THE ANSWER MIGHT SURPRISE YOU.
Low-dose birth control pills entered the market to make the pill safer for women. Which, thank goodness they did. The original birth control pills had pretty high levels of progestin and ethinyl estradiol, the latter of which increases women’s risk of experiencing things like blood clots and stroke, which are outcomes that most of us want to avoid. So, lower dose pills have been nothing short of life-saving for hundreds, if not thousands of women.
But are they more natural?
First, some necessary background information. Like what a low-dose birth control pill actually is. A pill is considered low dose if it contains less than 30 micrograms (mcg) of estrogen, and those that contain 10 mcg of estrogen are considered ultra-low-dose. This is the smallest dose of estrogen available in combination birth control pills. It’s worth noting that most pills that are currently on the market are considered low- or ultra-low-dose. This includes both combination pills (estrogen and progestin) and progestin only products (which have 0 mcg of estrogen).
Given that low-dose pills (especially those that are ultra-low-dose) contain less synthetic estrogen than their higher-dose counterparts, there is a tendency to assume that they will put our body in less of an unnatural state than those containing more synthetic hormones. There is also a tendency to believe that the low-dose label means that they will be associated with fewer psychological side-effects, like changes in mood or libido. But these ideas – even though they make sense when you hear them – probably aren’t true.
Let’s start with the natural thing. Which I get. It makes good, intuitive sense that fewer synthetic hormones = less fake stuff in the body = more natural.
But it isn’t necessarily going to work this way.
To get to the heart of this, let’s talk a little about a natural cycle. Each month, women’s hormones go through a beautiful ebb and flow that is the natural result of an egg maturing and being released from an egg follicle. This includes the estrogen-dominant follicular phase, resulting from egg follicles being stimulated and eventually developing a mature ovum. It also includes the progesterone-dominant luteal phase, which is created by the temporary endocrine structure that gets created by the empty egg follicle whose job it is to release progesterone. See my picture below to see this illustrated (taken from my book). And take it in! It’s such an amazingly intricate act of neuroendocrinology. And it happens every month. It still leaves me awestruck….
As you can see, women’s natural cycles are punctuated by a lot of hormonal activity. Like, a lot. And these hormonal changes help to create the “natural” experience of being a woman. Peaks and valleys. Highs and lows. A dynamic experience that (in my experience) makes life feel vibrantly three-dimensional.
Now, look and see what this all looks like on the birth control pill (also taken from my book).
Above, you are seeing the levels of synthetic estrogen and progestin that are in a randomly selected version of the birth control pill (which I can do because they all work pretty much the same way). This daily dose of progestin (plus estrogen, here) creates a hormonal milieu that prevents egg maturation / ovulation and thereby suppresses women’s own production of sex hormones. So, with the pill, you experience hormonal deja vu from synthetic hormones, which prevents the release of women’s own sex hormones. So, women’s hormonal experiences are pretty much a hormonal deja vu with the message being the one that is provided by the hormones in the pill.
So, what happens with a low-dose pill?
Well, with a low dose pill, you are probably not creating a situation that is more “natural”. Instead, you are simply turning down the volume on the synthetics, leading to less (synthetic) hormonal activity in the body. Remember, women’s own hormones are suppressed**, which means the majority of sex hormonal activity going on in pill-taking women’s bodies and brains is from their birth control. This could actually feel less natural to women than the experiences created by a higher-dose pill because a typical hormonal state for naturally cycling women is one punctuated by a lot of hormonal activity.
And there is evidence that this could be the case, at least when it comes to mental health. Research on the relationship between hormonal birth control and the risk of developing depression seems to indicate the the risk is greatest for some of the products that contain the lowest levels of synthetics, in particular, non-oral products like the vaginal ring and hormonal IUD. This is far from a smoking gun (extremely far!!!), but it is worth making a mental note of the fact that low levels of hormones don’t necessarily mean that you are going to be feeling maximally like yourself. Or that you’re going to feel more “normal” or “natural” than you would with a higher dose of synthetics.
**Let me add the tentative caveat that some of our most recent research indicates that women on ultra low dose pills **may** produce relatively higher levels of their own estrogen than women on higher dose pills (although, still far less than what is created in a natural cycle). This could maybe be interpreted as being more natural and may feel more “normal” to women. We are waiting on the data telling us how these women feel… [stay tuned]. We also know that lower dose prescriptions prompt the release of fewer sex hormone binding globulins, which would make less of women’s testosterone unusable by the body. This could also be interpreted as being more natural? Although this feels a bit like splitting hairs, this could be a biologically meaningful difference in some women, making them feel more at home in their own bodies.
The big take-away, here, is that each of us should choose the dose that feels most natural to our own bodies. Because no matter what you pick – if you are on hormonal birth control – it’s going to be unnatural (see figures above). That isn’t necessarily bad. It just is. There are plenty of natural things that are terrible (SARS-CoV2, anyone?) and plenty of unnatural things that are life-saving (ventilators). So it shouldn’t be about natural. It should be about how you feel. YOU. For some women, this might mean a higher dose prescription. For others, it might mean a low- or ultra-low- dose equivalent. Tune in to your body, trust how you feel, and work with your doctor to troubleshoot your prescription. Above all else, be patient and kind to yourself. That should be the most natural thing that any of us ever do. ❤
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