Like many women, Holly McComish went on hormonal contraception in the form of the pill aged 24 to avoid getting pregnant. Over a telephone call with her doctor, she was prescribed the combined pill. Three months later, Holly collapsed with a blood clot.
For healthy women, the risk of a blood clot on the pill is small: one in 3000. But Holly hadn’t been told it could happen at all. “I had no idea about the risk,” she tells Glamour. “As I didn’t even meet my GP face-to-face, I didn’t have the ‘regular’ checks of my height, weight and blood pressure before taking the pill, but I also think more tests like heart scans should be done before prescribing contraceptives to ensure there isn't a risk to our health.”
Holly isn’t the only one concerned about the health risks of contraception. Last week, a study from Oxford University found that women who take hormonal contraception have a 25% higher lifetime risk of breast cancer, adding to the seemingly mounting fear around the pill and other contraceptives.
Online, conversations about ditching hormones are on the rise, and it’s happening in the real world too: between 2000 and 2018, the proportion of women receiving a prescription for any contraceptive fell from 33% to 29%.
This change has been dubbed ‘hormonophobia’, coined in a 2021 study and defined as “an excessive fear of hormones based on irrational causes such as an overestimation of health risks associated with their use, that was already aroused by the recurring media controversies over hormonal contraception”.
But just how ‘excessive’ is this fear? The latest study on cancer risk was certainly significant, especially as it adds an extra layer of worry to women's already stressful worlds.
“The 25% increased risk sounds like a lot, but it’s 25% extra risk on an already very small number,” explains Dr Liz O'Riordan, a consultant breast surgeon and author of The Complete Guide to Breast Cancer: How to Feel Empowered and Take Control. Without contraception, the risk of developing breast cancer when you’re in your 20s is one in 1500. When you're 40, it’s one in 69; when you're over 70 the risk is one in 26. On contraception, the risk for people in their 20s rises to 1.25 in 1500.
“The two biggest risks of getting breast cancer are being a woman and getting older, which means breast cancer is largely out of our control,” says Dr O’Riordan. “I don’t think this study is a reason to stop using contraception, and if you do want to reduce your risk the boring stuff is the most important; you should be exercising, drinking sensibly and not smoking. When it comes to contraception, you need to do the right thing for you and your life and for many women the peace of mind that the implant, pills and the coil gives them are far more important.”
Still, it doesn’t feel fair that women have to deal with the emotional toll of terrifying headlines and regular studies that suggest risk or concern, especially when contraception has been around for over 60 years and male equivalents are kept off the market because of much smaller side effects.
Women’s contraception is regularly updated to ensure there are safe and useful options, assures Dr Julie Bowring, a consultant from London Gynaecology. “Over the last few decades, there's been a range of new contraceptives that have become available to women both in terms of the amount of hormone that is delivered and the mode of activation. There's now a greater choice of coils, as well as new methods like the vaginal ring, and the choice becomes wider for women every few years,” she says. Still, concerns around hormonal contraception range from mental health to fertility.
It's estimated that 78% of men would take contraception, but they fear the potential side effects.
Mood disruptions are the most common side effect of the pill, with one study suggesting over 43% of people taking oral contraceptives report mood changes. A study of one million women in Denmark found that hormonal contraception was also associated with a small but significant 1.23 times higher risk of first diagnosis of depression and subsequent treatment with antidepressants.
“I was on the pill for two years when I suddenly had terrible, terrible moods. I was so down, crying all the time and didn’t want to do anything,” Lucy* tells Glamour. “I ended up seeing a counsellor at university but they didn’t think it was the pill because I’d been on it for so long. Coming off it fixed everything though.”
For a few, mood changes can be a good thing, says Dr Bowring. “For women who are suffering from extreme PMS, the flip side is that they will potentially have improved mood on contraception,” she says. As was the case for Milly*, who says “I am a better person, emotionally, when I am using the pill.”
The problem is many women don’t know that the pill could cause mood changes. “It's something that women should be made aware of when they start taking contraceptives, and it's important that they know that if it's not one size fits all and that there are a number of options to find one without side effects,” adds Dr Bowring. Last year, a review into mood changes and contraception found that many of the older oral contraceptive pills, which contain a type of synthetic oestrogen, as well as progesterone-only contraceptives, were linked to severe mood problems. However, newer oral contraceptive pills containing physiological forms of oestrogen had less of a risk of depression and mood changes.
Mood flattening is one of the most discussed issues lately, with many people on contraception worried about how their personality or emotions have been ‘masked’. In 2019, Dr Sarah Hill’s book How the Pill Changes Everything: Your Brain On Birth Control started conversations about this, writing that coming off the pill felt like she had “woken from a ten-year nap I did not know I was taking.” In her TED Talk, she even referenced a small study that showed combined oral contraceptives dulled emotional brain reactivity.
Phoebe* has been on the pill for five years, but she’s considering coming off her hormonal contraception for this reason. “I am starting to become more anxious and emotional, and I am wondering if it’s the pill. The problem is that I also can’t remember who I was before taking it,” she says.
Dr Fran Yarlett from the contraception review site The Lowdown says: “A lot of the rhetoric I'm hearing at the moment is that women just want to feel like themselves, which is completely valid. But it’s so difficult to pinpoint personality shifts as we all change so much throughout our reproductive life. Who we are at 17 years old compared to now is different, but how much of that is down to hormones and what is down to just growing up?”.
While there is no medical need to take breaks from the pill, there is no shame in pausing (as long as you use other contraceptive options like condoms to protect against pregnancy) to check in with who you are and what you want. “You don’t lose anything by coming off of hormonal contraception, even if you end up going back on it. Instead, you gain knowledge about your body and what is best for you,” says Dr Yarlett.
Don't their preferences matter?
Dr Nicky Keay, an endocrinologist and author of Hormones, Health and Human Potential, explains that the combined pill, as well as some progesterone-only contraceptives, work by “suppressing ovulation via the pituitary gland in the brain. Essentially, they switch off at the power source so the ovaries don't do anything. That is what makes them such effective contraceptives.” This means that contraceptives can ‘mask’ our physical health problems, too.
This was the case for Chloe Hodgkinson, who was on the pill when she developed an exercise addiction and disordered eating. “Because I was still having breakthrough bleeds, I didn’t realise I was suffering from hypothalamic amenorrhea [where your periods stop as a result of low energy and excessive stress]. It wasn’t until I came off the pill and didn’t have a period for two years that I knew something was wrong,” she says.
“Doctors kept recommending me to go back on contraceptives so I would have a cycle and to protect my bone density [which can be impacted with HA as a result of low oestrogen] but I knew that would just mask the problem.”
Sometimes, switching off female hormones can help, especially for people suffering from female-hormone-led conditions like endometriosis, says Dr Keay. Last year, she had NICE change their guidelines to advise against giving hormonal contraceptives to women who present with irregular or missing periods. “They only reinforce the suppression of the hormones, when really we want to be finding out the root cause of the problem, whether it’s HA or ovarian failure or anything else,” she says. “The pill also doesn’t provide bone protection because the bones can’t use synthetic hormones in the same way as they can the real stuff, so you are at risk of osteoporosis.”
Here's what you need to know.
Andrea* has started to worry about whether or not she’ll be able to conceive after 14 years on the pill. Her fears about this spiked further when her smear came back with abnormal results. “I hadn’t really thought about having a family until I met my fiancé, but I’m getting married this year and I’m scared that being on the pill for so long would make pregnancy difficult. This with the abnormal smear has made my anxiety hellish,” she says.
Andrea isn’t alone; a 2018 study from Contraceptive Reproductive Medicine reported that “fertility after termination of contraception remains a big concern for women”. But what is the risk?
“The only contraception that can affect fertility is the injection, which can delay your return to baseline fertility by up to 12 months. Women should be counselled for this before they start,” explains Dr Yarlett. After stopping all other forms of hormonal contraceptives, your fertility should return within three months, she says.
“After six months, if your cycle hasn’t returned to normal, we would start to investigate. The really important thing is that it's your baseline fertility that is restored, meaning the same fertility you had before using contraception. If your cycle doesn’t regulate or you don’t become pregnant, it’s not likely the contraceptives' fault but more that there was an underlying women's health issue that hormonal contraception was either masking or treating,” adds Dr Yartlett.
According to research, contraceptives can actually improve fertility for certain women, like those with endometriosis, where the lining of your uterus grows outside of your womb. “Going on combined oral contraceptives after having surgery to remove endometriosis tissue can stop it from growing back and causing problems with fertility,” Dr Yartlett explains.
Most women have a positive experience with the coil, but some are having traumatic experiences – and their pain needs to be taken seriously.
Rachel* has just gone back on hormonal contraception at the age of 39. “With PCOS and endometriosis, I needed some control and regularity in my life. I had to get the contraceptives from an online pharmacy as my GP felt I was too old so I am a bit worried, but I don’t know what other option I have,” she says.
In general, hormonal contraception is fine to take until our 50s, says Dr Yartlett. “If you are fit and healthy with no medical or family history you can continue combined contraception until you are 50 and be on progestogen-only up to 55,” she says. “It’s actually a really good option for many people experiencing peri-menopause symptoms, so it’s not something to be dismissed.”
However, there are individual risk factors to consider as we age. “We may have discussions with you about the risks and benefits of certain contraceptives like the injection, which can affect your bone density. After the ages of 50 and 55, research suggests that the risk of being on it starts to outweigh the benefits, as the chances of cardiovascular disease and blood clots increase naturally and the likelihood of pregnancy massively declines. It's a very individualised decision requiring in-depth discussions and health checks with your doctor,” says Dr Yartlett.
For so many women, years on hormonal contraception help them get through life without pregnancy and pain. But it’s not that clear-cut for many women. The biggest and most real risk seems to be to women’s mental health, which is a huge problem when mood disorders are largely dismissed.
Whether or not this makes you want to come off or avoid contraception is personal. “You should have a check in with a doctor after three months on contraception to talk about any problems, rather than persevering, and you can always book further assessments if you require,” says Dr Bowring.
If you don’t feel taken seriously, organisations like The Lowdown can help, where trained doctors like Dr Yarlett can take calls with patients to discuss any concerns before recommending contraceptive advice. “I recommend reading up on all the information that's out there to make an informed decision before having a conversation with a healthcare professional to bounce your thoughts and feelings off of someone who knows what they're doing so you're comfortable with your decision,” she says. The burden of research is a huge block for many women, but it is best to make a decision with all the knowledge you can.
Holly’s experience led to her book, If Tits Could Talk, in which she touches on the failings of women’s health. When it comes to contraception, she is campaigning for an end to the “culture of ‘just try the pill and just see how you get on'.” Companies like Dama Health have the same aim, rolling out personalised contraception based on AI and genome testing in a bid to end “trial and error” prescribing that impacts women’s health and happiness. And maybe one day, there will finally be a male pill to take the burden off of women. Until then, know that you always get the final call on your own body and mind.
If you have any questions or concerns regarding contraception, speak to your GP or visit nhs.uk.
