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My first patient yesterday in the office was a 20 year old new patient having problems with her birth control pills.
She was originally seen by a colleague 6 months ago because she wanted to go on birth control pills. She was planning initiating a sexual relationship with her boyfriend, but had also heard that BCPs help with acne, PMS and heavy periods, all of which she had.
Her exam was normal and my colleague started her on a popular birth control pill, which she has taken consistently for the last 6 months.
While effective in preventing pregnancy, she’s noticed that her periods, rather than getting lighter, have gotten heavier. Her acne has not improved, and her PMS is marginally worse. She came to me for another opinion and to see if she could take a milder pill.
Her menses are currently every 28 days, lasting 7 days. She has noticeable acne. The rest of her exam was completely normal.
I reassured her that the problem was not that her birth control pill was too strong, but that it was actually too weak to provide her the other benefits. It certainly is strong enough to prevent pregnancy, but if she wants her acne to improve and lighter, shorter periods, she’ll need to increase the strength of the birth control pill (the strength of the progestin).
Ideally, the BCP will first suppress her ovarian function and then provide add-back estrogen, with total estrogen levels ending up a little lower than they were before she took the BCPs. But in her case, the BCPs progestin has not been strong enough to suppress ovarian function. Consequently, she has all of her own estrogen, plus the estrogen in the pill, making her a little hyperestrogenic all the time. That is what gives her the heavier, lengthier periods.
Ideally, with suppression of ovarian function, her androgen levels will drop by about one third, because one third of her androgens come from the ovaries. But if her ovaries are not suppressed, then although she won’t get pregnant, her androgens will remain unchanged, and she will get no improvement in her acne.
I changed her birth control pills to Portia, a generic form of LoOvral, which contains the very strong and long-lasting levonorgestrel as its’ progestin. I switched her in mid-pill-pack, although I certainly could have waited until the end of her current pack. I explained that she needed to wait 3 months before evaluating how she’s doing on the new pills, since it could take nearly that long for the new pill to demonstrate its’ effectiveness in reining in the troubling symptoms of acne and heavy, lengthy periods.
This brief delay in demonstrating ovarian suppression is also the reason that some women, when first starting birth control pills, will notice some annoying symptoms of headaches, fluid retention, weight gain and heavier flows during the first month that they take the pills. If they continue to take the pills regularly, I would expect all of those symptoms to disappear.
This patient had no trouble switching to a new pill. Occasionally, you’ll find a patient who is particularly attached to her original birth control pill. In such cases, you can offer her another alternative of changing to continuous pills rather than cyclical pills. When taken continuously, every day without letup, the pill progestin will likely be more effective at keeping the ovaries suppressed. Again, this may take up to 3 months before complete control is exerted, but it is another option that some people may prefer.
