From Dr Steven R. Goldstein, NYC Gyn
There are many misconceptions about Low Dose Birth Control Pills. When Dr. Goldstein was a medical student, pills came in 80 and 50 microgram strengths of estrogen. By the time he was a resident, they were 50 and 35 micrograms. Most of his career, they have been 35, 30, 25 and 20 micrograms. Now they make a 10 microgram. However, the lowest doses are not always the best choice for women under thirty.
Often a patient’s mother will come in with her teenage daughter and ask for birth control pills. Routinely, they often say, “I want the lowest dose pill.” When asked why, it appears they assume this it is the safest. Actually, these lowest dose pills are too low for young women.
What is it not explained or understood is that in pre or perimenopausal women, birth control pills act to turn off ovarian function, and thus substitute a low-dose of estrogen and progesterone all month long. Thus, the hormone in the pill is not on top of what a woman makes, but becomes instead of what she makes. This is one reason why the lowest dose pills are inappropriate for women under 30, especially regarding their bone health. Bone is a dynamic organ, and bone mass increases greatly until about age 30-35 and then falls slowly until menopause when there is a sharp decline. Young women on the lowest dose pills will see less bone growth at a time when it is growing geometrically than the growth with their own natural cycle. Thus, for women under 30, average-dose birth control pills are more appropriate than the lowest doses.
Bone is a hormonally sensitive organ. There is good evidence that women even on 20 microgram estrogen pills will have less bone growth through age thirty than those who are getting their own cyclic menses.
Another major misconception about birth control pills is that they will increase the risk of cancer, mainly breast cancer. Nothing could be further from the truth. 24 years ago, the author, Malcolm Gladwell wrote an article in the New Yorker magazine entitled “John Rocks Error”. John Rock was one of the inventors of birth control pills, and part of the thesis is that they should have brought these out as cancer reducing agents. This is related to the fact that modern women are having too many cycles. As higher order primates, nature thought women would have 8 children and have to nurse them all for 15 months, there being no bottles or formula in nature.
At most then, women would have perhaps 250 menstrual cycles in their lifetime as opposed to modern women who are often approaching 500 cycles. This explains one of the reasons why ovarian, uterine and even breast cancers are on the rise in modern industrialized nations. Women are cycling too much! It is actually closer to natural to suppress the ovarian cycle with birth control pills than to have women ovulate month after month after month without having children.
In that article 24 years ago, Gladwell, a non-physician wrote, ”A woman who takes the Pill for ten years cuts her ovarian-cancer risk by around seventy per cent and her endometrial-cancer risk by around sixty per cent.”
However, I believe you deserve data that is evidence-based and more recent than 24 years ago. In 2021, a study of over a quarter million women in the United Kingdom, based on their national registry, compared never-users of birth control pills to users of birth control pills. They found that in the women who used pills there was a 20% reduction in breast cancer, a 43% reduction in ovarian cancer, and a 57% reduction in uterine cancer all of which were highly statistically significant.
The longer women took pills the greater the reduction. The misconception about cancer and birth control pills is an inappropriate extrapolation from the Women’s Health Initiative, where use of hormone replacement therapy (HRT) in that study did increase a woman’s risk of breast cancer. HRT usually consists of estrogen with progesterone as does birth control pills. Thus, it is understandable why women about to take birth control pills might look at the pill and then look at their breast and wonder why would she put this in her body.
However, low dose birth control pills are excellent choices for perimenopausal women, especially if there are small fibroids or excessive bleeding. The reason for this is because the pill suppresses a woman’s own ovarian function. Thus, the hormone in the pill is not on top of what a woman makes, actually it is instead of what she makes.
Thus, the lowest dose pills actually deliver less total effective circulating hormone than a woman’s own cycle. This is desirable in perimenopausal women, especially, as mentioned, if they have excessive bleeding or fibroids but is too low for women who are still growing their bone mass until age 30 or 35.
Finally, a word about “natural.” Sometimes when Dr. Goldstein suggests birth control pills, patients will claim they are not “natural.” What did nature expect for women? As a higher order primate, left to nature, women would have eight children, probably two to three miscarriages, and have to nurse all the children for twelve to fifteen months, as there are no bottles or formula in nature. Thus, women would have probably approximately 250 menstrual cycles.
Modern women living in industrialized nations could have approximately forty years of reproductive life (age 11-51) with 13 cycles in each year and end up with as many as 500 menstrual cycles. It is therefore actually closer to natural to use birth control pills and not ovulate monthly without having children.
Dr. Goldstein is not suggesting that women have eight children and nurse them for twelve to fifteen months but do understand, what is “natural” and what we have socialized into.
Dr Steven R. Goldstein is a top NYC Gyn in private practice in New York City for over 25 years. He is a Professor of Obstetrics and Gynecology at New York University School of Medicine, a past President of the International Menopause Society, Certified Menopause Practitioner, and more. You can read more about him here
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