The Menstrual Cycle, Birth Control Pills, and Post-Pill PCOS

When coming off birth control pills to get pregnant or switching to bioidentical hormones in perimenopause, you might expect the transition to be smooth. Then, a month or two later, you notice acne, oily skin, and that your period hasn’t returned. What gives?

Oral contraceptives, also called birth control pills or “the pill,” are the most common form of birth control in the United States, with 25% of 15- to 44-year-old women who use contraception relying on them.

But most women who go on the pill aren’t educated about possible side effects or what to expect when coming off the pill. One possibility is post-pill PCOS, where the transition from oral contraceptives leads to elevated androgens and PCOS-type symptoms.

Today’s article will dive into post-pill PCOS and how to reestablish a healthy menstrual cycle after hormonal birth control. We’ll cover:

• The normal, healthy menstrual cycle
• How birth control pills work
• Pros and cons of oral contraceptives
• What is post-pill PCOS, and why working with your integrative gynecologist for a proper diagnosis is key
• How to reestablish regular menstrual cycles post-pill

Let’s get started with this vital information!

Normal Menstrual Cycle

The goal of a healthy menstrual cycle is ovulation. While the menstrual period gets a lot of attention, ovulation is really the star of the show! The brain signals the ovaries via the HPO axis (hypothalamic-pituitary-ovarian axis.)

In the first half of the menstrual cycle, called the follicular phase, estrogen levels rise. Estrogen promotes follicle development in the ovaries and builds the endometrium (uterine lining.) Before ovulation, there is a surge of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the brain. With ovulation, the ovary releases an egg into the fallopian tube.

In the second half of the cycle, called the luteal phase, the corpus luteum in the ovary that released the egg begins making progesterone. Progesterone levels rise to maintain the uterine lining and will continue to rise if the egg was fertilized. If the egg isn’t fertilized, progesterone and estrogen levels fall, triggering menstrual bleeding (the shedding of the uterine lining.) And the cycle starts again.

It's important to note that estrogen and progesterone aren’t just crucial for reproduction; they have body-wide effects and support the brain, bones, heart, metabolism, urinary tract, and overall wellness.

A healthy menstrual cycle is a vital sign; it signals the health of the entire body!

How Birth Control Works

Scientists developed oral contraceptives in the 1950s. They represent a significant reproductive justice milestone. Women could (finally!) use birth control to take charge of their fertility and family planning goals.

Birth control pills contain synthetic estrogen and synthetic progesterone (progestin). Some pill types are only progestin. Progestins inhibit follicle development in the ovary and ovulation. They also decrease the brain signal from the brain to the ovaries to release estrogen.

Essentially, high progestin levels “trick” the brain into thinking it’s already pregnant and suppressing ovulation. Without ovulation, there is no natural progesterone production, and natural estrogen production becomes very low, like in menopause. The changes in hormones also create an unfriendly environment for sperm.

With a typical oral contraceptive, you take the hormonal pills for three weeks and then a placebo for the 4^th week. The withdrawal from the hormones triggers the endometrium to release. This bleeding isn’t a true period (which requires ovulation) but is known as a “pill bleed.”

Pros and Cons of Birth Control Pills

The primary benefit of oral contraceptives is the prevention of pregnancy. The pill is over 99% effective with perfect use and 91% effective with typical use.

In addition to avoiding pregnancy, your provider may prescribe birth control pills to help manage menstrual pain, PCOS, endometriosis, heavy periods, acne, and other gynecologic concerns.

There is also some evidence to suggest that women who use oral contraceptives have a reduced risk of some cancers, including endometrial, ovarian, and colon.

However, like all prescription medications, oral contraceptives aren’t without side effects and risks. Side effects of the pill can include:

• Nausea
• Headaches
• Mood changes, including depression
• Sore breasts
• Weight gain
• Increased stress hormones
• Blood clots

Suppressing the body’s natural estrogen and progesterone production over the long-term may have some unintended consequences, including changes to the microbiome.

Nutrient deficiencies are birth control side effects not often discussed. Birth control pills can deplete nutrients, increasing the need for:

• Folate
• Vitamin B2
• Vitamin B6
• Vitamin C
• Vitamin E
• Magnesium
• Selenium
• Zinc

What is Post-Pill PCOS?

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in women. As a syndrome, it’s a collection of symptoms and presents differently in different women. Most commonly, PCOS patients experience elevated androgens and insulin resistance, which can lead to irregular cycles, inflammation, weight gain, and other metabolic changes.

What differentiates post-pill PCOS from other presentations is that post-pill PCOS shows up after discontinuing birth control pills. During the drug withdrawal process, women can experience a surge of androgens and the associated symptoms like acne, oily skin, and unwanted hair growth. Additionally, the menstrual cycle and ovulation may not return right away.

If your doctor prescribed birth control pills to manage PCOS, PCOS symptoms will likely return when you discontinue the pill. This situation is not post-pill PCOS. Women with post-pill PCOS likely had regular cycles and normal periods before taking oral contraceptives. Unlike PCOS which is a chronic condition, post-pill PCOS is temporary.

Many women experience symptoms when they stop the pill; the collection of symptoms is coined post-birth control syndrome. It’s important to work with your integrative gynecologist for a proper evaluation of symptoms and to differentiate a typical drug withdrawal or post-pill PCOS from an underlying hormonal issue.

While we often expect to stop birth control and get pregnant right away, it does take many women some time to reestablish a regular, ovulatory menstrual cycle, even in cases without any underlying issues.

How to Reestablish Healthy Menstrual Cycles After Stopping Birth Control

There are many reasons a woman may choose to discontinue oral contraceptives. Perhaps she no longer needs them for birth control. She might not like the side effects and wants to try another option. She might be ready to become a mom. Or, after taking oral contraceptives for a long time, she may be entering perimenopause and desire a different approach.

No matter the reason behind stopping birth control, it may take some time for your body to adjust and reestablish the brain-ovary communication required for ovulation and hormone production.

The first tip is to give your body the time and space it needs. If you want to get pregnant, give yourself around six months to support reestablishing your cycle between stopping oral contraceptives and trying to conceive.

In addition to time, here are some other strategies to support the transition off birth control and back to ovulatory cycles:

• Optimize nutrition. Ensure you are eating enough nutrient-dense food, including protein, healthy fats, veggies, and whole carbs like fruit, legumes, and tubers with meals. When you undereat, your brain can de-prioritize fertility (and the return of your menstrual cycle) because there aren’t enough nutritional resources.

• Restore micronutrients. Since the pill can deplete critical micronutrients, work with your TārāMD nutritionist to optimize vitamin and mineral status. They can analyze your diet, test micronutrient levels, and create a nutrition plan to meet your needs. Optimal micronutrient status will support you in whatever life phase, including preparing the body for pregnancy or supporting the perimenopausal transition.

• Track your cycle. Using an old-fashioned chart or cycle app, track your period, symptoms, and basal body temperature to gather information about your hormones and how your body is adjusting. Share this information with your integrative team to aid in any necessary treatment approaches.

• Support liver and gut health. Reproductive hormones and the synthetic versions in oral contraceptives are detoxified in the liver and leave the body via the large intestine. Ensure daily bowel movements to help rid the body of these metabolites. If you need help, focus on hydration, dietary fiber, and movement. Bitter foods, cruciferous vegetables, and green tea (or matcha) are supportive for the liver.

• Consider supplementation. Targeted supplements can help restore micronutrients, balance hormones, and address other imbalances. Consider a quality multivitamin and mineral supplement, magnesium, and probiotics during and after taking the birth control pill. For high androgens in post-pill PCOS, zinc, licorice, peony, and nettles could help. TārāMD can help you build a personalized supplement plan.

It takes time to reestablish the menstrual cycle after discontinuing birth control. Still, you can help your cycle return more quickly with these tips and address any underlying concerns with your TārāMD provider. Remember, a healthy menstrual cycle is a sign of health, and your natural hormones offer many health benefits over time. If you’re thinking of going off the pill, have irregular or missing periods, or have any other hormonal issues, please reach out today.

References

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