Continuing the Conversation about Depo-Provera

In keeping with my latest posts on progesterone, progestins, and birth control, I 'm posting this link to a post about Depo-Provera.  I know many of you have had negative experiences with the shots and this may help others to think twice about getting them for your PMDD.  There's a lot of good information on this site overall regarding all things menstrual, so it's well worth your time to look around once you get there. 

Enjoy, and may you be having a PMDD-free day.

Are Oral Contraceptives Really the Answer for PMDD?

Is Levora® making your PMDD worse?  We're going to take a little side trip today, because in the past month alone I've had over 100 requests for information on this subject.  According to information provided by the website Drugs.com, it's possible.

Levora® is a combination drug that contains female hormones that prevent ovulation and also causes changes in your cervical mucus and uterine lining, making it harder for sperm to reach the uterus and harder for a fertilized egg to attach to the uterus. It's primarily used as an oral contraceptive that provides 21 active white tablets and 7 inactive peach tablets.  The tablets contain levonogestrel (a totally synthetic progestogen) and ethinyl estradiol (a synthetic estrogen).  Inactive ingredients in the pills include FD&C Yellow No.6 (which may contain aluminum) and three forms of lactose.

For more specific information on patient-reported Levora side effects, go to: the Rate a Drug site

and/or Treato: The Voice of the Patient.

It should also be noted that continuous combined birth control formulas (such as the one found in Levora®), as opposed to sequentially-based hormone regimens that mimic the natural female cycle, have also been shown to frequently lower a woman's sex drive.

According to Dr. Winnifred B. Cutler, in her book, Hormones and Your Health, a test on monkeys showed that the combination of ethinyl estradiol and levonogestrel (the combination in Levora®) caused large elevations in the stress hormone cortisol, as well as great increases in their heart rates.  Rising rates of cortisol, among other things, messes with your metabolism, causes you to gain weight and suppresses your normal immune functions, leaving you susceptible to every cold and flu that comes your way.  In time your body can get so run down that you develop something serious, even terminal.

For instance, Dr. Cutler also recommends that women avoid ethinyl estradiol after age 45 because it also increases the risk of having a stroke.  In fact, she recommends that (no matter what your age) you have your triglycerides and CRP (C-reactive proteins) checked (via blood tests) if you start ANY oral estrogens at three and/or six months after you start taking them.  You will need to switch hormone regimens if your CRP or triglycerides rise, as rising levels of either of these is predictive of heart disease, even more so than rising levels of LDL (aka the bad) cholesterol. 

No matter what form of oral contraceptive you may be taking, I urge you to find out what exactly is in it, and if it is a continuous formula or a sequential one.  This will go a long way in determining which side effects may or may not apply to you.  Besides, it's just plain smart to know what you're putting into your body.  For instance, if you're having trouble thinking and remembering things, it might be due to the ethinyl estradiol in your hormone pills.  "Estrogen like" as in synthetic estrogens, is not the same as bioidentical estrogen.  Far from it.  Each will have a different impact on your thinking processes.

The rest of the information that follows seems to be the standard patient information for all oral contraceptives, which include Levora®, but may or may not be specific to Levora®.  Still, I looked up the medical terminology you find in your patient information packets, and translated them into everyday words we can understand.

That said, you should not take any combination birth control pills if you have high blood pressure, heart disease, a blood-clotting disorder, circulation problems, diabetes, pre-diabetes, unusual vaginal bleeding, liver disease or liver cancer, jaundice caused by birth control pills, a heart attack, stroke, or blood clot.  Note that there is the possibility of a risk of heart disease even in very young women who take oral contraceptives.  So if you are young, don't go around thinking you're invincible. While a cause and effect relationship has not been scientifically established, some studies have also reported an increased relative risk of developing breast cancer, particularly at a younger age.  This increased risk appears to be related to how long you take the pills.  The risk for benign liver tumors increases after four or more years of use.  (Death can occur if a tumor ruptures.)  Studies have also shown an increased risk of developing liver cancer in long term (greater than 8 years) use of oral contraceptives.

You should discontinue use of your oral contraceptive if you experience unexplained or complete loss of vision, bulging eyes, swelling of the optic nerve, or lesions (scars, bumps, bubbles) in your retinal veins.

Also, be aware that cigarette smoking increases the risk of serious cardiovascular side effects from oral contraceptive use.  This risk increases with age and with heavy smoking (15 or more cigarettes per day). 

Still, if you use oral contraceptives, you should not smoke.  Period.  If you are looking for a way to go off the pill, please check out this website. 

If you do smoke while taking oral contraceptives, some nasty things that can happen include heart attack, blood clots (in the lungs and legs), stroke, liver tumors, and gallbladder disease.  The risk increases significantly if you already have high blood pressure, high cholesterol, diabetes, and/or are obese.  Obesity is defined as having a body mass index of more than 30.  You can figure out your BMI here.  

Oral contraceptives have also been shown to cause glucose intolerance in a significant percentage of users.  Oral contraceptives containing greater than 75 mcg of estrogen (which Levora® does) can cause abnormally high levels of insulin. People with too much insulin have frequent episodes of low blood sugar (hypoglycemia). These episodes can be characterized by a lack of energy (lethargy) and/or irritability. Repeated episodes of low blood sugar increase the risk for serious complications such as seizures, intellectual disability, breathing difficulties, and coma.

Lower doses of estrogen cause less glucose intolerance, but the progestogens in your oral contraceptive can also increase insulin secretion and create insulin resistance.  Therefore pre-diabetic and diabetic women should be especially careful while taking oral contraception.  Talk with your doctor frequently. 

The incidence of high blood pressure also increases with increasing concentrations of progestogens.  Women with a history of high blood pressure or high blood pressure-related diseases, as well as kidney disease, should use another method of contraception.

If you start to get migraines, or your migraines become more severe, stop taking oral contraception until you determine the cause.

When taking any oral contraceptive, you should follow up regularly with your doctor.  You need to pay special attention to your blood pressure, breasts, abdomen and pelvic organs, including pap smears.   Women--especially younger women--with a strong family history of breast cancer should think twice about taking oral contraceptives.

Birth control pills can also be a problem if you have varicose veins, a history of depression, an underactive thyroid, seizures or epilepsy, and/or a history of fibrocystic breast disease, lumps, nodules, or an abnormal mammogram.

As with any drug, you could have an allergic reaction to Levora®.

If any of these adverse effects occurs while you are taking oral contraceptives, call your doctor immediately:

·        Sharp chest pain, coughing of blood or sudden shortness of breath (indicating a possible clot in the lung)

·        Pain in the calf (indicating a possible clot in the leg)

·        Crushing chest pain or heaviness in the chest (indicating a possible heart attack)

·        Sudden severe headache or vomiting, dizziness or fainting, disturbances of vision or speech, weakness or numbness in an arm or leg (indicating a possible stroke)

·        Sudden partial or complete loss of vision (indicating a possible clot in the eye)

·        Breast lumps (indicating possible breast cancer or fibrocystic disease of the breast: ask your doctor or health care provider to show you how to examine your breasts)

·        Severe pain or tenderness in the stomach area (indicating a possible ruptured liver tumor)

·        Difficulty in sleeping, weakness, lack of energy, fatigue or change in mood (possibly indicating severe depression)

       Jaundice or a yellowing of the skin or eyeballs, accompanied frequently by fever, fatigue, loss of appetite, dark-colored urine or light-colored bowel movements (indicating possible liver problems)

It's the references to depression and anxiety that concern and confuse me.  Why would a doctor prescribe something for your PMDD when it could cause more of the very same symptoms you already have?  Plus increase your chances of developing heart disease, among other things.

Side effects they don't consider serious (but you might) include:

Increased blood pressure

Mild nausea

Breast tenderness or swelling, nipple discharge

Freckles or darkening of facial skin, increased bodily hair growth, loss of scalp hair

Rashes

Changes in weight or appetite

Fluid retention, particularly in the fingers and ankles

Problems with contact lenses

Headache

Anxiety

Dizziness

Vaginal itching or discharge

and

Decreased sex drive

And this is not a complete list of side effects.

Special note:  Certain drugs can make birth control pills less effective:  These include Phenobarbital and other barbituates, seizure medications, and St. John's Wort, which many PMDD women use to counter their depression.  So beware if you are self-medicating with St. John's Wort.

In all, there doesn't seem to be a lot of scientific information on the internet specifically about Levora® making your PMDD symptoms worse...which is probably why people are looking for it.  I hope this post has answered some of your questions, or at least pointed you in the right direction for the answers you seek. 

That done, I need to get on my personal bandwagon and ask you to reconsider using birth control to treat your PMDD.  Is the increased risk of heart disease, the number one killer of women, worth the risk of masking your PMDD symptoms for a few years?  Think about this.  Just because fertility and PMDD both involve hormones does not mean the medications for them are interchangeable.  That's like throwing something against a wall to see if it sticks.  A good naturopath or nurse practitioner should be able to help you come up with a hormone regimen individualized for your needs and your body. 

The problem with PMDD begins at ovulation.  Did you know bioidentical estrogen in high enough doses can prevent ovulation?  Without all the unpleasant side effects listed above.

I'm not recommending bioidentical estrogen as birth control, but to help manage your PMDD in a positive and healthy way?  It's certainly worth a shot.  Especially if you're in peri-menopause.

Of course you can't take unopposed estrogen in any form without adding back some progesterone, but again, with the right medical supervision, you can work out a regimen that best suits your body and needs and lifestyle.  That best suits YOU.  Rather than the one-size-fits-all mentality that prevails in the marketplace now.   

Don't you deserve to be treated as the individual that you are?

PMDD Wars: Progesterone vs. Progestins: Part 1, Progestins

There are many controversies surrounding PMDD, and one of the biggest is the use of progestins and progesterone to help mitigate the symptoms.  I think someone out there must be marketing progesterone for PMDD pretty heavily, because of all of the questions I'm getting on the subject.  So I'm going to back up and start at the very beginning, assuming you know nothing about progesterone and progestins, like I did when I first started researching this topic. 

First of all, we are talking about two different things.  Progesterone and progestins are not the same.  Progesterone is produced naturally in your body; progestins are synthesized to mimic what progesterone does for your body.  It's important that you do not confuse the two, and when reading articles or advertisements or results of clinical studies on hormones, it's important that you know which one they are talking about--natural progesterone, plant-based progesterone, or synthetic progestins, also called progestogens.  

Somehow it all gets lumped into being called "progesterone", and I think this is a big part of where our confusion as consumers comes from.

So:

Progesterone is what your body makes naturally

Bio-identical progesterone - a synthetic progesterone made from plant sources that is biochemically similar to those produced by the body

Progestins  - synthetic progesterone-like chemicals structurally different from what your body makes

Progestogens - synthetic progesterone-like chemicals structurally different from what your body makes

If you read nothing else of this post, please make sure you learn the above distinctions.

Because of the enormous amount of information on progestins alone, I will not get to the information on what is termed bio-identical progesterone today.  If that's all you want to read about, you will have to wait for a different post, but in the meantime I do encourage you to keep reading, as what follows may answer some of your questions, and may help to explain why you feel the way you do.  

Now, back to the basics:

Progesterone is a hormone naturally secreted by the ovary in the second two weeks of a woman's menstrual cycle.  Both bio-identical progesterone (synthesized from plant sources) and progestins (synthesized from chemicals) can also be taken in pill form, the latter by women taking birth control pills and hormone replacement therapy pills.  Progestins can also be used to induce a menstrual period in the case of stopped menstrual periods, or to regulate abnormal bleeding in the case of heavy blood flow problems.  Progesterone is also used in high doses for women with infertility problems and to prevent miscarriages.

There are several different kinds of progesterone being marketed today.  Today's post is about  progestins, the synthetic progesterone-like chemicals (also called progestogens) which bind to the body's progesterone receptors and function, for the most part, just like progesterone.  But because they are chemically different from our own natural progesterone, they have side effects.

Progestins were originally developed because they could be absorbed into the blood when ingested in pill form--this was before the development of micronized progesterone capsules. 

Progestins are only available via a prescription. You find progestins in birth control pills, also called oral contraceptives.  There are two main types of birth control pills: combination pills and progestin-only pills.  Most pills are available in both a 21-day or a 28-day pack, with the 28-day pack containing 7 placebos, or inactive pills, taken on the days you would normally have a menstrual period.  Combination pills are the most popular, due to the well-published side effects of synthesized estrogen-only therapies, and contain both synthesized estrogen and progestin. 

However, all combination pills raise the risk of heart attacks, stroke, and blood clots.  That risk rises if you are either smoker or over the age of 35.  Other factors, such as being obese or having a family history of heart disease make these blood clots more likely, therefore the FDA advises women against taking any combination birth control pills if you have a history of blood clots, heart attack, or stroke. 

One type of birth control pills carries a higher risk of deep vein thrombosis or pulmonary embolism (blood clots that start in a leg vein and travel to the lungs) than others.  Those are the pills that contain the ingredient drospireone and include Beyaz, Gianvi, Lornay Ocella Safyral, Yasmin, Yaz, and Zarah.  According to a post in the blog re: Cycling, as of April, 2012, pharmaceutical giant Bayer (makers of Beyaz, Yasmin, and Yaz) faced 11,300 lawsuits from women who have been seriously injured and family members of women who have died after taking Yaz or Yasmin.  In December of 2012 the company reported they settled the first 3500 cases with a total of $750 million in payouts.  As of this date, the latest case filed, November 28, 2012, is from a woman in Oklahoma who took Yaz for only two months, ten years ago, and developed deep vein thrombosis.

That said, the following side effects, usually severe or sudden, may be caused by blood clots:

Headache or migraine

Loss of or change in speech, coordination, or vision

Numbness or pain in chest, arm, or leg

Unexplained shortness of breath

 More common side effects of progestins include:

Changes in vaginal bleeding

Light bleeding or spotting between withdrawal bleeds

Symptoms of blood sugar problems (Dry mouth, frequent urination, loss of appetite, or unusual thirst)

Mental depression

Nausea

Skin rash

Unexpected or increased flow of breast milk

Abdominal pain or cramping

Breast tenderness

Bloating or swelling of ankles or feet

Blood pressure increase

Dizziness

Headache

Mood changes

Nervousness

Unusual or rapid weight gain

Acne

Brown spots on exposed skin

Hot flashes

Loss or gain of body, facial, or scalp hair

Loss of sexual desire

Trouble sleeping

Certain doses of progestins may also cause a temporary thinning of your bones, which is a factor in developing osteoporosis, but on the other hand, it has been found that progestins *may* offer some protection against osteoporosis in postmenopausal women.  Smoking, drinking alcohol, and taking or drinking caffeine can also thin your bones, so be aware of the added stress you may be placing on your bones by taking progestins.

Progestin-only pills (also called the mini-pill) are most commonly used by nursing mothers, women at risk for blood clots, and other conditions that prevent them from taking estrogen.

Combination birth control pills come in different phases, depending on whether the level of hormones in the pills changes throughout the month.  Monophasic (one phase) pills contain the same amount of estrogen and progestin in all of the active pills.  Two-phase pills change the level of hormones once during the menstrual cycle.  Three-phase pills change the levels of hormones every seven days during the first three weeks of pills.  Then you have the inactive pills for the fourth week, which is when you get what is called a withdrawal bleed.  It's not to be confused with a period.  You bleed, but you don't have a true period.  You can't, because you didn't ovulate.  Four-phase pills change their hormone levels four times per cycle. 

Is it safe or healthy to skip periods?  If you aren't taking oral contraceptives, you need a period after ovulation to shed the lining that's built up in  your uterus in preparation to receive a fertilized egg.  But when you're taking birth control pills, they suppress ovulation, so no eggs are released, and therefore your uterine lining doesn't build up.  The reason you bleed is because of the week of inactive pills in your birth control packet.  And sometimes you might not bleed at all. 

I am of the opinion that it's not a good thing to chemically suppress any natural body functions, but every woman has to decide for herself.  More information on this (so that you can make your own informed decision) can be found at the blog, Sweetening the Pill.

So, in addition to regulating your menstrual cycle by suppressing ovulation, and treating women with no period (amenorrhea) in an effort to bring about a period if possible, progestins are used:

To prevent estrogen from thickening the lining of your uterus

To treat pain related to endometriosis

To help treat cancer of the breast, kidney, or uterus—as progestins can stop the growth of an estrogen-fed tumor

To help prevent anemia (low iron in blood)

and, in high doses:

To stop heavy menstrual bleeding

To help a pregnancy occur during egg donor or infertility procedures

and

To help maintain a pregnancy when not enough progesterone is made by the body to do so.

So both progesterone and progestins are tricky things:  High doses can either start or stop menstrual bleeding, and can be used to help support pregnancy, while low doses can prevent pregnancy from occurring.

However, there have been some reports that high doses of progestins during pregnancy may cause birth defects in the sex organs of a male fetus, and some progestins may cause male-like changes in a female fetus and female-like changes in a male fetus. 

Hormones are powerful things, ladies, so buyer beware.

Before taking progestins, you should also tell your doctor if you have or have had any medical issues with the following, either through your family history, or having experienced these issues yourself, as progestins may make these conditions worse:

Allergies (to medicines, food dyes, preservatives, or animals)

Asthma

Epilepsy

Heart or circulation problems

Kidney disease

Migraines

Bleeding problems

Blood clots

Breast cancer

Deep vein thrombosis

Heart attack

Liver disease

Pulmonary embolism

Stroke

Blood clots in the veins

Breast lumps or cysts

Diabetes

Memory loss

Vision changes

Note:  Just as each woman is individual in her hormonal makeup, each synthetic progestin has a different side effect profile, due to the various formulations, so it is hard to pinpoint which progestins will cause which symptoms in which women.  I'm just trying to cover all the possibilities here so that you can see where, if at all, you fit in. 

Proposed off-label uses for progestins include treating hot flashes (interesting, since they can apparently also cause hot flashes) and polycystic ovary syndrome (PCOS).  An off-label use is one that has not been approved by the FDA, but once a drug has been approved by the FDA (in this case, birth control or hormone replacement therapy) to treat a specific condition or disorder, doctors may then prescribe it as they see fit.  Much marketing is done in the area of off-label use for many drugs touted as PMDD symptom relievers, and several drug companies have been reprimanded and fined by the FDA for promoting non-approved uses of their drugs to treat these symptoms.

We'll talk more about that next time.