Drug Survey: Hormonal Birth Control

I had several requests for a post on hormonal contraceptives. I did quite a bit of research on the actual medications in the past. I had the luxury of consulting several medical journals back when I was a chemistry grad student and had access to all the medical journals I could possibly want. Since then I have tried to keep up with the specifics on the individual medications, but I have to be a little more creative in obtaining information. This topic is quite extensive and rife with emotions, controversy, and confusion. I don’t believe a blog post would really do it justice, so I direct you The Pill (http://cbhd.org/content/the-pill), edited by Linda Bevington, MD and Russell DiSilvesto, PhD,  that is available for free from the Center for Bioethics and Human Dignity. I have not read all of the essays in the book, but I appreciate the introductory essay as well as CBHD’s perspective on bioethics issues. This is a great resource for answering questions and is fair with all the perspectives that are permissible from a Christian worldview.

Rather than reiterating what is in this book, I will try to work to my strengths and discuss the chemistry and physiology of this medication, as well as summarize the ethical positions that are presented in much more detail in The Pill.

Protestants hold many different positions on hormonal birth control, so for clarity, my position is that hormonal birth control can be ethically permissible if it is used cautiously, carefully, and correctly. Particular brands of hormonal birth control are ethically permissible as long as the aim and effect of the medication is to stop ovulation. Not everyone responds to hormonal birth control the same way, so I believe there should be much more doctor-patient interaction than there typically is, including additional tests and precautions to make sure that ovulation is NOT occurring while on the pill.

Secondly, everyone who takes hormonal birth control or has a spouse that takes hormonal birth control should wrestle with this decision. Some people take hormonal birth control without any idea of how it works physiologically, or without every considering other options than hormonal, daily pills that are ingested.

Thirdly, there are certain people who, for other health reasons, should not be on hormonal birth control pills. For example, people who smoke should not take hormonal birth control pills. People who are prone to blood clots or have liver issues should not take combination hormonal birth control pills. People who have experienced adverse side effects or whose bodies cannot tolerate additional hormones should consider non-hormonal options.

It is important to monitor how hormonal birth control works (in you), that it is working properly (in you), and you are very careful to monitor your side effects. It is a medication that is given to an otherwise healthy person, so it should be held to a very high standard (See my initial Drug Survey post). It is my belief that no reproductive decision should be taken lightly, even the decision to not have children (for the time being or at all). Every Christian should wrestle with the relationship between sex and procreation and what is part of God’s design, what is a result of the Fall, and what is an artifact of our culture. The introduction to The Pill addresses the various Biblical interpretations pertinent to this matter.

Most hormonal birth control pills, shots, patches, or rings have some combination of the hormones estrogen and progesterone, or one of these ingredients. Brands such as Ortho-tri-cyclen, OrthoLo, Yasmin, and Seasonale are daily oral pills that contain a combination of an estrogen and progesterone.

Ortho-tri-cyclen has varying ratios of estrogen and progesterone depending on the week within the cycle. This may more closely mimic what occurs in the body. Yasmin and Yaz, another combination hormonal contraceptive, has come under scrutiny because of severe side effects in some people. Ortho Evera is a patch that is placed on the body. It delivers estrogen and progesterone to the body through the skin. It has come under scrutiny because it has been shown to cause a higher incidence of blood clots than oral contraceptives do. NuvaRing is a ring that is inserted intravaginally once per month. Progesterone and estrogen are administered through the ring and absorbed through the vaginal lining. Depo Provera is an injection administered once every three months. It and progesterone only “minipills” are progesterone-only; they do not contain estrogen. Progesterone only medications are often taken by women who are sensitive to estrogen or who are prone to blood clots.

While the first intention of these above mentioned hormonal contraceptives is to stop ovulation, they can also serve to thicken the mucous lining, making it difficult for sperm to reach the egg within the fallopian tube. They may make the womb environment hostile to implantation. If ovulation and subsequent fertilization does occur, the embryo may not implant properly. In this case, an abortifacient effect has occurred.

Progesterone only “minipills” and low dosage combination hormonal birth control pills have been shown to be more at risk for inconsistently stopping ovulation. The progesterone only “minipills” are more likely to create a harsher womb environment.

It is difficult to determine if hormonal contraceptives act as abortifacients. Many women have become pregnant and delivered healthy babies on the pill, calling into question whether the abortifacient effect is commonly the case, or the exception. Because hormones are “signals” in our bodies, many of the difficulties in studying the effects of the pill may be due to hormonal responses being much more patient-specific than was once thought.

Additionally, something that most people forget to account for in oral contraceptive studies is user error. Few women use the pill correctly 100% of the time, making it difficult to distinguish actual effects and effects from user error. The pill should be taken at the same time every day. While many women report taking the pill correctly, many doctors will tell you that patients often lie to their doctors, and based on my conversations with other women, very few women realize that the “same time” part of the instructions is just as important as the “every day” part of the instructions.

Lastly, because oral contraceptives are ingested, if a woman has any GI or digestive problems (such as vomiting, diarrhea, the flu), oral contraceptives may not work correctly.

All of the above mentioned hormonal birth control medications actually contain chemical derivatives of progesterone or estrogen. For example, the active ingredient in Depo-Provera is medroxyprogesterone acetate, which is a derivative of progesterone. Sometimes one form can have severe side effects in one person, but another form does not. The progesterone derivative that was originally used in Yasmin, for example, showed severe side effects in approximately 1/3 of users, while the progesterone derivative in other oral contraceptives did not see this large of a percentage of severe side effects.

Hormonal contraceptives have a sordid history. Originally intended for eugenic-based population control, scientists and doctors found that hormonal birth control (in daily pill form) was actually helpful in promoting fertility in some women (however, it could be related to infertility in other women). We have to be careful not to judge today’s use of birth control based on its historical origins, but we also shouldn’t ignore its history as that has certainly influenced our current cultural climate. People have been practicing various forms of family planning for centuries using barrier-type methods or natural family planning. While hormonal birth control may have come from eugenic origins, family planning did not necessarily come out of these motivations. We also need to be mindful that man is sinful and God is in the business of redemption. Some technologies, actions, or procedures may have been developed for nefarious reasons, but are used for good. Similarly, some technologies or procedures may have originally had good uses but have been hijacked for nefarious purposes. The story of Joseph’s brothers selling him into slavery is one example of God taking what man intended for evil and using it for good. The story of David and Bathsheba is another Biblical example of God redeeming a sinful situation. Using hormonal birth control can be unethical, depending on the intentions and circumstances of the user, as well as the type of hormonal birth control that is used and when it is taken. So-called morning after pills (or Plan B) have a similar chemical composition to hormonal birth control pills, but in much higher dosages. They are taken to abort a pregnancy, not to stop ovulation. In this sense, the intention and use of this drug is quite different and ethically problematic.

Hopefully this overview is helpful and informative. I recommend looking at the CBHD documents above for an in depth treatment of the subject.

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Joel Goodnough, MD
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Joel Goodnough, MD

Very well said, Heather. Just to confuse the issue more, different groups use different definitions for some of the terminology used in discussions on oral contraceptives. While I might define conception as the union of the sperm and the oocyte (fertilization), the American College of Ob Gyn (ACOG) defines conception as the act of implantation of the embryo into the lining of the uterus. I might therefore define pregnancy as beginning with fertilization (conception) while ACOG defines pregnancy as beginning with implantation (also conception). Neither is right or wrong but the use of these definitions can be used to color… Read more »