POV: You notice that your period is irregular or missing. And after a few months, you casually mention it to your doctor.  

You’re not overly concerned about your health – you are the “healthy one” who eats clean and exercises daily. After all – and your health care team assures you that everything is okay, you have no reason to worry. “Losing your period is normal if you’re active,” they say, “but let’s start you on birth control to regulate things.”  

… Sound familiar? 

The inconvenient truth is that hormonal birth control does not regulate your cycle like many women are led to believe.  So what does this mean for your fertility, and are there other unexpected consequences? 

Before we dive into this misconception, though, let’s review the science behind birth control pills.

How Birth Control Works

In a healthy cycle without oral contraceptive pills (aka birth control), low levels of two hormones: estrogen and progesterone – trigger the hypothalamus in our brain to release Gonadotropin-releasing hormone (GnRH). This GnRH stimulates the release of follicle stimulating hormone (FSH), among other hormones, which causes the follicles – small sacs in the ovaries that contain eggs – to mature. Follicles produce estrogen as they mature, which causes the lining of the uterus (endometrium) to thicken and triggers a massive surge in luteinizing hormone (LH). This surge triggers an egg to be released from the most mature follicle, which is an event known as ovulation. After ovulation, an individual is set up to either get pregnant, if that egg is fertilized and implanted in the endometrium, or shed the uterine lining via your period. 

In summary, low estrogen and progesterone levels at the beginning of your monthly cycle trigger a series of hormonal changes that help your body mature and release an egg. Once this egg is released, there are two possible outcomes: you either get pregnant or you get your period.

In women with hypothalamic amenorrhea (also known as functional hypothalamic amenorrhea, FHA), the body is under too much stress. Typically, this is because of under fueling and overexercising – to produce adequate amounts of reproductive hormones in response to GnRH. The hormone cascade stalls out in the follicular phase, and no follicular maturation or ovulation occurs.

Birth control pills, on the other hand, provide the body with a steady supply of estrogen and progesterone. Your brain will never detect the low estrogen and progesterone state like it does during a typical, birth-control-free cycle. As a result, GnRH is not released. FSH and other hormones are not produced. The endometrium does not thicken, and ovulation does not occur.  The placebo pills at the end of a birth control pack do not contain any hormones. So the sudden withdrawal of these artificial hormones causes the thin, underdeveloped lining of the uterus to break down and shed.  This mimics a monthly bleed, but let me be clear –  this is not a true period. 

So what happens when a woman with HA takes hormonal birth control? 

Hormonal birth control appears to fix HA because it causes a monthly bleed for ~1 week per month.But it does not regulate or “kickstart” your cycle because it does not address the fact that the body is under too much stress to support adequate hormone production.  It masks the underlying issue so once birth control is stopped, the same hormone issues resurface. 

Side note: Hormone replacement therapy (HRT) and Provera (synthetic form of progesterone given to induce a withdrawal bleed) also don’t regulate your cycle or “jump start” your cycle. Although they are often offered as a solution to women experiencing missing periods due to Hypothalamic Amenorrhea. More on that below.

Birth Control & Bone Health

Another equally frustrating misconception shared with many of my clients is that hormonal contraceptives help protect bone health.  Where did this belief originate from, and is there any truth to it? 

Estrogen, along with its role in the menstrual cycle, plays a key role in maintaining bone health because it reduces bone resorption[1]. Adequate estrogen levels protect bone, whereas low estrogen levels as seen in HA leave bone vulnerable to increased breakdown. With this in mind, many medical professionals encourage women to take hormonal birth control because they believe that the estrogen found in these pills will supplement the estrogen that they are missing.  This has been investigated by leading researchers in the field, however, and their conclusion is clear: “[they] suggest against patients with FHA using oral contraceptive pills for the sole purpose of regaining menses or improving bone mineral density.”[2] Furthermore, because these oral contraceptives provide a steady stream of artificial hormones, they mask any progress you may be making in recovering from HA. 

Additional Consequences of Birth Control

In addition to what birth control doesn’t do, it is important to know what using these oral contraceptives does to a user’s overall health.  Oral contraceptives have been shown to deplete levels of B Vitamins, Vitamin C, Vitamin E, folic acid, magnesium, selenium, and zinc [3]. They also reduce the diversity and abundance of gut microbes [4].  These effects can lead to reduced immunity, fatigue, muscle weakness, and GI issues, along a slew of other issues. And set one up poorly to conceive if they choose to try upon stopping birth control. 

Alternative Solutions

If someone is experiencing Hypothalamic Amenorrhea (HA) and has loss a considerable amount of bone mass to put them in the category of having early onset osteoporosis. Hormone replacement therapy (HRT) can be a better bridge to prevent further decline in bone mass as an individual continues to work on weight restoration, nutrition rehabilitation, and decrease in the intensity and duration of their exercise training to support getting their body to cycle naturally.

If you’re struggling with a missing or irregular cycle due to HA, the true solution is to address the root cause of your hormone dysfunction through increased rest and proper fueling. Yes, this can be challenging. But the registered dietitians and support coaches in the Food Freedom Fertility Society have helped hundreds of women break free from their dependence on exercise, redefine their relationship with food, and restore their fertility naturally. Space is limited, so apply now to join in this life-changing group!

REFERENCES

1. Hadji, P., Colli, E., & Regidor, P.-A. (2019). Bone Health in estrogen-free contraception. Osteoporosis International, 30(12), 2391–2400. https://doi.org/10.1007/s00198-019-05103-6 
2. Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Misra, M., Murad, M. H., Santoro, N. F., & Warren, M. P. (2017). Functional hypothalamic amenorrhea: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(5), 1413–1439. https://doi.org/10.1210/jc.2017-00131
3. Palmery, M., Saraceno, A., Vaiarelli, A., & Carlomagno, G. (2013). Oral contraceptives and changes in nutritional requirements. European Review for Medical and Pharmacological Sciences.
4. Palmery, M., Saraceno, A., Vaiarelli, A., & Carlomagno, G. (2013). Oral contraceptives and changes in nutritional requirements. European Review for Medical and Pharmacological Sciences.