This week, the Cut is talking advice — the good, the bad, the weird, and the pieces of it you really wish you’d taken.
You might not give your particular method of hormonal birth control a second thought, but maybe you’ve heard terrifying stories about women having strokes or blood clots, or freaked out after reading the prescribing information, or have vaguely worried about the long-term consequences of taking hormones like estrogen and progestin. Yes, tragic things have happened to women on the pill (and IUD, shot, ring, implant, and patch), but these methods are well-studied and their use is widespread. Of the 67 percent of women in the U.S. who use nonpermanent contraception, the majority rely on hormonal methods, according to the Guttmacher Institute, an organization that seeks to advance reproductive and sexual health worldwide. Still, you might be concerned about what these drugs can do to your body and if the risk for possible health problems increases the longer you’re on them. So we asked several ob-gyns: How long can you safely take hormonal birth control?
First, it’s important to put any possible risks of taking birth control into the context of preventing an unplanned pregnancy, says Mary Jane Minkin, M.D., F.A.C.O.G., and clinical professor of obstetrics, gynecology, and reproductive sciences at the Yale School of Medicine. In 2008, 51 percent of the pregnancies in the United States were unintended, according to the American Journal of Public Health, and there were an estimated 6.6 million pregnancies that year. Slightly less than half of the 3 million or so unintended pregnancies yearly occur when a woman has used some form of contraception during that cycle, Dr. Minkin told the Cut, so if you don’t want to get pregnant, use your preferred method faithfully.
And here’s some perspective: You have a greater risk of getting a blood clot during pregnancy than while taking any form of hormonal contraception because your hormone levels are naturally higher with a bun in the oven, she says. “No matter what your clot risk is with any birth-control pill — and even in the old days [with] the really, really high-dose pills — that pregnancy is still riskier,” Dr. Minkin says. Jill Rabin, M.D., professor of obstetrics and gynecology at Hofstra North Shore-LIJ School of Medicine, agrees. “The clot risk is logarithmically higher in pregnancy than from one of these methods,” Dr. Rabin says.
But what about taking hormonal methods on and off for years, with breaks if you want to have children? “Almost everybody can take them pretty much forever,” Dr. Minkin says. If you’ve been on your hormonal birth control for at least a year without health problems, you’re probably fine. “The highest risk time is actually in the initiation phase,” she says, which is the first few weeks. When her patients start a new prescription, Dr. Minkin tells them what symptoms are worth a call to her office. “I say, ‘You get any leg pains, you get any chest pains, you start getting any weird headaches, I’ve gotta know about it.’”
But before that conversation would ever happen, you and your doctor need to discuss your family history so you can choose a method with the lowest risks for you. “If somebody doesn’t want to become pregnant, you want to use the most effective, safest method for them, and it’s not a one-size-fits-all,” Dr. Rabin says. For instance, if you smoke or have a family history of significant blood clots, your doc might choose a long-acting IUD that is either hormone-free (the copper IUD, Paragard) or progestin only (Mirena). “Those have basically no risk to them as far as blood clots,” Dr. Minkin says.
Aside from blood clots, there have been studies linking hormonal-birth-control methods to increased breast-cancer risk. Dr. Rabin says hormones like estrogen and progestin do play a role in the development of biologic processes including cancers, but it hinges on your individual risk factors. “Depending on the person, it may accelerate the risk of breast cancer. It may,” she says. “We don’t really know the final answer.” But she might not even suggest hormonal options to a woman with a family history of breast cancer. “For each patient, I make a menu of potential contraceptive options from most advised to least advised,” she says. “We go through the risks, benefits, and alternatives and make a decision together.”
With someone like this, Dr. Rabin might also turn to the non-hormonal IUD or the progestin IUD, which uses a low dose of a hormone called levonorgestrel. “As far as the dozens and dozens of studies that I’ve gone over, as well as Cochrane reviews, I can’t find a real elevated [breast cancer] risk in terms of that progestin,” she says. “But they may find out that it does have a role.” Though she doesn’t think women shouldn’t spend a lot of time worrying about the unknown. “There’s nothing that’s 100 percent safe, except maybe abstinence,” Dr. Rabin says. And abstinence does not a family make.
There have also been studies linking hormonal methods and cervical cancer, which is caused by the sexually transmitted infection HPV. Dr. Minkin says the association there is likely because many women on hormonal birth control don’t use condoms, not because the drugs themselves increase your risk of getting HPV. (Reminder: Birth control alone doesn’t protect against STIs.)
“The most important thing women need to know about birth control and cancer … is that the best reducer of ovarian cancer, which is a terrible disease, is actually birth-control pills,” Dr. Minkin says. This is true even for women who have the breast-cancer gene BRCA, which also increases a woman’s risk for ovarian cancer. She says if a young BRCA-positive woman wants to have children in the future, doctors would likely discuss hormonal birth control as a way to reduce her cancer risk until she’s had kids and is ready to consider more treatment options like ovary removal. But Dr. Rabin points out that we really don’t know at this point if such a strategy, while potentially life-saving in terms of ovarian cancer, could increase a woman’s risk for breast cancer down the line. “We know more than we used to, but we also have more questions,” she says. “We’ve gotten better at helping people live longer so we know more answers, but we still — believe it or not — have more questions than answers.”
And what about the belief that using birth control for long periods of time can affect your ability to get pregnant? “There is no long-term association with decreased fertility,” Dr. Minkin says. It may take you a month or two to get “regular,” but it could happen even sooner. “If somebody’s thinking about having a kid and stops the pill, I always tell her, ‘If you don’t want that kid that first month, I want you using contraception,’” she says. “There are people who get pregnant two weeks after they stop their pill.” And hormonal birth control can help suppress endometriosis, a condition where the uterine lining grows and sheds outside the uterus, which can affect fertility. Dr. Minkin says that women with endometriosis are sometimes prescribed the pill specifically to improve their chances of conceiving in the future.
When looking at the fears surrounding hormonal birth control, Dr. Rabin says she doesn’t blame people because, on the surface, these are scary waters to negotiate. Yet our concern about these issues is the result of our good health. “We’re going to keep living longer and we’re going to have more and more questions, but that’s okay, we’ll have more and more research also,” she says.
“There’s a lot of anxiety and fear out there, which really doesn’t need to be there. Of course I respect birth control — I respect all medication — but you want to maximize the benefits to people and minimize risks for everything,” she says. For anyone who’s still worried about taking hormones, Dr. Minkin suggests asking your doctor about the IUD, which she calls an “excellent” method. And it happens to be among the most effective reversible options, preventing more than 99 percent of unintended pregnancies.