days that pretend the kitchen has turned into a functioning kitchen. We have eaten several dinners prepared by you in that tastefully and timely decorated kitchen of yours. Sitting at that dinner table, we have talked about so many global issues from politics to climate change. But we never have taken the time to talk about women like Maribell. I have several Maribell that visit me regularly at work.

Maribell (a fictional name to protect the identity of the patient) is a 23 year old girl. Maribell became a mother a few months ago. After her 6 weeks postpartum visit with her MD, she was sent to us to start a hormonal birth control method. She did not want any more pregnancies for now. So, our clinic was the perfect place to visit. After a medical history assessment and rule out of pregnancy, she could start any hormonal birth control method that she desired. She was not breastfeeding and she desired to start combination pills. Combination pills are those hormonal birth control methods that have both estrogen and progesterone hormones in them. That day she was sent home with three packs of pills. Today, she is back for the refill of her pills but with tears in her eyes. She is sitting in front of me and telling me in a choking voice that these three months have been very devastating for her. She thinks birth control pills are making her crazy. She is riding a constant emotional roller coaster. According to her, “I am on the edge constantly. This is messing up my relationship with my boyfriend.”  Maribell did not have any emotional issues previously before starting the pills. I consulted my provider and switched her birth control method. I gave her a different method for three months as a trial, hoping this will make things better for her in her life. After all, that is all she wanted; to have a better life.

Hormonal birth control methods are very effective in preventing pregnancy if taken consistently.  But these methods come with several side effects. One of the major side effects of hormonal birth control methods is mood swings. Patients like Maribell are not alerted about them beforehand. Hence, they end up at the office with tears in their eyes. Beside the emotional instability or mood swings there are several other severe side effects of hormonal birth controls. The other major side effects are blood clots (VTE), cardiovascular issues, headaches, breast sensitivity, libido changes, vaginal discomfort, weight gain, irregular periods, deplete calcium in bones causing fragile bones. And above all, the unknown effects of adding hormones in the body. There has not been enough research on this topic. The question mark still lingers among users — what happens to the natural secretion of the hormones that the pituitary gland maintains for the normal rhythm of menses and fertility in a body?

Nature has given child bearing responsibilities to women. The society has assigned the prevention responsibility to women too. Young girls like Stacy (fictional name to protect the identity of the patient) have been taking this responsibility as early as 15 years of age. Her mother brought her to the clinic to start a birth control method as she started dating a boy. When I saw her the other day on her regular Depo Progesterone (DMPA) visit, and tried to explain the mechanism of progesterone only hormone in the body, she looked clueless. So, I started with her explaining the basic mechanism of menses in a woman’s body.  Each month a woman’s body goes through a reproduction cycle. Naturally, two glands in our brain that control the reproductive endocrine system talk to our ovaries, telling them when it’s time to release an egg. When an egg is released, estrogen levels fall and progesterone levels rise, preparing the uterus for pregnancy. If an egg doesn’t get fertilized after ovulation, progesterone levels will drop back down, sending a signal back to the uterus and brain that it’s time to move on to the next phase of the menstrual cycle. That’s when the menses happen. Menses are the shading of the uterus lining at the end of each month. Hormonal Birth Control (BC) methods or synthetic hormones are created to alter this natural process of the body.

BC methods are made with two major synthetic hormones — estrogen and progesterone to mimic the natural rhythm of the body. There are progesterone only BC and combination BC in the market. The combination BC is made with a certain portion of progesterone and a portion of estrogen hormones. These two types, Combination and Progesterone only BC work differently  to produce the final result of no pregnancy in a woman’s body. The progesterone and estrogen combination method works in several ways — by stopping the ovulation from occurring, altering the lining of the uterus so that a fertilized egg doesn’t attach to it and making the cervical mucus thick, which makes it harder for sperm to get through. The Progesterone only hormonal BC method works by thickening the cervical mucosa which makes it harder for implantation of sperm and prevents pregnancy.

Our clinic’s birth control procool is considered very strict in comparison to the teladoc and several other family planning clinics. In our clinic, girls can start hormonal birth controls methods once they start menses and have four to six regular cycles. After the pregnancy though, progesterone only methods could be started at any point. But it is preferred to start after six weeks of delivery. At the post pregnancy stage, Progesterone only contraceptives are preferred because it carries fewer contraindications than combination methods, which makes it safer for women at that phase of their life. Once the woman is educated about all the options and side effects, and is able to make informed consent, pregnancy has to be ruled out. Sometimes, if pregnancy cannot be ruled out but women meet the criteria to receive the morning after pill (Plan-B) the BC can be initiated from the day after Plan-B.

I had Lilia (fictional name to protect the identity of the patient) come in just the other day. Who was on high blood pressure medication, with obese BMI and in her late twenties, was on combination pills prescribed by an outside provider. She was transferring her care to our office but wanted to continue the same pills. If Lilia is to continue her method, she would be taking more risk of bad side effects of those birth control methods. The higher the comorbidities the risk of bad side effects of BC increases. Therefore, the medical history, current medications, age, BMI, and blood pressure plays a major role in deciding the right birth control for the patient. The best method will be the one that is less risky for the patient. So, it is very important for providers to receive thorough medical history from the patient. Also, a patient needs to be honest with answers to prevent being prescribed the wrong kind of medication for their own safety.

In the market there are several options on birth controls methods these days. They can be categorized in two groups. The short-acting hormonal methods like pills, ring, patch and injection. The long term options like IUD and implants. IUD goes inside the uterus of a woman. The implant is inserted in an arm. Sterilization called Bilateral Tubal Ligation (BTL) in medical terms is the final option of birth control. It is the litigation or cutting of fallopian tubes, providing a permanent method of birth control.

The most popular form of BC is the pill form. This option has been in the market for over 60 years. It is considered effective with 1% of chance of pregnancy. But it is one of those methods which is very easy for people to forget to take it. This increases the cause of pregnancy. The pills come in 21, 28, 91 days of tablets to be taken each day. There are several different brands in the market and different brands contain different medications or doses with different risks and benefits. So, it is very important to read the manufacturer’s information carefully before starting any method of birth controls.

The second most popular form of BC is Depo Provera (DMPA). It is a progesterone only method, which is administered every three months in a clinic setting. DMPA works by thinning out cervical mucosa, which prevents menses for the majority of women. The hope of no menses, one time injection for three months and the effectiveness of the metod, makes it a very popular method among the young generation. Then there is Annabella (fictional name to protect the identity of the patient) who can’t handle the spotting, irregular period, weight gain and taking calcium everyday (as DEPO, pulls calcium out of bone), that came as a package deal with DMPA use. After two injections, she decides to switch to pills. She concluded that she will keep a reminder on her phone and rather take a pill everyday to get the sense of regular rhythm in her body.

The ring and patches belong to combination methods, which means they contain progesterone and estrogen hormones on them. Patches are changed every week a ring is exchanged once a month. The long term options like IUD and implant are progesterone only methods. Hormonal IUD goes into the uterus for three or five years, depending on the choice of the patient. The implant is inserted on the upper arm for three to five years. There is a non hormonal IUD called Paragard which is inserted for ten years. Paragard is the only BC option that comes without any side effects of synthetic hormones in the body. There is no hormone in this option. It is made out of copper and works very effectively to prevent pregnancy.

The best birth control option is the method that works best for the patient. Like for Maria (fictional name to protect the identity of the patient). She is a 30 years old patient of mine who has been taking BC since her teen years. She started with pills, and has switched around and tried every option out there. She has settled on DMPA. She thinks it’s her perfect fit. The best fit is the BC option that a woman is comfortable using and is safe for her. It will be considered best fit, if the woman can be consistent with the method and is able to use it correctly taking all the precaution and care that came with the use of hormonal BC.

Andrea (fictional name to protect the identity of the patient) was prescribed a vaginal ring, after assessing her reproductive goals, age, marital status and religious beliefs. When she came to the clinic for the first time in the beginning of this year, she was very new to birth controls methods. She desired less hormones but an effective method. She was provided with options and information about all the methods. Her goal was to receive IntraUterine Device (IUD) eventually. She was going to assess using a vaginal ring and make a decision about IUD. We work patients towards priming for long term options. Long term options will create less frequent visits to the clinic and more time for the patient to enjoy their life.

Recently, I have been seeing an influx of young girls wanting to start hormonal BC methods. They are in the clinic as early as 10 or 12 years, trailing behind their mothers or grandmothers. I want each and every one of the patients to understand the complication and risk of adding hormones in the body. The nutritionist has been trying to make us understand that the human body is the sum total of what we eat, drink, think, and act upon. Similarly, adding synthetic hormones in the body will have its own consequences. These young women are prescribed synthetic hormones to prevent pregnancy and for many other reasons. Some take hormones to treat acne, to regulate/lighten up periods, to treat PCOS or endometriosis. Adding hormones in the body will be affecting the natural production of progesterone and estrogen in our body. The long term consequences of using them have not been studied enough. But the findings of emotional and neurological symptoms are increasing in women and are linked to hormonal birth control use.

There are many different formulations in the market that have different amounts and combinations of synthetic progesterone and estrogen. As every patient’s body chemistry is different and there is no one uniform type of dose of birth control that everyone takes. Because of this variety, the pill can affect everyone who takes it a little differently, says Gillian Dean, MD, Senior Director of Medical Services at Planned Parenthood Federation of America. This can explain why some people experience side effects like headaches, spotting, and decreased sex drive — or even the more anecdotal, less-understood side effects like mood swings and brain fog — while others dont. Natural hormones keep the body in balance by binding to specific receptors, synthetic hormones are capable of cross-reactivity within the body’s receptors, causing hormonal imbalances and other uncomfortable side effects. Could this be the cause of Maribell’s emotional roller coaster?

Therefore, we have come to the cross point of needing further research on synthetic hormone use. The whole purpose of prescribing BC method to Maribell was to enhance her relationship, make her life productive and create a space between her children. If the method is creating the opposite effects, it’s time to dive deeper into the issue and come up with effective non hormonal birth control options for women. So, they can prosper, grow and can be productive members of society.

My dear daughter, you being in the social education field, and working with young people understand our society’s needs very well. Our society is in a dire need of education and emphasis on safe sex, delayed gratification and authentic relationships. Young boys and girls need to grow up learning about responsible relationships.  I was watching Saadguru (Founder of Isha Foundation), on YouTube the other day. According to him, every emotional and physical relationship leaves an imprint in our body. Life will be easier and lighter with as few  imprints as possible. This concept made sense to me. I might be dreaming of an utopian society, when I say it should be a core philosophy in society. We can dream of an utopian society and start living the talk. The responsibility falls on women again. We need to start prioritizing our health and make informed consents before saying “yes” to the hormonal BC methods. We need to take care of ourselves. So, we can have strong and healthy daughters for the future.

With lots of love,

Mamu