Pelvic pain after starting birth control

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By Joshua Gonzalez, MD

The advent of oral birth control pills in the 1960s was heralded as a huge victory for women’s rights. Finally, women could take control of their bodies and their fertility. Since then, oral contraceptive pills (OCPs) have become ubiquitous in reproductive aged women with nearly 10 million women today using The Pill as their primary means of contraception (Guttmacher).

Unfortunately, most of those women have no idea how these medications work and often have not been told of their potential side effects. Worse yet, many women are given oral birth control pills for non-contraceptive reasons: erratic mood, recurrent migraines, irregular menses, menstrual cramping, endometriosis, and even acne. Starting in adolescence, OCPs are handed out to women like candy. Women can spend many years in their young adult lives on these medications simply because they haven’t been properly counseled on alternative forms of contraception.

So what’s the big deal? Why should you be worried if you’re on an OCP? Well, let’s talk about how these medications work. OCPs are drugs mostly comprised of synthetic hormones. That is, fake hormones. These medications trick your ovary into thinking there’s enough real hormone around by exposing it to a hormone-like compound. Consequently, ovarian production of very important sex steroid hormones stops, as does ovulation. Hence, no pregnancy!

The problem is that your body needs sex steroid hormones for lots of different things. Estrogen, progesterone, and testosterone are all important for the health of a woman’s body. Yes, I said testosterone (more on that later). These hormones are important for bone health, cardiovascular health, libido, mood, cognition, and especially the health of the genital tissues. And when the body isn’t exposed to these hormones, like when you’re on an OCP, there can be consequences.

One recent study found that women using a hormonal contraceptive method experienced less frequent sexual activity, arousal, pleasure, and orgasm and more difficulty with lubrication (Smith). It is not uncommon for young women on OCPs to report pain with intercourse (called dyspareunia) as well. Some women may not experience dyspareunia but can present with other symptoms like urinary urgency, urinary frequency, recurrent urinary tract infections (UTI) or yeast infections. All of these things can happen with OCP use, but often go unrecognized or ignored.

To understand why this happens, one must appreciate the anatomy of the genital tissues and how they respond differently to specific hormones. These details are not known by most patients on OCPs and often are lost on the physicians who prescribe these medications.

The female genitalia are comprised of three unique anatomic structures: the vulva, the vagina, and the vestibule. Each of these tissues arise from different embryological structures during fetal development. And each of these tissues respond uniquely to specific sex steroid hormones.

The vulva and vagina primarily rely on estrogen to maintain their health. When a woman goes through menopause and her ovary stops producing estrogen, these tissues can become dry, inflamed, chronically irritated, and literally shrink (atrophy). Similar things can happen to younger women on an OCP. When these tissues are chronically irritated they become a breeding ground for bacteria and yeast and can lead to recurrent infections. The lack of estrogen can also cause less vaginal lubrication, which can lead to pain with sexual activity.

The vestibule is a thin rim of tissue at the opening of the vagina. If you’ve never heard of it, you’re not alone. It is often ignored and easily missed during routine pelvic exams. Your gynecologist probably went right by it when she inserted that speculum. But it can cause even more problems than the vulva and vagina combined. The vestibule is an area responsible for mucus secretion, which provides lubrication during sexual activity. It is an area also intimately related to the urethra, the opening to the bladder that you urinate from. And unlike the vulva and vagina it is an area rich in testosterone receptors. When vestibular tissue is unhealthy, like when there are low levels of circulating testosterone caused by OCP use, it too becomes chronically inflamed or irritated. This can lead to pain with penetration and/or urinary symptoms that can be incorrectly assumed to be a UTI or yeast infection.

But the real damage of OCPs is their effect on a naturally occurring protein in your body called sex hormone binding globulin (SHBG). SHBG is a protein in the blood that binds testosterone and renders it inactive. Only a small amount of the testosterone your ovary makes then is actually used by the body. The rest is bound to SHBG. When women take OCPs, their SHBG skyrockets! Many physicians who prescribe these medications do not appreciate this point. With higher SHBG levels, more testosterone is bound and not usable by the body. OCPs already decrease ovarian testosterone production and now most of what’s left of your testosterone is being gobbled up by all the SHBG floating around. Worse yet, SHBG levels often remain elevated even after OCP discontinuation.

Many women I’ve treated have been misdiagnosed for years, told they have recurrent UTI or yeast infections or interstitial cystitis. Their physicians failed to appreciate that their symptoms were primarily a hormonal deficiency and that their OCP use was to blame. If you’re on The Pill now or were at one time you could be at risk. If you recognize or have experienced any of the symptoms I’ve mentioned, it’s worth discussing this with your health care provider. If they don’t believe you or have never heard of these potential adverse effects from OCPs, then maybe it’s time to find a new provider.

Case Example:

One particular patient stands out in my mind. When we first met, CL was 24 years old and had already been struggling with the effects of her birth control for more than two years. She first noticed pain in her vulva and vestibule (termed vulvodynia and vestibulodynia, respectively) during and after sexual intercourse. The pain was mild at first, but then intensified and lasted for longer periods as time went on. Soon she could barely sit more than a few minutes before a similar raw, burning pain would suddenly flare. She started avoiding sex and noticed a significant decrease in her libido. She began experiencing urinary frequency and urgency too. She was told by numerous physicians that she had recurrent urinary tract and yeast infections, prescribed countless rounds of antibiotics and fluconazole. She was even diagnosed and treated for interstitial cystitis. Despite being dismissed by many, she knew all the while the problem had not been addressed. This problem wasn’t in her head and it certainly wasn’t an infectious issue. Her problem was The Pill. When I first explained the real cause of her symptoms, CL cried both tears of sadness and relief.

Women have stayed quiet about these issues for far too long because they think painful sex or recurrent infections are “normal.” They’re not. I have no doubt that The Pill did a great deal for women’s reproductive rights, but at what cost? With alternative methods of contraception—non-hormonal, often more reliable methods—why are we still so quick to prescribe these jagged little pills. They may be easy for women to take, but the consequences may be ultimately too hard to swallow.

Continue on to Part Two: Treatment solutions and alternative birth control options here.

Additional reading:

In 2015 an International Consensus Conference on Vulvar Pain was held to examine levels of evidence surrounding causes of vulvar pain and associated factors. During this meeting, it was decided that hormonal insufficiencies can cause vulvar pain. The details and resource list have been published in three locations, the references are listed below.

References.

Retinal Vein Occlusion (RVO)

What is retinal vein occlusion (RVO)?

The front of the eye contains a lens that focuses images on the inside of the back of the eye. This area is the retina. The retina is where the eye focuses the images we see. It is covered with special nerve cells which convert light into signals that are sent via the optic nerve to the brain, where they are recognized as images. Conditions that affect the retina affect the ability to see.

Arteries carry blood from the heart to other parts of the body, and veins carry the blood back to the heart. A blockage in an artery or vein is called an occlusion or stroke. When the flow of blood from the retina is blocked, it is often because a blot clot is blocking the retinal vein. This condition is called retinal vein occlusion (RVO).

Nerve cells need a constant supply of blood to deliver oxygen and nutrients. Blood vessels provide this supply. In a stroke, a small blood clot blocks the flow of blood through one of the arteries in the brain, and the area that is not getting blood becomes damaged.

This same type of damage can happen anywhere in the body. When a retinal vein is blocked, it cannot drain blood from the retina. This leads to hemorrhages (bleeding) and leakage of fluid from the blocked blood vessels.

There are two types of RVO:

  • Central retinal vein occlusion (CRVO) is the blockage of the main retinal vein.
  • Branch retinal vein occlusion (BRVO) is the blockage of one of the smaller branch veins.

How does retinal vein occlusion (RVO) cause vision loss?

  • Macular Edema: The macula is the small, central area of the retina that allows sharp, detailed vision, such as that necessary for reading. Blood and fluid leaking into the macula cause swelling, a condition called macular edema, which causes blurring and/or loss of vision.
  • Neovascularization: RVO can cause the retina to develop new, abnormal blood vessels, a condition called neovascularization. These new vessels may leak blood or fluid into the vitreous, the jelly-like substance that fills the inside of the eye. Small spots or clouds, called floaters, may appear in the field of vision. With severe neovascularization, the retina may detach from the back of the eye.
  • Neovascular glaucoma: New blood vessels in certain parts of the eye can cause pain and a dangerous increase in pressure inside the eye.
  • Blindness: The complications of RVO, especially if they are not treated, can lead to irreversible loss of vision.

Why do people get retinal vein occlusion (RVO)?

Retinal vein occlusion happens when a blood clot blocks the vein. Sometimes it happens because the veins of the eye are too narrow. It is more likely to occur in people with diabetes, and possibly high blood pressure, high cholesterol levels, or other health problems that affect blood flow.

How does the doctor know whether someone has a retinal vein occlusion (RVO)?

The symptoms of retinal vein occlusion range from subtle to very obvious. There is painless blurring or loss of vision. It almost always happens in just one eye. At first, the blurring or loss of vision might be slight, but it gets worse over the next few hours or days. Sometimes there is a complete loss of vision almost immediately.

If these symptoms occur, it is important to schedule an appointment with your doctor as soon as possible. Retinal vein occlusion often causes permanent damage to the retina and loss of vision. It can also lead to other eye problems.

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Whether you’re looking to get pregnant or quitting for medical reasons – many women stop taking the pill and don’t know what to expect or be aware of. Whatever your reason, you might experience a few hormonal and bodily changes as you return to your natural cycle.

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“Keep in mind that the pill is a type of hormonal medication,” explains Ob/Gyn Salena Zanotti, MD. “Every woman reacts differently to going on the pill and then coming off it. Some women may notice huge changes, while others notice very little difference.”

Here’s what to keep in mind as your body adjusts when you stop taking the pill.

1. You could get pregnant! (Yes, right away.)

Many women don’t realize how quickly their bodies can start ovulating again after going off BC. Once you stop taking the pill, the hormones will be out of your body in a matter of days and you’re no longer protected from pregnancy.

“There are some women who go off the pill and never even get a period because they get pregnant right away,” says Dr. Zanotti.

So if getting pregnant isn’t on your radar quite yet – be mindful that no pill means no contraception and you should be using an alternative method of birth control (like a condom).

2. It could take a while to get your natural period back.

Some women go right back to having a regular cycle after ditching the pill, while other women might not get their period again for three months. Dr. Zanotti’s advice is to be patient and track your cycle. If your period is still confused by month three, then make an appointment to see your doctor.

3. PMS symptoms might reappear.

“Many women go on birth control to help with premenstrual symptoms like cramps, bloating and nausea,” says Dr. Zanotti. “So the unwanted side effects of your period will probably return after you stop taking the pill.”

Birth control helps regulate cycles and control hormonal symptoms, so don’t be surprised if you feel like your breast are more tender right before your period or if you feel more irritable or moody.

Some women might also see the return of a menstrual migraine right before they get their period. (What a joy!)

4. Your period might be longer and heavier.

If you’ve been on the pill for a while then you’re probably used to shorter and lighter periods. But after going off the pill, you might notice that your period is heavier, longer in duration and the interval has changed. This is all normal.
“For most women on the pill – their periods are right on track and often last only a few days,” says Dr. Zanotti. “But once the hormones are gone, you might notice a change in flow and duration.”

5. You probably won’t lose weight.(Sorry!)

Weight gain is actually not a consistent side effect of the pill, explains Dr. Zanotti. Everyone is different, but research has found that being on the pill usually doesn’t cause more than a pound of weight a year.

Sure there might be some women who retain more fluid and water weight, but if you’ve gained weight while on the pill and haven’t changed much about your life style, you probably won’t see any significant weight loss once you come off it.

6. You might feel a little frisky.

Some women complain about a low sex drive while taking the pill. The good news? You could see a spike in your libido once you stop taking birth control.
“The pill can cause vaginal dryness,” says Dr. Zannotti. “So this change in discharge and natural lubrication can increase libido in some women.”

Oral contraceptives and the skin

What is an oral contraceptive?

An oral contraceptive, or birth control pill, is a medication that prevents pregnancy. They contain either two hormones combined (oestrogen and progestin) or a single hormone (progestin).

  • The oestrogen component is usually ethinyl oestradiol.
  • The progestin component is of one of several progestins.

OCPs suppress ovulation and thicken cervical mucus (which stops sperm getting into the womb).

Who takes oral contraceptives?

Oral contraceptives are mainly used by women of childbearing age for birth control. They also have non-contraceptive health benefits.

What skin problems are treated using oral contraceptives?

Oral contraceptives are used to treat signs of hyperandrogenism in women. The associated skin problems are

  • Acne vulgaris and comedonal acne
  • Hirsutism
  • Seborrhoea
  • Female pattern hair loss

Hyperandrogenism refers to an excess of male hormone either in the circulation or due to increased sensitivity of individual pilosebaceous cells (hair follicle and sebaceous gland).

Women with signs of hyperandrogenism should be evaluated for underlying disorders such as polycystic ovarian syndrome, congenital adrenal hyperplasia, adrenal or ovarian tumours.

Skin conditions treated with oral contraceptive

How do oral contraceptives work for skin diseases?

Combined oral contraceptives suppress luteinising hormone (LH)-driven androgen production and increase sex hormone binding globulin. The result is a decrease in the levels of free androgen leading to improvement in acne and reduction in excess hair growth

The action of combined oral contraceptives depends on their oestrogen-progestin balance. Progestins are weak androgens.

  • Oestrogens can reduce acne.
  • Androgens can aggravate acne.

In a combined oral contraceptive, the effects of the oestrogen outweigh the effects of the progestin, so androgen levels decrease overall.

  • Older first and second-generation progestins may sometimes activate the androgen receptor, making acne worse.
  • Newer third and fourth-generation progestins such as norgestimate and drospirenone have less activity at the androgen receptor.

Progesterone-only oral contraceptives (the minipill) are not effective in the management of androgen-mediated skin conditions and can make acne worse.

What skin problems may be caused by oral contraceptives?

Skin problems sometimes caused by oral contraceptives include:

  • Acne
  • Melasma
  • Autoimmune progesterone dermatitis
  • Spider telangiectasis
  • Pyogenic granuloma
  • Porphyria cutanea tarda
  • Erythema nodosum
  • Acanthosis nigricans

What are contraindications to oral contraceptives?

Before starting oral contraceptives, especially oestrogen-containing OCPs, patients should be questioned regarding any possible contraindications, due to the risk of adverse effects. These include thromboembolism (blood clots) and liver disease.

Absolute contraindications to oral contraceptives

  • Migraine with aura
  • Smoking: women aged over 35 years who smoke >15 cigarettes/day
  • Ischaemic heart disease, past or current
  • Stroke
  • Active liver disease: viral hepatitis, cirrhosis, or tumour
  • Major surgery with prolonged immobilisation (combined oral contraceptives should be stopped 4 to 6 weeks before such surgery)
  • Deep venous thrombosis, past or current
  • Hypertension: poorly controlled (systolic >160 mmHg or diastolic >100 mmHg)
  • Breast cancer, current (diagnosed within the last 5 years)

Relative contraindications to oral contraceptives

  • Migraine without aura: in women aged over 35 years or in smokers
  • Smoking: in women aged over 35 years who smoke <15 cigarettes/day
  • Concurrent treatment with certain anticonvulsants (including phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine)
  • Postpartum: first 3 weeks (if not breastfeeding), first month (if breastfeeding)
  • Hypertension: well controlled or moderately well controlled (systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg)
  • Breast cancer, diagnosed more than 5 years earlier.

Women using medication to treat a variety of medical conditions are often unaware of the potential side effects. One common side effect of medications such as blood pressure medication, birth control pills, antidepressants, and cancer treatments is dry mouth. The technical term for dry mouth is xerostomia.

Xerostomia can lead to undesirable effects in the oral cavity including periodontal disease and a high rate of decay. Many women who have not had a cavity in years will return for their routine exam and suddenly be plagued with a multitude of cavities around crowns and at the gum line, or have active periodontal disease. The only thing that the patient may have changed in the past six months is starting a new medication.

Saliva washes away bacteria and cleans the oral cavity, and when saliva flow is diminished harmful bacteria can flourish in the mouth leading to decay and gum disease. Many medications can reduce the flow of saliva without the patient realizing the side effect. Birth control pills can also lead to a higher risk of inflammation and bleeding gums. Patients undergoing cancer treatments, especially radiation to the head and neck region, are at a greatly heightened risk of oral complications due to the possibility of damage to the saliva glands.

There are many over the counter saliva substitutes and products to temporarily increase saliva production and help manage xerostomia. One great option for a woman with severe dry mouth or high decay rate is home fluoride treatments. These work in a number of ways, including custom fluoride trays that are worn for a short period of time daily at home, a prescription strength fluoride toothpaste, or an over the counter fluoride rinse. If you have more questions on fluoride treatments, make sure to ask Dr. Mark Obman at your next visit to our office.

The benefits of many of the medications on the market outweigh the risks associated with xerostomia, however, with regular exams you can manage the risk and prevent many oral consequences of medications.

Hormones and Oral Health

What is the link between hormones and women’s oral health?

Women have an increased sensitivity to oral health problems because of the unique hormonal changes they experience. These hormonal changes not only affect the blood supply to the gum tissue, but also the body’s response to the toxins (poisons) that result from plaque build up. As a result of these changes, women are more prone to the development of periodontal disease at certain stages of their lives, as well as to other oral health problems.

What are causes and symptoms of hormonal changes that may affect oral health in women?

There are five stages in a women’s life during which changes in hormone levels make them more susceptible to oral health problems – puberty, the monthly menstruation cycle, when using oral contraceptives, during pregnancy, and at menopause.

Puberty: The surge in production of the female hormones estrogen and progesterone that occurs during puberty can increase the blood flow to the gums and change the way gum tissue reacts to bacterial plaque. This causes the gum tissue to become red, tender, and swollen, and more likely to bleed during brushing and flossing.

The monthly menstruation cycle: Due to the hormonal changes (particularly the increase in progesterone) that occur during the menstrual cycle, some women experience oral changes that can include bright red swollen gums, swollen salivary glands, development of canker sores, or bleeding gums. Menstruation gingivitis usually occurs a day or two before the start of the period and clears up shortly after the period has started.

Use oforal contraceptives (birth control pills): Women who take certain oral contraceptives that contain progesterone might experience inflamed gum tissues due to the body’s exaggerated reaction to the toxins produced from plaque. The most profound changes in the gums are seen in the first few months after starting the birth control pills. Newer birth control pills, however, have lower concentrations of the hormones, which lessens the inflammatory response of the gums to dental plaque.

There is another reason for telling your dentist if you are taking oral contraceptives. Certain medicines, such as antibiotics, that your dentist might prescribe can lower the effectiveness of oral contraceptives. Always tell your dentist the names and dosages of all the medicines you are taking. He or she needs to know this information when planning your course of treatment, especially if prescribing medicines is a part of your care.

Hormone connection to TMJ: Researchers have evidence that the use of synthetic estrogens (birth control pills) can lead to decreased levels of natural estrogen. Decreased levels of natural estrogen are associated with another oral disorder, one affecting the temporomandibular joint (TMJ).

The temporomandibular joint connects your jaw to the side of your head. Temporomandibular disorders result from problems with the jaw, jaw joint, and surrounding muscles that control chewing and moving the jaw.

Because more women than men experience temporomandibular disorders, researchers thought there might be a hormone-related connection to this disorder. According to recently published research, this connection between birth control pills, decreased natural estrogen and TMJ appears to be true. Changes in the bones of this joint have been seen. Also, the combined effect of the compression within the joint caused by TMJ disorders and low levels of natural estrogen can lead to increased inflammation. In some individuals, this inflammation can result in osteoarthritis in the joint.

Always tell your dentist the names and dosages of all the medicines you are taking. He or she needs to know this information when planning your course of treatment, especially if prescribing medicines is a part of your care.

Pregnancy: Hormone levels change considerably during pregnancy. An increased level of progesterone in particular can increase your susceptibility to bacterial plaque causing gingivitis which is most noticeable during the second to eighth month of pregnancy. This condition is called pregnancy gingivitis where the gums become swollen and bleed easily. Your dentist might recommend more frequent professional cleanings during your second or early third trimester to help reduce the chance of developing gingivitis.

Menopause: Numerous oral changes can occur as a consequence of advanced age, the medicines taken to combat diseases, and hormonal changes due to menopause. These oral changes can include altered taste, a burning sensation in the mouth, and greater sensitivity to hot and cold foods and beverages, and decreased salivary flow that can result in dry mouth.

Dry mouth, in turn, can result in the development of periodontal disease because saliva is not available to moisten and cleanse the mouth by neutralizing acids produced by plaque. Dry mouth can also result from many prescription and over-the-counter medicines that are commonly prescribed to older adults.

The decline in estrogen that occurs with menopause also puts women at greater risk for bone loss or osteoporosis and inflammation of the tissues surrounding the teeth (called periodontitis). Loss of bone, specifically in the jaw, can lead to tooth loss. Receding gums can be a sign of bone loss in the jawbone and also expose more of the tooth surface to potential tooth decay.

Hormone therapy may play a role in preserving dental health in postmenopausal women. Estrogen therapy prevents bone loss in both the skeletal bones and the jawbones. This suggests that hormone therapy protects against tooth loss in postmenopausal women.

What can I do to prevent the development of oral health problems?

Following these tips will help:

  • Brush your teeth at least twice a day with a toothpaste containing fluoride. Floss at least once a day.
  • Visit your dentist twice a year for a professional oral examination and cleaning.
  • Eat a well-balanced diet.
  • Avoid sugary or starchy snacks.
  • Ask your dentist if he or she thinks you should use an antimicrobial mouth rinse.
  • If you have dry mouth, ask your dentist about treatments for this condition, such as artificial saliva.

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