Completing the Stress Cycle

Most of us know how stress manifests for us personally. For some it’s trouble falling asleep and increased irritability, for others it shows up as anxiety or a lack of energy and motivation. But how does stress affect us on a physiological level, and how does it impact our sex hormones? What’s happening inside our body before we get to the point of being irritable and drained of energy?

To fully understand how stress impacts our menstrual cycle and sex hormones, first let’s take a look at the stress response.

When we talk about stress we need to distinguish between stressors and stress. Stressors are things that activate our stress response, such as work, financial issues, relationship tension, illness, etc.  The stress response is a system of changes activated in our brain and body in response to stressors.

There are three main types of stressors:

  • Mental/emotional: feelings such as fear, guilt, worry, anxiety, grief, sadness, existential angst, etc. (mental and emotional stress is perceived, and therefore different for everyone)

  • Physical/trauma – fractures, muscle injuries, nerve compression, sleep deprivation, chronic illness, chronic dieting, etc.

  • Chemical/biochemical – blood sugar imbalances, food allergies/sensitivities, alcohol, drugs, parasites, bacteria, viruses, etc.

The hypothalamus-pituitary-adrenal (HPA) axis is responsible for controlling the stress response in the body. The hypothalamus sends signals to the pituitary, which in turn sends messages to the adrenal glands. The adrenal glands are endocrine glands that sit above the kidneys. The adrenals are made up of two main parts  - an outer cortex and an inner medulla. The outer cortex is divided into three zones – zona glomerulosa, zona fasciculata and zona reticularis.

The stressors we experience are sensed by our sympathetic nervous system, which stimulates the adrenal medulla to release adrenaline. The hypothalamus then senses the adrenaline in the bloodstream and releases corticotropin-releasing hormone (CRH), which is sent to the pituitary. The pituitary then releases adrenocorticotropic hormone (ACTH), which is sent to the adrenals. The zona fasciculata region of the cortex releases cortisol. Cortisol enhances adrenaline and supports the fight, flight or freeze stress response.

We’re all familiar with this response. It’s designed to protect us and save our lives in the case of danger. When this happens the body is worried about survival, and survival only. Your body isn’t worried about digesting food, getting pregnant, or building muscle. Unfortunately the stress response hasn’t adapted enough to know the difference between a tiger chasing you in the wild and you fighting with your significant other, so this stress response can be activated frequently if you deal with chronic stress or don’t handle stress well (I’m talking to my fellow highly sensitive people and empaths here).

In a normal stress response, once our body knows we are safe and have survived the stressor our cortisol levels return to normal and adrenaline decreases, thanks to the HPA negative feedback loop.

When we are under chronic stress, the hypothalamus can have a reduced sensitivity to cortisol. Cortisol levels stay elevated, and cortisol dominance occurs. 

In the zona reticularis section of the adrenal cortex, DHEA and androgenic steroid hormones are produced. DHEA is the precursor hormone of androstenediol, androstenedione, testosterone and estrogens. While the majority of estrogen and androgens are produced in the ovaries (we know a large amount of estrogen is produced by the maturing follicle during the follicular phase of the cycle, and by the corpus luteum during the luteal phase), this estrogen conversion is still important.

DHEA also serves as a counter-regulatory hormone to cortisol. It is an anabolic hormone that promotes the growth and repair of protein, especially muscle tissue. DHEA helps to negate the harmful effects of excess cortisol. But when we are experiencing chronic stress the pituitary can end up sending more ACTH to the zone that produces cortisol, and less to the zone that produces DHEA. If this continues on long enough it results in not only lower DHEA levels (and an imbalanced cortisol to DHEA ratio) but also decreased testosterone and estrogen levels.

So if we are experiencing chronic stress what can we do to prevent this hormonal cascade? This is when we need to complete the stress cycle.

 

The Stress Cycle

The advice “reduce stress” or “stop stressing so much” has never resonated much with me. As a chronically stressed out person myself, I know stress is inevitable. We can’t always reduce stress in our lives. However, what we do need to do is allow the stress cycle to complete.

In Come As You Are, author Emily Nagoksi, Ph.D. states “The key to managing stress (so it doesn’t mess with your sex life) is not simply “relaxing” or “calming down”. It’s allowing the stress response cycle to complete.”

How do we let the stress cycle complete? We can do this by relaxing (think breathing and being mindful, not staring at a TV screen), physical activity, or feeling alllll your feels, to name a few.

As I mentioned above, our stress response is fight, flight or freeze.

During a stress cycle there is a beginning (the threat or risk), a middle (the action taken – fighting, taking flight or freezing) and an end (hopefully a feeling and realization of “I’m safe!”).

Unfortunately, we’ve got a lot more chronic stressors than acute stressors. Acute stress doesn’t last long. It’s being written up for being late to work, as opposed to the chronic stress of walking into a job everyday that you hate with coworkers you don't get along with. Acute stressors have a clear beginning and end. Where chronic stressors are never-ending, or at least they feel that way.

If we live with chronic stress we aren’t allowing the stress cycle to complete. This is especially true if we often find ourselves running around from place to place and not taking the time to relax, sit with our emotions or move our body in a way that feels good. If you find yourself frequently in a place that isn’t appropriate to complete the stress cycle or constantly surrounded by people who are uncomfortable with you fully expressing your emotions and feeling all your feels, it may be time to reevaluate your schedule and surroundings.

So what do we do?

We can complete the stress response cycle by allowing our emotions to work through us fully. This means we run, we move, we cry, we journal, we meditate, we talk it out. Whatever works best for us personally.

This is where our intuition comes into play. We can ask ourselves “what does my body need right now?”. Sometimes we need to dance it out. Sometimes we need to lift weights. Sometimes we need to talk it out with someone who is good at listening. Expressive self-care such as art or journaling can help. Other times we just need to scream in our car on the drive home from work until tears are streaming down our face and we feel better.

What does your body need? What ways do you complete the stress cycle?

A final note on dealing with the stressors vs. dealing with the stress:

Have you ever completed a stressful week at work with tons of deadlines only to feel just as stressed as you were when the week began? Or you collapse into exhaustion at the end of the week? It’s because you have dealt with the stressor (all of the deadlines and projects) but your body still needs to finish dealing with the stress (meaning you need to complete the stress cycle). Make sure you are taking time to complete the stress cycle before you go all in on the next project.

Need some help with identifying the stressors in your life and coming up with ways to complete the stress cycle? Download the free PDF worksheet I created here. It’ll help you to feel all your feels and work through them without any judgement or shame.

More questions on the stress cycle, your menstrual cycle or interested in working with me to balance your hormones? Contact me at veronica@veronicamcnelis.com.

WTF is a normal period?

After ovulation, if you have not become pregnant, your dominant follicle ruptures, and transforms into the corpus luteum gland. Ten to sixteen days later, at the end of the menstrual cycle the corpus luteum shrinks, and progesterone levels drop off (the corpus luteum is responsible for producing progesterone). The drop in progesterone stimulates the uterus to contract and shed its lining, beginning your period.

If you are healthy, and your hormones are balanced, your periods should arrive smoothly and without any spotting or pain. But how long should it last? Is it only blood? Are clots okay? And WTF is "normal" anyway? You and three of your friends all have periods that are different colors, flow and lengths, is that normal?! (The answer is yes, it is!)

WTF is menstrual fluid?

Menstrual fluid is made up of mostly blood, cervical mucus, vaginal secretions and endometrial tissue (uterine lining).

Fun fact: 2/3 of your endometrial lining is actually reabsorbed by your body!

Another fun fact: the majority of other mammals actually reabsorb their uterine lining if they don't conceive. In order to conceive, humans need a much thicker uterine lining compared to other mammals, making the human uterine lining too thick to be 100% absorbed. 

WTF should the color of my menstrual fluid be?

The color of your menstrual fluid will vary a bit depending on how fast your flow is. Blood turns darker when exposed to air, so if you are flowing slowly or spotting, your blood may be a reddish-brown color.  If you are bleeding quickly the blood will be a bright red color. 

WTF is a normal amount of menstrual fluid to lose?

The average amount of menstrual fluid to lose over the several days of your period is about 50mL (equal to about three tablespoons).  Anything less than 25mL is considered a very light amount, and more than 80mL is considered a heavy flow.  You probably don't measure the amount of menstrual fluid you lose (does anyone?). But using a menstrual cup makes this easy to do. If you don't use a cup, one regular sized tampon holds about 5mL (fully soaked), and one super tampon holds about 10mL (fully soaked). So an average amount of blood to lose is equal to about 10 fully-soaked regular tampons, or 5 fully-soaked super tampons over the course of your period.

What if my period is randomly extremely light, or extremely heavy?  If you have a random heavy period or extremely light one, either of these scenarios can be caused by an anovulatory cycle - a cycle in which ovulation did not occur. Having an anovulatory cycle is normal here and there, and nothing to be concerned about. If you have anovulatory cycles on the regular, or frequently light (<25mL) or extremely heavy periods (>80mL), this is not normal, and is a period problem that deserves your attention.

WTF are clots? And why the fuck do they happen?

Clots tend to happen more often if you have a heavy flow. The body releases natural anticoagulants to thin the blood and allow it to flow more easily. When you have a heavy flow, the anticoagulants may not have time to do their job, which is normal - as long as the clots aren't too large. The normal size of a clot is about the size of a dime.

Why would you have a heavy flow? A heavy flow can be caused by higher levels of estrogen, or lower levels of progesterone, or possibly a combination of both. Estrogen thickens the uterine lining (and causes a heavier flow), and progesterone thins the uterine lining, counterbalancing the effect of estrogen. If you do not ovulate you will not produce progesterone, and won't get the beneficial effects that come along with it.

WTF is a normal length of a period?

Anywhere from 2 to 7 days is a completely normal period length. Most women average between 3 and 5. Day one starts on the first day of normal or heavier bleeding - not spotting (this is also the first day of your follicular phase).  

Why would you spot? If you have spotting at the end of your luteal phase, before the start of your period, along with a higher basal body temperature (confirming you ovulated), it could be a sign of poor ovulation or luteal phase insufficiency. In this case, the corpus luteum starts to break down too soon, resulting in the premature shedding of the uterine lining. The corpus luteum should live for at least 10 days so if you are consistently experiencing spotting before ten days into your luteal phase I advise you to see a doctor to rule out other conditions such as thyroid issues, endometriosis or fibroids. 

WTF is a normal length of a menstrual cycle?

On average, a normal menstrual cycle is between 21 and 35 days. You can read more about what affects the length of your menstrual cycle here.

Hopefully after reading this you are more clear on WTF a normal period is. If you feel like your period may not be "normal", I highly advise you to start tracking it. Period apps, like Kindara and Clue (my two current favorites), allow you to track your period length, flow, cycle length, temperature and so much more. 

If your period isn't "normal" and your experiencing period problems, enrollment for my group coaching program opens on Monday, June 4th. Follow me on instagram (@veronicamcnelis) or join my email list here to make sure you don't miss the announcement.

Is 28 Days REALLY the Length Your Menstrual Cycle Should Be?

We’ve been lead to believe a healthy menstrual cycle is 28 days. But the truth is, not all menstrual cycle lengths are the same from month to month and from woman to woman. Meaning your cycle may average between 30-32 days each month, and your best friend’s may average between 21 and 23. And absolutely nothing is wrong with either. 

The “average” 28 day cycle was born from the contraceptive pill. The pill was designed to mimic a woman’s natural cycle and the nice average number of 28 days, or four weeks, was chosen. The pill had to be marketed to “regulate menstruation” (which if you have been following my blog posts you know isn’t possible), since contraception was illegal.

Your menstrual cycle begins on your first day of heavy bleeding (not spotting) and ends the day before the start of your next period.

So how long is a “normal” menstrual cycle? The length of your menstrual cycle is determined by the sum of it's three main phases:

  1. The Follicular Phase (which can last 7 to 21 days)
  2. Ovulation (1 day)
  3. The Luteal Phase (10 to 16 days)

Let’s take a look at each phase of your cycle..

Phase One: The Follicular Phase

The follicular phase begins on day 1 of your cycle (the first day of bleeding) and lasts until ovulation. During the follicular phase about 6 to 8 of your ovarian follicles enter the final phase of their journey to ovulation (the complete journey is about 100 days). This is kicked off by the hypothalamus sensing low hormone levels in the blood and releasing Gonadatropin Releasing Hormone (GnRH) to the pituitary. The pituitary then releases follicle stimulating hormone (FSH) and luteinizing hormone (LH) to the ovaries. Follicle maturation is stimulated by the release of follicle stimulating hormone (FSH).

As the follicles grow and mature they release estrogen. Estrogen levels gradually rise during the follicular phase, causing FSH levels to decrease. As estrogen levels increase, the production of LH is stimulated (LH production is NOT stimulated with low estrogen levels). At the end of the follicular phase, when estrogen and GnRD levels are high they cause a massive surge in LH, which triggers ovulation.

The most mature follicle (sometimes, but rarely, two follicles) will reach ovulation.

The length of the follicular phase can be influenced by:

  • The amount of FSH your pituitary produces. The younger you are the less FSH you produce, resulting in a longer follicular phase. As you age you produce more FSH, resulting in a shorter follicular phase (common during perimenopause). A teenager can have a follicular phase as long as 32 days. 
  • Stress, Illness, Undereating or Polycystic Ovarian Syndrome (PCOS) can all cause a long follicular phase, if you are younger than 45
  • Thyroid Disease, PCOS, or the transition to menopause for those older than 45 can cause a longer follicular phase

 

Phase Two: Ovulation

As mentioned above, a single dominant follicle will reach ovulation at the end of the follicular phase. This follicle will swell and then burst to release an egg, triggered by the surge of luteinizing hormone.

The swelling of the follicle takes a few hours and the rupture of the egg lasts only a few minutes. The exact day on which ovulation occurs depends on the length of your follicular phase.

The egg that has been released is then transported into one of your fallopian tubes, where it has the potential to be fertilized (if sperm is present).

The other follicles (the remaining 5 to 7) are reabsorbed by your ovary.

 

Phase Three: The Luteal Phase

The luteal phase happens ONLY if you have ovulated (if you do not ovulate you have what is called an anovulatory cycle). The emptied follicle that released the egg during ovulation forms into a temporary endocrine gland called the corpus luteum. The corpus luteum forms within one day and stays alive for 10-16 days.

The corpus luteum secretes estrogen, inhibin and progesterone. Inhibin has a negative effect on your pituitary gland, and inhibits the secretion of follicle stimulating hormone (which makes sense because during this time no other follicles need to be maturing and growing). The rise of progesterone levels along with inhibin levels also inhibit the release of GnRH from the hypothalamus, causing a slow down in the production of estrogen. Towards the end of the 10-16 day period, as the corpus luteum begins to disintegrate, and there is no fertiliation of the egg, progesterone levels drop. The decline in progesterone along with other hormones no longer inhibit the secretion of GnRH from the hypothalamus, and the shedding of the endometrial lining is triggered, beginning a new cycle.

The luteal phase lasts 11-16 days, and can never last longer than 16 days. The most common cause of a short luteal phase (less than 11 days) is stress, but undereating or illness can also be culprits. 

To summarize, the length of your menstrual cycle can be affected by many things; age, stress levels, illness, and caloric intake.  As these things can vary from month to month, especially stress levels and caloric intake, it makes sense the length of your cycle would vary by a few days as well. As an adult, a healthy cycle can be anywhere from 21 to 35 days. In your teenage years, after you first get your period it is completely normal for your period to take a few years to regulate and normalize. Between your 20's to mid 40's things should stay fairly regular, for you - meaning, compare your cycle each month to the months prior, not to someone else's cycle.

Any drastic changes in the length of your cycle, or consistently long (35 days+) or short (less than 21 days) are worth investigating.

3 Simple Ways to Combat Post-Birth Control Syndrome

Ditching hormonal birth control can feel liberating – it’s a chance to become more in tune with your body and your natural cycle and benefit from your body’s natural hormonesunless you start to experience symptoms such as heavy and/or painful periods, acne, mood swings, PMS, anxiety, or maybe even no periods at all. Those symptoms don't feel so liberating. These post-pill breakup symptoms have such an impact on women's lives they’ve been titled Post-Birth Control Syndrome (PBCS). These symptoms may not happen right away either – they can take up to four to six months to appear, so you may not even realize ditching your hormonal birth control (HBC) was the cause behind them.

There’s certainly a chance you may not experience any of these negative symptoms at all. Instead you may gain more energy, have a greater sex drive and develop a better mood. But if you happen to experience the negative side effects of ditching hormonal birth control, the best way to deal with them is to be prepared for them, and to know how to handle them when they show up. And know, with the right natural treatment you can experience the positive side effects of ditching hormonal birth control, too

 

So what kind of symptoms can show up?

The following are some of the most common Post-Birth Control Syndrome symptoms:

  • Loss of Periods (Amenorrhea) 
  • Heavy Periods
  • Painful Periods
  • Acne
  • Mood Swings
  • Loss of Sex Drive
  • Weight Gain and/or Difficulty Losing Weight
  • Disgestive Issues
  • Short Cycles
  • PMS

I want to break down a few of the most common ones in more detail.

Post-Pill Acne

If you went on hormonal birth control to clear your acne you can expect to have your acne return once stopping HBC. Post-Pill Acne is typically the worst 3 to 6 months after stopping the pill. Two things happen post-hormonal birth control that can cause acne to get worse. The synthetic estrogen in HBC, along with several types of progestin, suppress the production of sebum (skin oil). In return your body has to up-regulate the production of sebum, and the up-regulation will continue once you stop HBC. This can result in more sebum than you had prior to starting the pill, resulting in acne. The second thing that can happen is an increase in androgen production, as you come off of hormonal birth control and your ovaries start to produce androgens again. The upside here is your ovaries will start to produce estrogen and progesterone again, which are both beneficial for your skin. 

Heavy, Painful Periods

If you had heavy and/or painful periods prior to starting the pill you can expect them to return. If you started hormonal birth control shortly after getting your period for the first time (within the first few years) this may just be your period regulating itself. As I’ll discuss more below, it can take up to 12 years for your period to regulate and mature. Make sure you are reducing inflammation in the body, clearing out excess estrogen and ovulating to produce progesterone.

Missing Periods

If your period was regular prior to starting HBC you can expect your period to return within 3 months. If your period was irregular prior to HBC it can take up to 6 months for it to return.

 

So what causes these negative post-pill symptoms?

Real Period for the first time

You are experiencing a real period for the first time in a long time. (Pill bleeds are not periods.) Ask yourself what your periods were like before you started hormonal birth control. According to Dr. Jerrilynn Prior, a Canadian endocrinologist, it can take up to twelve years for your period to mature. Chances are you started hormonal birth control within the first twelve years of getting your period, and you’ve probably been on it for a while, which means it can take a bit of time for your period to regulate and become “normal” after stopping hormonal birth control.

Lack of ovulation

It may take months or in some cases even years for regular ovulation to occur again. Hormonal birth control suppresses ovulation, and therefore suppresses communication between your hypothalamus, pituitary gland and ovaries. Use the fertility awareness method to track your cycle and make sure you are ovulating (and producing progesterone!) each month.

Withdrawal from synthetic estrogen

Synthetic estrogen is strong, four times stronger than your own estradiol. Track your cycle post-hormonal birth control to make sure you are ovulating and producing natural estrogen and progesterone. Progesterone will help to balance the negative side-effects of estrogen.

Increase in androgen levels

Androgen levels will increase when stopping hormonal birth control. A small increase is beneficial – helping to improve mood and libido. A drastic increase can cause acne and hair loss. If you’ve been on hormonal birth control that has a progestin with a low androgen index you will have a rebound of androgens and an increase in androgen sensitivity, which may cause you to experience the negative symptoms of high androgen levels when you stop taking it.

PCOS may also play a role in high androgen levels post HBC. If you had PCOS symptoms prior to starting birth control you may expect those to return. If you developed insulin resistance PCOS due to being on HBC this may cause excess androgen levels as well.

 

So how can you combat Post-Birth Control Syndrome?

The majority of the symptoms caused by Post-Birth Control Syndrome can be cured using the same methods, as the underlying causes are the same. (These methods will also help with PMS, even if it isn't caused by stopping hormonal birth control). For issues such as PCOS, more in-depth healing is probably needed.

Diet

Eating a diet that balances blood sugar plays a large role in hormonal health. Your liver is responsible for clearing excess hormones out of the body. It is also responsible for converting glycogen into glucose when your blood sugar levels are low. If your liver is spending too much time working to balance blood sugar levels it won't have enough energy left to clear excess hormones out of the body. Find a way to eat that stabilizes your energy levels throughout the day, instead of crashing after each meal or feeling hangry in between.

Diet also plays a large role in inflammation in the body. If you deal with digestive disorders, start to become extremely mindful of what you put into your body and how you feel after eating it. If you are sensitive or allergic to any foods (especially if you have an autoimmune disorder such as Celiac Disease) it is extremely important to eliminate those foods from your diet while you heal the lining of your small intestine. In order to clear excess hormones out of the body we have to be having regular bowel movements and what you put into your body plays a huge role in this. Our gut microbiome is also very important when it comes to hormonal health. The healthy bacteria living in our gut help to regulate the HPA axis, reduce inflammation, metabolize estrogen and activate thyroid hormone. If you have a lot of inflammation in the body or are frequently bloated, these are signs that you have dysbiosis, meaning an imbalance of good and bad bacteria living in the gut.

Lastly, focus on macronutrients and micronutrients. Protein, fat and carbohydrates, the macronutrients all play an important role in period health. Without enough of these macronutrients your hypothalamus won't send out the signals to your ovaries that its okay to make a baby (or have a period). A healthy period also requires micronutrients such as zinc, magnesium, Vitamin D and iodine, among others. While supplements may be necessary to obtain enough of these micronutrients, first you should aim to consume them via food. 

Support Detox Pathways to Eliminate Excess Estrogen

Supporting your liver, digestive system and lymphatic system can help to clear out excess estrogen and excess metabolized hormones in the body. Your body has natural detox pathways that work on their own (read: you don't need a juice cleanse or to fast in order to detox). However, you can support your body's natural detox pathways by consuming less alcohol and processed foods and focusing on protein and micronutrients. 

Support the Mind-Body Connection

Your hypothalamus will not send the message to your pituitary gland to release follicle-stimulating hormone (FSH) or luteinizing hormone (LH) if it perceives your body can not handle a pregnancy. You may not want a baby, but if your hypothalamus perceives you are under too much stress you won't ovulate, and no ovulation means no period. The two main questions to ask yourself here are "am I under a lot of stress?" and "Am I eating enough?".

You don't have to be underweight to lose your period. If you are not eating enough you will not be able to support a pregnancy, so you will stop ovulating. Make sure you are feeling nourished and satisfied each day. Another question to ask yourself is "Am I eating enough carbohydrates?". Not eating enough carbs, despite eating enough food overall can impair hypothalamic signaling.

Stress is inevitable, but unfortunately your body doesn't know the difference between being chased by a lion or a stressful deadline coming up at work. Find ways to offset stress daily. 

 

What if you haven't stopped HBC yet?

If you are currently still on hormonal birth control and considering coming off of it, the best way to eliminate post-birth control syndrome is to put the above strategies into use before you are forced to. Focusing on your diet, supporting your detox pathways and eliminating stress can go a long way, especially if you begin months prior to stopping HBC.

For more personalized help with your post-birth control syndrome symptoms feel free to reach out to me at veronica@veronicamcnelis.com

Hormonal Birth Control Break Down

What is hormonal birth control and how does it work?

Hormonal birth control is a general term for all contraception methods that use steroid drugs to suppress ovulation and prevent pregnancy, including tablets, patches, injections, some intrauterine devices and the vaginal ring.

Hormonal birth control (HBC) works to prevent pregnancy by stopping ovulation, preventing the formation of fertile mucus and/or thinning the uterine lining. 

The steroid drugs (or pseudo-hormones) in birth control travel to the pituitary gland and prevent the pituitary from releasing luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Without the release of these hormones, ovulation does not occur. Luteinizing hormone is responsible for signaling to your ovaries to release an egg and follicle stimulating hormone is responsible for stimulating ovarian follicles to grow (each ovarian follicle contains one egg and produces estrogen, progesterone and testosterone).

No ovulation = No pregnancy

but it also means,

No ovulation = No period

The following comes from 'TAMING THE CYCLE: HOW DOES THE PILL WORK?' published on Hardvard.Edu and is worded so well, I thought I would include it here: "Although the outward appearance is the same (menstrual bleeding in week 1 of a 28 day cycle) the constant high levels of P and E for a woman taking the Pill actually abolish the normal hormonal cycling that underlies ovulation. The Pill therefore replaces the normal menstrual cycle with an artificial cycle (3 weeks of “mimicking pregnancy”, followed by 1 week with breakthrough bleeding)." [1]

What this means is you do NOT have an actual period while on hormonal birth control because you do not ovulate. A period is the result of a series of hormonal events in the body, including ovulation. Hormonal birth control is not "regulating" your hormones, or "normalizing" your period. Instead, it's shutting down your natural hormonal system. You are having a withdrawal bleed from the pill steroids when you do bleed on hormonal birth control. 

What are you missing out on by not producing your natural hormones? Estradiol is produced by your ovarian follicles and it stimulates mood and libido by increasing the neurotransmitters serotonin and dopamine. Estradiol also benefits your bones, muscles, brain, skin, sleep and metabolism. After you ovulate, the emptied follicle forms into the corpus luteum which produces progesterone. Progesterone helps to boost thyroid hormone, reduce inflammation in the body, supports sleep and helps to calm the nervous system (progesterone converts to allopregnanolone which is a calming neurosteroid). As you'll read in a bit, synthetic estrogen and progestin do not have these benefits in the body.

So why do you bleed every 28 days when taking birth control then?

Back when the pill was created, it was marketed for “cycle control” since contraception was not yet legal in the U.S.. Socially, legally and politically contraception was taboo thanks to the Comstock Law (which lumped talking about contraception with pornography). In Canada, the pill was available by 1960 for “menstrual regulation” but it wasn’t legal to even discuss contraception or prescribe the pill for contraception purposes until 9 years later in 1969. So since the pill had to be marketed to "regulate menstruation" it was designed to mimic a woman's natural cycle. [2]

Having a withdrawal bleed on the pill also helps to prevent break through bleeding, but it does not need to be every 28 days – as you can see from pills like Seasonique, which give the user a withdrawal bleed once every three months.

Before I dive into the steroid drugs in hormonal birth control, let's talk about a bit more about your natural hormones first. 

The natural ovarian hormones are estradiol and progesterone.

Estradiol is released by the developing ovarian follicles. Estradiol stimulates the uterine lining to grow and thicken, as well as stimulates the production of fertile mucus. (Fertile mucus has the main purpose of helping sperm to survive and travel to the egg.) 

Progesterone is a steroid hormone made by the corpus luteum (a temporary endocrine gland). Progesterone is essential for pregnancy, but also counterbalances estrogen and thins the uterine lining, as well as produces infertile mucus. Progesterone has many benefits to the body outside of supporting a healthy menstrual cycle and pregnancy. Progesterone protects brain and nervous system tissue, is a natural anti-inflammatory agent, and promotes deep sleep. 

Steroid drugs in hormonal birth control, also known as pseudohormones include ethinylestradiol and progestin (which comes in many different forms, which I'll list below).

Steroid drugs are chemical messengers, but they are NOT human hormones. They are in fact different molecules and different molecules have different effects in the body. The term 'progestin' is used to describe all molecules that are similar to progesterone. But here's the thing, when comparing the levonorgestrel molecule (a type of progestin) side by side to the progesterone and testosterone molecules, levonorgestrel is actually more similar to testosterone than it is progesterone. So while progesterone does some amazing things for your body like promote hair growth, levonorgestrel actually causes hair loss. [3]

Please do not be tricked into believing progestin and progesterone are the same thing.

Types of Progestin Include [4]:

  • Norethindrone
  • Norethindrone Acetate
  • Ethynodiol Diacetate
  • Levonorgestrel - most widely prescribed contraceptive progestin worldwide, and more similar to testosterone than it is to progesterone
  • Norgestrel
  • Desogestrel
  • Norgestimate
  • Drospirenone

PROGESTINS SUPPRESS OVULATION

NO OVULATION = NO PROGESTERONE

Which means you won't get the amazing benefits of progesterone listed earlier. 

 

Different Types of Hormonal Birth Control

So now that I've covered real hormones versus pseudo-hormones I'll break down the different types of hormonal birth control available.

  1. Combined (Estrogen Plus Progestin)

Combined hormonal birth control is a combination of two pseudohormones; ethinylestradiol plus one of the types of progestin listed above.

Examples of combined birth control:

  • The Pill
  • Nuvaring
  • Contraceptive Patch

What makes all of the different combined HBC options different? The amount and timing of estrogen and the type of progestin (and of course the delivery method) are what differentiate the different types of combined hormonal birth controls. 

*A note about delivery method: Hormonal birth control that is not consumed orally and is instead placed directly on the skin or in the vagina, deposits the steroid drugs (pseudo-hormones) directly into the blood. This means they are not first being filtered through the digestive system and liver. 

2. Progestin Only

How do progestin only methods of birth control work? They prevent pregnancy by thinning the lining of the uterus (a thin uterine lining can not support a pregnancy) and impairing the production of cervical mucus (without cervical mucus sperm cannot travel to the egg).

Examples of progestin only methods include:

  • Progestin Only Pill (also known as the mini-pill)
  • Implants
  • Injections
  • IUDs – Mirena and Skyla

Side Effects

Major Side Effects

  • Blood Clots
    • The risk of blood clots has existed since HBC came into existence. Each new generation of progestin is supposed to be better, but it seems that each new generation actually carries a greater risk of blood clots. Transdermal patches and vaginal rings carry the highest risk of blood clots, with a 7.9 and 6.5 times increased risk, compared to nonusers of hormonal birth control [5]. Patches and vaginal rings dispense psuedo-hormones directly into the blood stream, unlike the pill which results in psuedo-hormones being processed by the digestive system and liver first. if you're debating using the NuvaRing, I encourage you to read this article first.
  • Cancer
    • A recent study in Denmark confirmed that the risk of breast cancer is increased with the current or recent use of hormonal contraceptives and the risk increases with longer durations of use. [6] A high dose estrogen pill increases your risk for breast cancer by three times. [3]

"Minor" Side Effects

  • Depression
    • The onset of depression can happen within one day or one year of taking hormonal birth control. A study in Denmark that tracked over 1 million women, ages 15 to 34, over a 13 year period found that women who use hormonal birth control, especially adolescents, are more likely to be diagnosed with depression. [7] This diagnosis peaked after six months of using HBC. And keep in mind, this study only included the women who went on to be diagnosed with depression and take antidepressants. It did not include the women who experienced changes in mood or an onset of depression and failed to report it. It makes sense that hormonal birth control would cause depression as it shuts off our natural estrogen production, which boosts are feel good neurotransmitters, and lowers our natural testosterone production. 
  • Hair Loss
    • Hair loss is caused by hormonal birth control with progestins that have a high androgen index. Remember above when I said the progestin molecule is actually more similar to the testosterone molecule than it is to the progesterone one? Well, some progestins have a high androgen index meaning they are even more testosterone like. These types of progestins slowly shrink your hair follicles over time leading to hair loss (meaning it may be months of years before you begin to notice). This is not an easy thing to reverse. Excess androgens may also lead to acne.
  • Loss of Libido
    • Remember above when I said your ovarian follicles produce testosterone? And you need FSH to stimulate the ovarian follicles to grow? Without FSH stimulating your ovarian follicles to grow, your ovarian follicles can't produce testosterone. Testosterone increases your libido (and also helps to improve your mood and energy levels so with a lack of testosterone you may not only see lack of libido, but depression and fatigue). Not only do you not produce testosterone, but you may end up with elevated levels of sex hormone binding globulin (SHBG). SHBG binds to excess hormones in the body, making them unavailable for use. Your body naturally produces more SHBG when you are on hormonal birth control to help keep you safe from the high ethinylestradiol (synthetic estrogen) levels in HBC [8]. Studies have shown SHBG levels stay elevated even after coming off of hormonal birth control. The use of hormonal birth control has been associated with less frequent sex, less frequent feelings of arousal, pleasure, orgasm, and vaginal lubrication [9]. It seems a little ironic that hormonal birth control allows us to have sex with out risk of pregnancy, but causes a lack of interest in sex!
  • Weight Gain
    • Hormonal birth control has been shown to contribute to insulin resistance. Insulin resistance is when there is too much insulin in the body and it leads to inflammation and weight gain (if you have PCOS this is a topic worth doing more research into, as increased insulin impairs ovulation and causes your ovaries to make testosterone instead of estradiol). 

Side Effects Specific to Certain Types of HBC

  • The Pill (specifically Yaz and Yasmin)
    • Common side effects include anxiety and depression - and possibly blood clots. If you're considering Yaz or Yasmin, please read this.
  • Nuvaring – blood clot risks much higher than the pill
    • Contains the progestin etonogestrel (a form of desogestrel which is a third generation progestin) which carries a higher risk of blood clots than earlier generations of progestin
    • Ethinylestradiol goes directly into blood stream, meaning it does not pass through the liver
    • Nuvaring dispenses hormones directly into blood stream vs. the pill that loses up to half it’s hormones in digestive system
  • Contraceptive Patch
    • Carries a higher risk of blood clots because hormones are released directly into the blood stream
  • Implants
    • Has been shown to cause weight gain and erratic bleeding
  • Injections
    • Has been shown to cause unstoppable weight gain, temporary bone loss, and carry the risk of breast cancer

A word about hormonal birth control and labels

“Americans may assume that the fine print in a drug’s packaging represents the collective scientific knowledge about that medication, allowing doctors and patients to make informed health care decisions. In fact, negotiations between pharmaceutical companies and the FDA over warning labels are common during the drug approval process, with drugmakers endeavoring to cherry-pick what’s included in order to present their products in the best possible light.”[10]

It's sad but true, the labels on hormonal birth control do not tell the entire story.

When to go on HBC

From reading this blog, you can clearly tell I am not a fan of hormonal birth control. However, it is your body and your choice. Please ask yourself, is the risk worth the reward? You may have read all of the above and have decided that taking hormonal birth control is still the best option for you in order to prevent pregnancy (I'll be covering non-hormonal birth control options in a blog post next week!). Or you may have decided hormonal birth control is the best option to handle your period problems. If you are dealing with a serious condition such as endometriosis or adenomyosis you may decide hormonal birth control is the best choice (however there are natural methods that do help - reach out to me to learn more!). 

Questions to ask your doctor

If you've read the above, and you're still deciding to use hormonal birth control please get specific information about the type of HBC your doctor is prescribing for you. Knowledge is power. The questions below are a good starting place to get more information.

  • Why are you choosing this specific hormonal birth control to prescribe me?
  • What type of progestin is in this hormonal birth control?
  • Is it a combination HBC or a progestin-only?
  • What are the most common side effects of this HBC?

What to do if you go on HBC

If you do make the informed decision to go on hormonal birth control I highly suggest tracking any signs and symptoms. You can do this in a daily journal or download one of the many period tracker apps available. Track things like weight, mood, libido, hair loss, skin and even sleep and cravings.

Conclusion

While I personally do not support the use of hormonal birth control, I believe it is a woman's right to choose and decide what we do with our own body. I wrote this blog to so you could make an informed decision, but please also know there is so much more information out there about hormonal birth control that I couldn't include for the sake of the length of this blog - so please continue to do more research. And as you are doing research be careful of where information comes from and who is funding the research (being mindful if the manufacturer of hormonal birth control is funding the research it's probably going to be biased). If you do decide to still continue with hormonal birth control after reading this, please keep track of any signs and symptoms you may experience and do research into the specific hormonal birth control your doctor is prescribing you. I believe decades ago that hormonal birth control was a step in the right direction for women's rights, but now 50+ years later it is an outdated method and better, safer options are available. Continuing with the theme of birth control this month, I'll be covering how to come off of hormonal birth control and what to expect, and non-hormonal birth control options, later this month. In the meantime, feel free to contact me with any questions at veronica@veronicamcnelis.com

 

References

[1] http://sitn.hms.harvard.edu/flash/2008/issue40/

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520685/

[3] Period Repair Manual Lara Briden ND

[4] https://www.verywell.com/different-progestin-types-906936

[5] https://www.ncbi.nlm.nih.gov/pubmed/22577198

[6] http://www.nejm.org/doi/full/10.1056/NEJMoa1700732

[7] https://www.ncbi.nlm.nih.gov/pubmed/27680324

[8] https://drbrighten.com/birth-control-pill-low-sex-drive/

[9] https://kinseyconfidential.org/hormonal-birth-control-sexual-functioningwhats-deal/

[10] https://www.huffingtonpost.com/2013/12/18/nuvaring-blood-clots_n_4461429.html