Birth Control

One possible reason for my weight gain that I haven’t focused on are my progestin-only birth control pills.  It’s of course been something I’ve wondered about.  But I didn’t want to be one of those people.  I have patients who swear some random symptom is caused by their IUD, and I tell them that I think it’s unlikely.  Sure enough, they have the IUD removed and the symptom remains present.  I didn’t want to necessarily blame my weight gain on the pills, when the fact is I have had poorer eating habits and haven’t been exercising.

But the fact is that progestin-based methods of birth control are known to cause weight gain.  I spend a lot of time counseling patients about birth control methods, and I see it all.  It’s amazing how differently each method affects different women.  With any particular method, some women love it, and some women hate it.  There are certain side effects that are common or expected, like weight gain with the Depo-Provera injections.  But even then, sometimes I have women who don’t gain weight with it.  Once I had a woman who said she lost weight with a method- I can’t remember if it was the pill or what, but that was the reason she didn’t like it (and she wasn’t super thin).  Um, ok.  Everyone else would be all over that method if that worked for them!

Prior to pregnancy, I was on the birth control pills.  I’m lucky that they work really well for me.  I don’t have any of the unpleasant side effects, and if anything I have the good side effects.  Supposedly studies have not shown birth control pills to be effective at treating PMS.  But with my N of 1, I can tell you they’ve definitely helped with mine.  I used to get all moody and extra hungry and such prior to my periods.  On the birth control pills, even when I had regular cycles on them, I no longer had the PMS symptoms.

Better yet, I learned in residency that there is no benefit to having my periods.  So I started trying the continuous regimen.  In other words, I would continue taking the active pills for longer than 3 weeks to avoid having periods each month.  A lot of my patients think it’s bad not to have a period each month.  They are correct, in that if you are skipping periods on your own, that is not normal.  If you have oligomenorrhea, and are one of those women who don’t have periods for several months or more at a time, it can put you at risk for developing endometrial (uterine) cancer if left untreated.  Don’t worry, this usually takes years to occur.

But if we gynecologists are causing you to skip periods, that is perfectly safe.  That is because we are giving you hormones that make your uterine lining thinner.  That process, in addition to making periods lighter and/or less frequent, also helps prevent endometrial cancer.

Initially, I tried a couple types of pills, and every time I reached the 6 week mark, I’d start spotting.  So I’d have to give myself a short period every 6 weeks.  Finally, I found a pill that worked to stop my periods altogether.  Hooray!  So prior to trying to conceive, I didn’t have any periods for years.  And since delivering, I haven’t had one yet.

Now, this also works for me because I’m able to take my pills consistently daily, so my lack of period was never a fear that I might be pregnant and not know it.  For my patients who have difficulty with a daily pill, this is not ideal.

So after having WZW, I switched to the progestin-only pill or mini pill, which contains norethindrone only, as opposed to the regular pills that have a progestin (norethindrone or a different type) plus estrogen (ethinyl estradiol).  I chose it because it doesn’t affect milk supply like the regular birth control pills.  Especially now that I’ve breastfed, I understand how anything that might affect milk supply should be avoided if at all possible.  The downside is that unlike the regular pills, they have to be taken at the same time each day.  You can’t be late by more than an hour, or you’ll risk unintended pregnancy.

The other reason I avoided the regular pills is that my own doctor/colleague/friend said that she looked into it when she had her first child, and was concerned about some excretion into the breast milk.  I figured she was a reliable enough person to listen to.  If she didn’t feel comfortable taking it, then I certainly didn’t.

Just now I decided to check the drug information.  The package insert with the drug information says (I’m paraphrasing slightly) that some of the medication gets passed on to the child in the milk.  A few adverse effects on the child have been reported, including yellowing of the skin (jaundice) and breast enlargement.  It also says it may decrease the amount and quality of your milk.  You should consider starting oral contraceptives only after you have weaned your child completely.

Based on hearing that alone, it’s not a comforting thought to potentially risk those adverse effects.  I’ve had patients get pregnant not long after having one baby.  Sometimes because they stopped breastfeeding, sometimes because they thought they’d still be protected due to breastfeeding.  I certainly didn’t want to take any chances.

Since I knew I wouldn’t be waiting super long before trying for baby #2, I didn’t think it would be worthwhile to try the longer-term methods like the IUDs or implant.  Nexplanon, the implant that goes in the arm, is a very reliable method that lasts for 3 years.  While some women do great on it, it is also a progesterone-based method that tends to cause irregular, unpredictable bleeding for the entire 3 years.  Also, like the Depo-Provera injections, a lot of women gain weight with it, and/or have other hormonal side effects.  So it’s not my favorite, but it is good for women who really need something reliable, because it’s nearly impossible to mess it up.  Plus, many women don’t feel comfortable with the thought of something in their uterus like an IUD.

I think after baby #2, I would consider the Mirena IUD.  I haven’t needed to try it before, since the pills have always worked so well for me.  But taking the mini pills around the same time each day is a pain.  One trick I found is that if I anticipate waking up late on the weekends, I can take an extra pill in the evening Friday, and that way it doesn’t matter if I take the pill later than usual on Saturday morning.

The nice thing about the Mirena IUD is that the progestin hormone mostly acts in the uterus.  That means it thins out the uterine lining, causing periods to be lighter and less frequent.  For some women, it stops cycles completely.  As I mentioned before, this process decreases one’s risks of endometrial cancer.  The hormone activity is much lower systemically, so the side effects are less common compared to the other methods like the Depo-Provera injections, Nexplanon, and progestin-only pills.  Therefore weight gain is less likely.  And once it’s in place, there is nothing to remember daily.

You can keep it in for up to 5 years.  And actually, good research has shown it to be effective up to 7 years.  So sometimes when I use it for menstrual control in my ladies in their late 40s or even 50s, I have them keep it for up to 7 years.  Especially for the morbidly obese patients whose excess fat tissue has increased estrogenic activity- these patients are at higher risk for endometrial cancer, so the Mirena helps reduce that risk.

Overall, I love the Mirena for my patients and place many of them.  The downside is that either type of IUD can sometimes expel spontaneously.  It doesn’t happen that often, but it’s not something you can control.  Sometimes it moves down too low in the uterus and into the cervical canal, or comes out completely.  In that case, one would not be protected from pregnancy.

The ParaGard, or copper IUD, is just as effective at preventing pregnancy as the Mirena, but doesn’t have hormones.  So you still have your normal periods, but they will tend to be longer and heavier.  I personally wouldn’t want that, even though my periods were normal.  So I find that it’s less popular.  But like all methods, there are some women who are very happy with it.

I’ll never know how much of my weight gain was due to the progestin-only pills versus breastfeeding, since I’m stopping both concurrently.  In any case, I’m hoping I won’t be as hungry and can work on my weight control.  This week, I was looser on the pumping schedule, and then over the weekend I minimized the breastfeeding.  It seems like despite not pumping during the day, I did continue to make some milk when he would breastfeed.  It makes me a little sad not to continue at least breastfeeding without pumping, but mentally, I have decided that I need to stop completely.  I need to get back on the regular pills and attempt to get back on track with my own health, before I reach the point of no return.

I took a pic of his last breastfeeding session yesterday evening.  It was getting dark, so the picture came out more grainy- which is probably better, so you can’t really see my boob.  He’s grabbing onto my nursing bra.  He was finally starting to enjoy it more, so I will miss that.  But I can also see how weaning an older baby who gets a lot of comfort from breastfeeding would be challenging.  My mom once told me that her mother, who breastfed 8 kids, would put a little wasabi on the nipple to wean.  Yikes!  Not sure I’d recommend that, but I guess it worked.