The Hormonal Effects of Contraceptive Methods

By Elizabeth Davis

No discussion of contraception would be complete without mention of safe sex as a means to protect oneself from HIV and other sexually transmitted diseases. Although condoms and latex dams are simple enough in concept, some women have difficulty insisting on their use. This is dangerous, as the incidence of AIDS is rising most dramatically among women, particularly heterosexual women.

The need to take precautions changes sexual dynamics, particularly those of foreplay. Ideally, a couple should discuss safe sex in advance, but often the issue rises concurrently with passion. Some women have been pleasantly surprised at how bringing up mutual risks and responsibilities sets them on equal footing with their partners. In heterosexual unions, conventional roles of man as aggressive and woman as passive all but wither away. Foreplay becomes literally playful; acts of securing the condom or placing the dam can be humorously erotic. To compensate for loss of spontaneity, more egalitarian sexual interactions may be experienced.

Although barrier methods are surveyed later in this section, the female condom should be mentioned here. This device consists of a sheath of latex with one open and one closed end, each encircled by a rubber ring. The smaller ring (closed end) is inserted and placed over the cervix; the larger ring remains outside the body, resting over the labia. Originally developed in Europe, this method is only recently available in the United States, so we have little data on user satisfaction. But some women have reported discomfort during intercourse, presumably from the outer ring rubbing against the labia or clitoris -- still, the female condom gives a woman the prerogative.

Regarding the more popular methods, we will start with oral contraceptives. Put bluntly, the birth control pill completely wipes out the cyclical pattern of emotional and sexual response we have discussed. The pill works by effecting a state of minipregnancy, with hormone levels high enough to trick the body into believing it's pregnant so that ovulation does not occur. Most formulas combine estrogen and progesterone; others use progesterone only (the minipill). Each of these hormones, should the dose prove excessive, is responsible for specific side effects such as weight gain, acne, breast tenderness, nausea, headaches (other than migraines), and fatigue. A woman's response to a particular formula is somewhat unpredictable because much depends on her preexisting balance and sensitivities. This is why a gynecologist may suggest five or six brands before discovering one that is satisfactory.

Ultimately, though, the day-to-day hormone mix is uniform. A woman on birth control pills is hormonally monotone, always the same. Gone are the natural peaks of estrogen, progesterone, and testosterone. Gone are the creativity and passion during ovulation, the intense desire immediately before or during menstruation. Gone too is the psychological richness associated with the above, plus the benefits of cyclic completion and renewal. For there is no real menstruation when on the pill; it takes ovulation to trigger the full buildup and release of the uterine lining. All pill users have is a little breakthrough bleeding when they have taken the last of the batch and hormone levels drop temporarily. This flow is lighter and typically uniform, without variation in length or consistency.

Even sequential pills (triphasic), which attempt to duplicate a more natural rhythm of estrogen and progesterone, produce an artificial pattern ultimately foreign to a woman's own. When clients tell me of their desire to get off the pill, albeit with some reluctance, they often cite the primary reason as wanting to be more in touch with their bodies. As we talk further, what they really seem to miss is being in touch with themselves, their own unique mind-body blend. It's disturbing to think that artificial hormonal influences could alter personality, but considering the singular powers of estrogen and progesterone, such is clearly the case.

At last, women are beginning to find clinical confirmation of their loss of interest in sex when on the pill. Rosemarie Krug, a psychobiologist from the Department of Clinical Neuroendocrinology at the Medical University of Lubeck, ran a study of women's response to erotic imagery, comparing women on the pill to those who were not. Three times a month, study participants were exposed to a series of rapid shots of naked men, babies, women combing their hair, and so on, and were asked to categorize them as sexual, maternal, or body related. At ovulation, women not on the pill were much quicker to spot the babies and naked men and to read sexual connotations into hair-care images; after ovulation, they took longer to respond to the babies, as might be expected. But women on the pill responded always the same, which Krug linked conclusively to a lack of hormonal peaks and valleys and low testosterone levels.

Signs of Estrogen Excess

• nausea and vomiting

• dizziness

• edema

• leg cramps

• increase in breast size

• chloasma (brown pigmentation on face)

• changes in eyesight

• hypertension

• certain headaches (vascular)

Signs of Estrogen Deficiency

• early spotting (days 1 to 14)

• reduced menstrual flow

• nervousness

• painful intercourse due to vaginal changes

Signs of Progesterone Excess

• increased appetite

• tiredness

• depression, mood changes

• breast tenderness

• vaginal yeast infection

• oily skin and scalp

• hirsutism (excess body hair)

Signs of Progesterone Deficiency

• late spotting and breakthrough bleeding(days 15 to　21)

• heavy menstrual flow, with clots

• decreased breast size

As mentioned earlier, the pill may be therapeutic for certain gynecological problems, such as endometriosis or pathologically painful menstruation. Nevertheless, it's important to remember that relief obtained in these cases merely masks underlying causes. Again, acupuncture may effectively reeducate the system to a more harmonious condition.

Acupuncture may also be useful for women coming off the pill. It is not uncommon for women to miss a period or two; the body has forgotten what to do, so to speak, and needs to get back on track. If the rhythm is lost for six months or more, a combination of acupuncture and herbs can stimulate pituitary secretion of LH and FSH, with appropriate ovarian response. I find this treatment preferable to the use of Clomid, a potent fertility drug notorious for causing multiple pregnancies. Problems with delayed cyclical function are much more common after the age of 30 -- ironically, a time when women often quit the pill specifically to get pregnant.

Estrogen-Producing Herbs

• blue cohosh

• black cohosh

• basil

• sage

• black currant

• licorice

• raspberry leaf

Progesterone-Inducing Herbs

• sarsaparilla

• wild yam root

• tansy

• chaste tree (vitex)

Now, let's consider the effects of the intrauterine device on a woman's cycle. With the exception of the Progestasert, the IUD does not directly affect hormonal balance. However, many women do report heavier periods with greater discomfort. Originally, women receiving the IUD were told that these problems were merely mechanical, that the device caused low-grade irritation with side effects of cramping and increased flow. What they were not told was that the IUD does not actually prevent conception, merely implantation of the already fertilized ovum. After all, there is no mechanical barrier to prevent the sperm from meeting the egg. The so-called heavy periods with the IUD are in fact spontaneous miscarriages, month after month after month.

Thus the hormonal effects of the IUD, though indirect, are quite drastic; with conception, dramatic changes in the levels of estrogen and progesterone occur. I recall piecing this realization together many years ago while wearing an IUD. I couldn't wait to get it out! The idea of miscarrying over and over, plus going through intense hormonal changes on a nearly continuous basis, was physically and emotionally offensive to me. I realize that certain women are satisfied with the IUD and consider it a godsend. But so extensively has it been linked to fertility problems (due to uterine scarring, tubal pregnancy and rupture) that it is nearly off the market, except for the Copper 7 and Progestasert devices. The latter works something like the minipill: increased levels of progesterone on a daily basis tend to prevent the egg from maturing and chemically alter the cervical mucus in a way that makes it inhospitable to sperm. Menstrual irregularities are common, such as prolonged bleeding and occasional amenorrhea.

There are two other progesterone-based methods of contraception currently available. Norplant inserts provide up to five years' protection from pregnancy by slowly releasing hormones into a woman's bloodstream. Depo-Provera injections are given every three months. The primary difference between these two methods is the amount of progesterone -- Norplant levels are similar to those of the minipill, whereas Depo-Provera is very high-dose. Accordingly, side effects from Depo-Provera are more extreme: cessation of menses, weight gain, breast tenderness and depression that may persist for many months after discontinuation, bone density decrease when used over long periods of time, and dramatic reduction of high-density lipoprotein cholesterol (the good kind, which keeps blood cholesterol levels low). And Norplant not only causes menstrual irregularities similar to the minipill, but may precipitate the development of ovarian cysts.

The nearly foolproof method of tubal ligation, long touted as having virtually no side effects, merits closer investigation. Numerous studies published in the 1980s show that certain procedures, such as high-frequency and endocoagulation methods, cause hormonal and menstrual cycle disruption in nearly one-third of all cases. Diminished estrogen and progesterone levels may even contribute to early menopause or the onset of menopausal symptoms. Other methods, like the Hulka clip, seem to produce good results and maintain hormonal balance.¹⁰

What about the barrier methods? Obviously, these have no physiological effect on a woman's cycle. Local effects and inconveniences are considerable, including chemical irritation from spermicide, lack of spontaneity, messiness, and reduced sensation.

My extensive experience with the cervical cap has led me to favor it both personally and professionally. As compared to the diaphragm, it uses very little spermicide: no additional applications are required for repeated intercourse. It can be left in place for several days and is small enough to be virtually undetectable. A little-known fact about the diaphragm is that although it feels snug when first placed, the vagina expands so much with arousal that even an oversized fit will move and slide around freely during intercourse, readily admitting seminal fluid. Thus the jelly inside the diaphragm becomes so diluted that more must be added before having sex again, hopefully to catch the sperm before they get over the rim. But the cap fits the cervix securely with suction, forming a stable mechanical barrier. In addition, when the user is fertile, the cap retains her mucous secretion so that the natural, sperm-killing acidity of the vagina is maintained (seminal fluid is alkaline, as is fertile mucus; sperm need this in fresh, abundant supply or they die rapidly). Thus the cap works with a woman's chemistry rather than against it, and it is more truly a barrier method than the diaphragm, which relies heavily on chemical effect.

A bonus of cap use is increased familiarity with one's cycle; it is fairly easy to see what phase you are in depending on the type of secretion your cap collects. Also, women who use the cap report less yeast and other vaginal infections than with the diaphragm, since chemical disturbance of vaginal flora is virtually nonexistent.

Having used a diaphragm for 14 years, as well as having fitted them extensively, I know the frustrations of overriding discomfort and disrupted spontaneity. There were numerous occasions I was tempted to leave the diaphragm in the drawer or toss it into the trash can. Eventually, I recognized that much of my resistance was due to reduced levels of sensation during intercourse. Around this time, news of the Graffenburg spot (or G-spot) hit the press, and suddenly it all made sense. By virtue of its design, the front rim of the diaphragm must displace the G-spot in order to lodge behind the pubic bone. No wonder I couldn't feel as much! Once I learned fertility awareness and could safely use my diaphragm only when necessary, I was able to make a real comparison. The problem was solved completely when I switched to the cap; it sits way back on the cervix alone, nowhere near the G-spot.

As mentioned earlier, some women use fertility awareness as birth control, abstaining during the ovulatory phase. However, this may cause considerable frustration, as intense desire must routinely be ignored or expressed in ways other than vaginal/penile intercourse. Increasingly, women in my practice choose to combine fertility awareness with a barrier method of some kind.

A number of women alternate use of the cap or diaphragm with condoms. They say it feels good to share the responsibility, switching back and forth from month to month, or from time to time. A comment from Suzanne: "My partner and I had run the gamut in birth control, and ended up with barrier methods for safety's sake. But it didn't feel right to me to always be the one who had to remember to take charge. It's nice when my partner uses a condom: I can just sit back and relax, and I like the feeling of my body being completely natural. It helps me enjoy sex more."

10. Lois Jovanovic and Genell Subak-Sharpe, Hormones: The Woman's Answer Book, (New York: Ballantine, 1987).