Unexpected Side Effects of Oral Contraceptives: What to Watch For
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Of all the choices out there, oral contraceptives can be the best choice for birth control for many people. The pill does come with some side effects, but how each person is affected is determined by their unique biology and history, as well as the medication, says Amanda French, MD, a pediatric and adolescent gynecologist at Massachusetts General Hospital in Boston.
“The best type of contraception for any given person is the one they feel most comfortable on,” she says.
How Does the Pill Work?
Let’s start with a little background. These days there are a number of different types of contraception to choose from. Oral contraception is always hormonal, but there are differences in the types and doses of hormones different pills contain.
“Anytime we’re giving hormones we’re altering what’s already occurring in the system and there is always a chance you will encounter side effects,” says Alexandria Wells, MD, an ob-gyn in Complex Family Planning Fellowship in Seattle and a fellow with Physicians for Reproductive Health.
Some birth control pills just contain one hormone, progestogen, while others, called combination pills, contain both progesterone and estrogen. According to the Mayo Clinic, combination pills prevent the ovaries from releasing an egg, or ovulating. According to the American College of Obstetrics and Gynecology (ACOG), the progesterone-only pill, sometimes called the mini-pill, also can stop ovulation, but does so inconsistently — about 40 percent of women on this type of birth control ovulate. But progesterone-only pills also thicken the mucus lining of the cervix, which makes it difficult for sperm to reach a released egg. If it does, progesterone also thins the lining of the uterus, making it more difficult for the egg to attach.
“We do tend to see more side effects with the combined pill, the one that has both estrogen and progesterone, given the fact that you’re giving two types of hormones,” Dr. Wells says.
Progesterone-only pills have traditionally used the same type of progesterone and have had one significant drawback: They had to be taken at the same time every day. But in 2019, the U.S. Food and Drug Administration (FDA) approved a progesterone-only pill called Slynd (drospirenone), which uses a different type of progesterone that allows people to take it within a 24-hour period of a missed pill, rather than needing to be taken at the exact time every day, similar to the combination pill, for it to be effective, she says.
No pill is perfect, and finding the perfect fit can take a few rounds of trying different medications, notes Wells. Here are some of the most common side effects that may occur when taking oral birth control and how to manage them.
1. Yeast Infections
According to Wells, a one-off yeast infection probably isn’t a side effect of your birth control. But recurring or chronic yeast infections might be.
It’s not completely clear why this is, but Wells says it may have something to do with the hormones in the pill altering the levels of estrogen in the vagina, which changes the pH in the vaginal microbiome, which can make it more hospitable to candida, the type of yeast that causes vaginal yeast infections.
Wells says a person’s birth control pill prescription can be adjusted to a lower-dose hormone or a person can switch the type they’re on if yeast infections are an issue. Yeast infections can be diagnosed by your health care provider and treated with suppository creams that are inserted into the vagina or with oral antifungals.
2. Vaginal Dryness
Vaginal dryness can happen when hormones are altered, including when someone is taking hormonal birth control. But it’s an easy one to remedy, notes Wells.
A doctor can provide topical estrogen to apply to the area, which can help. Otherwise, altering the dose to a smaller dose is also an option, depending on what type of progesterone is in the birth control a person is taking, though this might not work for everyone. Wells also warns that lowering the hormone dose can lead to breakthrough bleeding — spotting or bleeding between periods — which is something to be aware of. Changing which pill a person is on can help relieve vaginal dryness.
3. Decreased Libido
Several studies have found that it’s quite common for people taking the pill to have a decreased desire to have sex, or experience decreased arousal when they’re having sex.
A review of more than 100 studies, published in 2022, in the Journal of Clinical Medicine, found that decreased desire to have sex was the number one side effect of hormonal birth control. One of the studies reviewed found that of more than 3,400 women who were on birth control, 43 percent reported their sexual desire was reduced while taking hormonal birth control, compared with 12 percent who used hormone-free contraceptives. If decreased libido is an issue that someone taking the pill would like to remedy, there are other types of birth control that they could try, such as an intrauterine device (IUD), which is less likely to affect sex drive, according to a study published in the Journal of Clinical Medicine.
4. Breakthrough Bleeding
Hormonal birth control can lighten periods, according to the Office on Women’s Health, which can be a positive side effect, especially for those who have heavy or painful periods. But progesterone-only pills in particular can also cause bleeding or spotting between periods.
According to a study published in 2023 in the journal Breastfeeding Medicine, 40 percent of people who take progesterone-only birth control pills experience breakthrough bleeding, compared with 10 percent of those on combination pills.
5. Breast Tenderness
A review of two clinical trials published in 2023 in the journal Contraception included more than 3,700 people who took progesterone-only birth control pills. Of those, about 1,800 — or about 4 percent — reported breast tenderness, the second-most common reported side effect. Breast tenderness, or soreness, can occur anywhere on the breast and nipples.
Like many of the other potential side effects of birth control pills, breast tenderness can be a result of altered hormones, Wells says. Choosing a different birth control pill or nonhormonal birth control option may help ease discomfort.
6. Changes in Mood
The mental health effects associated with hormonal birth control are far less studied, and far less understood, than physical side effects.
“There isn’t reliable data that links hormonal contraceptives to mental health, and that’s one of the problems,” says Dr. French, noting that while it’s possible hormonal birth control pills do cause some mental health issues, it’s difficult to determine if the pills actually caused it.
A survey study published in 2023 in the journal Contraception and Reproductive Medicine included 188 people who used hormonal birth control. More than 43 percent reported experiencing mood changes as a side effect of hormonal birth control at some point in their lives. Those who had a history of mental health disorders were twice as likely to report mental side effects compared with participants with no history.
In a study published in 2023 in the journal Epidemiology and Psychiatric Sciences, which included more than 264,000 women from the UK Biobank, researchers found depression was more common within the first two years of starting birth control pills. Those who started taking the pills as teenagers were 40 percent more likely to have depression than those who started later in life.
If someone has an underlying mental health condition before they start taking the pill, French recommends they should keep an eye on their moods and speak with their doctor if anything changes. If they’re seeing a mental health professional, she says they should also let those providers know they are starting a new medication so they can take note of any changes they notice as well.
“There are many choices for hormonal contraception, and for that reason, if someone starts something new and feels they are having mental health effects from it, we can change it,” French says.
7. Blood Clots
Blood clots are a rare but potentially life-threatening side effect of combination birth control pills. The good news is, progesterone-only birth control pills don’t carry this risk, says Wells.
For people who have a history of blood clots or other risk factors, including high blood pressure, migraine with aura, or lupus, progesterone-only pills can be a safer option, Wells notes.
If you’re taking combined birth control pills, it doesn’t hurt to know the signs of venous thromboembolism (VTE) and deep vein thrombosis (DVT) so you can intervene early if you suspect you may have a blood clot.
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