Pill bleeds are not periods

Hi and welcome to episode one of the Lara Briden podcast where I bring you simple explanations for women’s health topics and answer your questions. 

I’m your host, Lara Briden. I’m a naturopathic doctor and author of the books Period Repair Manual and Hormone Repair Manual, which you can buy anywhere—or obtain from your library. And are also available as audiobooks.

As you can hear from my accent, I’m Canadian, mixed with a few years in Australia, but I currently live and practice in Christchurch, New Zealand where I’m recording today on a rainy February summer morning.

For this episode—my first episode—we’re going to look at something that, I think, is very central to women’s health and that is “why pill-bleeds are not periods.” 

I feel like if we could just get this straight, and start to use the right words for menstrual cycles, then a lot of other things would start to make sense.

So, let’s start by defining a real period. By period, I mean the bleed that comes at the end of a natural ovulatory menstrual cycle, which is a series of hormonal events in which ovulation occurs and the hormones estradiol—our main estrogen—and progesterone are made by the ovaries.

Stay tuned for a future episode about why ovulation is the main event of the menstrual cycle, but for now, just trust me that it is. And therefore that any bleed that does not come approximately two weeks after ovulation is not actually a menstrual cycle. It’s either 1) an anovulatory bleed—which is common—and we’ll talk about it in a future episode, or 2) a pill withdrawal bleed—which is the topic of today. 

So. If ovulation is the main event of a menstrual cycle, and the pill suppresses ovulation then obviously, the pill cannot promote or regulate a menstrual cycle—although it’s sometimes prescribed for that purpose, which is, of course, confusing, and we’ll come to that.

But, let’s look at what is the story with a so-called period when you’re on the pill? Well, basically, any kind of combined estrogen-progestin method of birth control — whether it’s a pill, Nuvaring or a patch—can if dosed in the right way—induce a withdrawal bleed on any schedule—including n a regular monthly pattern. 

But that monthly withdrawal bleed is only mimicking a menstrual cycle.

The whole point of a monthly cycle is that a month is approximately how long it takes to progress to ovulation, to ovulate, and then to have a two-week post-ovulation luteal phase when you make progesterone and then eventually lose progesterone, resulting in a bleed. 

And of course, on the pill or the Nuvaring, there are none of those things—no ovulation, no luteal phase, and no progesterone. Which is why a pill bleed can be dosed on any schedule 
And, it’s safe to say, there is no medical reason to have a monthly withdrawal bleed from contraceptive drugs.

The other thing to keep in mind here is that on the pill, there is no estradiol or progesterone. Instead, there are contraceptive drugs that have names like ethinylestradiol and levonorgestrel—and are only kind of like estradiol and progesterone.

Consider this. If, while on a combined estrogen contraceptive method such as the pill or NuvaRing, you were to try to measure blood levels of estradiol and progesterone, 
you would find almost none. In fact, both hormones on the blood test would be at menopausal levels. 

And why is that? Because, well, the pill suppresses ovarian function and suppresses estradiol and progesterone. And contraceptive drugs are not those hormones so cannot be picked up on a blood test. 

Not only do contraceptive drugs not show up on a blood test as hormones; they don’t have the same health benefits as hormones because they’re not hormones.

And this is where things start to get kind of important. Our actual hormones estradiol and progesterone are good for us and not just for making a baby. They promote long-term health in several ways. For example, estradiol is great for metabolism and mood. It builds muscle and bone; it improves insulin sensitivity and boosts the mood-enhancing neurotransmitters serotonin and dopamine. You could say estrogen is a pretty profound mood enhancer. The contraceptive drug ethinylestradiol—the pill’s estrogen—delivers only a partial version of those benefits. 

And that’s only the beginning of all the ways that contraceptive drugs are not as good as real hormones. 

The most profound difference is not with estrogen, but actually with progesterone compared to progestins. Progestins are the manufactured steroids that are only approximately like progesterone. 

Unlike synthetic estrogen, which can still deliver some benefits to mood and general health, progestins have mostly negative effects in all the aspects of health where progesterone has positive effects. 

For example, real progesterone is good for hair and skin because it helps to shelter the body from androgens or male hormones. 

Many progestins, on the other hand, are androgenic or testosterone-like and so can cause or worsen androgen symptoms like skin breakouts and facial hair and hair loss. 

Another example of the difference between progesterone and progestins is that progesterone is usually very good for mood and sleep whereas progestins have been found to cause or worsen anxiety and depression. 

Finally, progesterone may reduce the risk of breast cancer, whereas all types of progestins have been found to slightly increase the risk of breast cancer. 

In fact, the only way that progesterone and progestins are similar is that they both have a beneficial thinning effect on the uterine lining, therefore, making periods lighter, which is a good thing.

In every other part of the body including the breasts and brain, progesterone and progestins can have opposite effects.

So, in summary: I think we’re getting to the answer here—there are two reasons that pill bleeds are not periods. Because contraceptive drugs are not real hormones as we’ve seen. And they don’t provide the same benefits as real hormones. And as I mentioned earlier—there is no medical reason to bleed monthly on combined estrogen birth control.

Whereas there are two very good medical reasons to have an approximately monthly natural menstrual cycle. The first reason is that monthly ovulation is how the body makes its monthly dose of beneficial hormones, and the second reason is that monthly ovulation is an indicator that the body is healthy. 

Ovulation as an indicator or barometer of health is what the American College of Obstetricians and Gynecologists were referring to in 2016 when they released their statement called Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign.

In that statement, the college recommends that doctors should "always ask patients about menstruation"—by which they mean menstrual natural cycles—and furthermore, "that doctors should advise girls to chart their cycles." Which is pretty radical. It was very exciting to me to read that back in 2016. By doing so, the statement says, doctors will demonstrate to patients that natural menstruation is an important reflection of overall health.

Now. If you were prescribed the pill to regulate your menstrual cycle, you might be a bit confused by this point—and I’m sorry—you’re not alone. Because of all the people who take the pill, almost one in three take it to regulate their period. 

And yet here I am telling you that it can’t do that. Because a pill bleed is not a menstrual cycle, which should be obvious by now, and because contraceptive drugs do not regulate hormones but actually shut them down. That’s what I meant at the beginning of the podcast when I said that we need to start using the right words to describe the menstrual cycle. 

It would be accurate, for example, to say that contraceptive drugs suppress menstruation and therefore can relieve some of the symptoms associated with menstruation. And for painful conditions such as endometriosis, that could be a good thing—although, of course, I would acknowledge there are other ways to treat endometriosis as I discuss in Period Repair Manual.

And for a condition of irregular periods like PCOS or polycystic ovary syndrome, it would be accurate to say that certain types of contraceptive drugs can suppress androgens and produce withdrawal bleeds in a regular way that mimics periods and also, thins the uterine lining and protects the uterine lining. Of course, there’s still no reason to do that—have the withdrawal bleed monthly, and as I discuss on my blog, there are actually better treatments for PCOS including cyclic progesterone therapy with natural progesterone, which can both induce regular withdrawal bleeds, to start with, and then help the body promote or move towards regular ovulation and essentially reverse out of the symptoms of PCOS.

So, I hope that has been helpful and thanks so much for listening to my first ever episode. 

Please share and leave a review. And if you want to discuss this topic or ask a question for a future episode, you can do so on my forum at larabriden.com. 

I’ll see you next time where I’ll discuss heavy periods.