birth control – watercress words by Dr Aletha

Our bodies make the sex hormones-estrogen, progesterone, and testosterone- naturally, but sometimes doctors prescribe synthetically-made ones therapeutically. Like any drug, we should only use them when the benefit clearly outweighs the risks, after considering issues of safety, effectiveness, side effects, ease of use, and cost.

post updated January 11, 2023

This information is current as of the publication date; it is general medical information that helps doctors and patients make decisions about what is right for them. Medical recommendations and practice change as we learn new things. Discuss with your physician or appropriate healthcare provider.

taken at the Tulsa Performing Arts Center

Hormone Pills for birth control

Most oral contraceptives, OCPs, or birth control pills consist of two hormones, an estrogen, usually ethinyl estradiol and a progestin-norethindrone,levonorgestrel, desogestrel, norgestimate, or drospirenone.

For women who cannot or prefer not to take estrogen, norethindrone can be used alone. The FDA has approved another progestin-only pill.

The new pill contains drospirenone . It prevents pregnancy effectively although was not specifically tested opposite norethindrone. Another benefit of the drug is controlling acne. As with other new drugs, Slynd, brand name, is more expensive than generic norethindrone.

Homones through the skin

Hormonal birth control can be delivered by patches applied to the skin, that is transdermal. These also contain an estrogen-ethinyl estradiol and a progestin-levonorgestrel, or norelgestromin, 1 patch every 3 weeks with 1 week off.

Vaginal hormone birth control

Women have had the option of using an estrogen/progestin vaginal ring, kept in place for 3 weeks, then removed and replaced with a new ring 7 days later. (Nuvaring, ethinyl estradiol/etonogestrel) .

Now there is a new option- a ring that contains a different progestin. Annovera is a silicone elastomer device containing ethinyl estradiol and segesterone. The cost, $2000, (per GoodRx) sounds excessive, but this ring can be reused for 13 4-week cycles,unlike Nuvaring which is replaced every 4 weeks. Both rings effectively prevent pregnancy.

photo by Dr. Aletha, taken at the Santa Fe New Mexico airport

Three LARCs –Long-acting reversible hormone contraception

Three forms of long-acting reversible hormone contraception (birth control) are available to women in the United States.

The birth control injection (shot) is a progestin, depot medroxyprogesterone acetate (Depo Provera). Women who use this method receive an injection every 90 days which effectively prevents pregancy.

Etonogestrel, a contraceptive implant, slowly releases the hormone progestin and does not have estrogen. It can be used in women who cannot take estrogen. The small device is implanted under the skin of the upper arm and replaced every 3 years. Brand names are Nexplanon and Implanon.

Hormonal intrauterine devices, IUDs, contain the progestin levonorgestrel. The newest version (2023) named Liletta is effective for 8 years. Earlier brands could be left in place from 3 to 8 years.

Here is a link to facts about other forms of contraception from the Department of Health and Human Services

Reproductive Health

at the New York Metropolitan Museum of Art

Hormone therapy and heart disease

A 2015 Cochrane review of 40,410 postmenopausal women examined the use of oral hormone therapy (estrogen with or without progesterone) taken for at least six months, compared with placebo (no real drug), to determine the effect on death from any cause, and deaths caused by heart disease, stroke, and blood clot in a leg or lung.

The review found no benefits for preventing heart attack (fatal or nonfatal), or death due to any cause. And other studies and reviews have found no long term increased risk of death from hormone use, although the risk of cardiovascular disease is increased while taking the drugs.

Here is a link to a review of hormone therapy benefits and risks.

Menopausal Hormone Therapy

Vaginal estrogen and heart health

While oral estrogen replacement after menopause can decrease night sweats, hot flashes, and vaginal dryness, it potentially increases the risk of developing cardiovascular disease-heart attacks and stroke, and some cancers-breast and uterine. But does estrogen given vaginally carry the same risk?

No, according to the results of the Nurses Health Study. Statistics over 18 years showed no increase in these complications in women who used vaginal estrogen, suggesting this is a safe option for women who choose to use estrogen to improve quality of life after menopause. (from the journal Menopause)

Controlling fibroids that bleed

Fibroids are a non-cancerous tumor of the uterus. They often cause no symptoms but can cause heavy and/or painful periods. Now a hormone combination can stop that.

Marketed as Oriahnn, two capsules daily taken morning and evening can decrease menstrual blood loss by 50% or more. One capsule contains 3 hormones-elagolix, estradiol, and norethindrone. The other contains only elagolix. Treatment should not exceed 2 years due to a risk of bone loss, similar to that seen after menopause occurs.

exploring the HEART of women’s health

I hope you enjoyed the photos. I took them all on various travels.

a statue of a woman holding a child, "CROSSING THE PRAIRIE" — “CROSSING THE PRAIRIE” by Glenna Goodacre, Broken Arrow, Oklahoma

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Abnormal menstrual bleeding is one of the most common problems that brings women to their physician. But what exactly is “normal”? When should you worry about your periods?

According to American Family Physician journal (Volume 99, Number 7)

“abnormal uterine bleeding falls outside population-based 5th to 95th percentile for menstrual regularity, frequency, duration, and volume.”

Or, you could say -“normal” is that periods vary widely for most women

How doctors talk about normal

Doctors sometimes use medical terms to describe abnormal bleeding-menorrhagia, metrorrhagia, even meno-metrorrhagia, which are imprecise and often misunderstood. In 2011 FIGO, the International Federation of Gynecology and Obstetrics developed standard definitions and descriptions of menstrual bleeding, also endorsed by the American College of Obstetricians and Gynecologists.

This post will outline the FIGO definitions. Anytime you are concerned about your bleeding you should talk to your doctor. This information may help you describe your concerns to your doctor and understand what is “normal” for you.

The frequency, regularity, duration, and volume of a period are all important to determine if they are normal.

What is Your Menstrual Cycle?

The Menstrual cycle is the length of time from the first day of a period until the next one starts; in other words, from day 1 to day minus 1. You can also think of this as the frequency-how often you have a period. Every 24 to 38 days is considered normal.

Infrequent->38 days
Normal 24-38 days
Frequent <24 days

The regularity of the menstrual cycle is how much the length varies over time, usually 12 months. Is it always 24 days, 28, 32? Or does it vary, sometimes 24, or sometimes 38? Either can be normal, but if your pattern suddenly changes, it may indicate something has happened.

Regular cycles vary by 2-20 days over 12 months
Irregular- cycles vary >20 days over 12 months

What is your menstrual period?

The duration or length of your menstrual period is how many days you bleed, no matter how much or how little. Again, what’s important is your usual pattern; for most women this stays consistent, so a change is usually noticed.

Short <4.5 days
Normal 4.5-8 days
Prolonged >8 days

How heavy is your period?

The amount, or volume of a period is how much blood you lose. From 5-80 ml , or for Americans 1 teaspoon to 3 ounces, is considered normal although most of us find counting pads or tampons per day is easier to understand.

Light <5 ml
Normal 5-80 ml
Heavy >80 ml

Amenorrhea means no bleeding for 90 or more days. Once a woman has not had bleeding for 12 months, this is menopause. (This does not apply if she stops bleeding because her uterus is removed, a hysterectomy. Menopause is defined differently in that case. )

What can change the cycle length or regularity, or the period length, duration, or amount of bleeding?

Using some form of hormonal birth control
Recent pregnancy
Breast feeding
Vigorous or intense physical activity
Serious illness, injury, or surgery
Starvation
Peri-menopause (the months prior to menopause)

If you doctor determines that your bleeding is “abnormal” she may evaluate you for the common causes-

complications of pregnancy-miscarriage, ectopic pregnancy
uterine fibroid tumors-leimyomata
cervical or uterine cancer
bleeding disorders
hormone dysfunction, including PCOS (polycystic ovarian syndrome)

Where to learn more about menstruation

Familydoctor.org offers this easy to understand outline of the causes and treatment of abnormal bleeding.

Abnormal uterine bleeding

Información en español – from the CDC

Sangrado menstrual abundante

Most cases of abnormal bleeding have a straight forward cause which can be determined by the history, examination, and appropriate testing. Most are treatable and not life threatening. However, since a few cases will be due to cancer, don’t ignore this important symptom.

Keeping track of your periods

You can use any blank paper or digital calendar to keep track of your periods but digital apps are a convenient way to keep track of your periods.

Flo Period & Ovulation Tracker

Flo Period Tracker, Ovulation & Fertility Calendar!

It’s a smart and simple female period tracker, helpful pregnancy week by week app, accurate ovulation and fertility calendar and PMS symptoms tracker for women all over the world. Flo Period Tracker not only tracks your period accurately, but it’s also a reliable pregnancy calculator, ovulation calendar, and true fertility friend for you. It’s the first period app, pregnancy calculator, fertility and ovulation calendar for women that uses machine learning (AI). All women, even those with irregular periods, can rely on this health tracker. Log your menstruation days in a handy period calendar, ovulation and fertility tracker, schedule menstrual cycle reminders, record moods and PMS symptoms, use a due date calculator, follow a pregnancy calendar and take full control of your health.

However you do it, take your menstrual record with you every time you visit your doctor.