Post Birth Control Syndrome - cautionary advice

Recently it came to my attention that something called "Post Birth Control Syndrome"

(PBCS) was trending on social media platforms and, in particular, women were being warned off of the contraceptive pill due to a perceived linkage between combined oral contraceptive pill (the Pill) usage and the development of PCOS.

As a gynaecologist this certainly came as somewhat of a surprise as my training had always focused upon the role of the Pill in treating PCOS. The thought that we might actually be inadvertently increasing the rate of PCOS in an otherwise unaffected population needless to say was a concerning notion. So I decided to do some research....after all, the scope of medical knowledge is a rapidly evolving discipline and anyone who claims to know it all is frankly delusional. Perhaps PBCS was a critical gap in my own knowledge and if so I certainly wanted to address it.

So what did I find?

Firstly, PBCS is not a recognised medical disorder. Does that mean that it is not necessarily real? Of course not. In the early days of many conditions there is a lag between initial identification and widespread acceptance. That said, as an evidence based clinician it does raise cautionary red flags. Examining the history of PBCS, near as I can tell the concept was initially coined by a Dr Jolene Brighten in a book titled Beyond the Pill. Based upon an interview with Dr Brighten (https://daveasprey.com/post-birth-control-syndrome-brighten/) she draws upon a variety of studies to allege a constellation of concerning physiological, micronutrient, anti-oxidant depletion and endocrine disruptions in women taking the pill. How real are these concerns?

This is where the cautionary note comes in....

The answer is not black and white.

As with many medications, the Pill has been demonstrated to have some adverse side effects. How significant these side effects are is a complex question to answer, both because in some instances the evidence is of low quality, and secondly the concept of what is and is not an acceptable side effect is very much a personal one for the patient rather than their clinician to decide. Added to this I feel comfortable in stating that not all women, and likely not even most, will experience any or all of the issues that Dr Brighten has identified....a fact that she herself acknowledges.

Now, this blog, long as my entries tend to be, does not have scope to address each and every one of the issues identified by Dr Brighten, other than to again stress that the evidence underpinning her concerns is either limited or, reassuringly, suggests that most women will not in fact suffer PBCS type issues of any clinical significance (which I would define largely as symptoms that the woman herself notices) - and note here that PBCS is being used by its proponents to include a return of the non contraceptive concerns that may have driven a woman to commence the Pill in the first place. I should also state, categorically, that I have no concerns with the lions share of advice that Dr Brighten provides in terms of dietary and exercise - a focus on healthy eating, anti-oxidant rich foods, exercise and the like would do us all a world of good. That said, I am quite cautious about her apparent suggestion that the Pill will lead to complete imbalance of your endocrine systems. Put simply, this is an over-reach as far as the clinical evidence is concerned.

So what about the Pill and PCOS?

Well, this is not a linkage that was immediately evident from Dr Brighten's interview...perhaps it is a theory that she or other proponents of PBCS espouse elsewhere. A quick literature search DID NOT identify any articles supporting such a linkage. At most, what can be said is that there is some concern that the oestrogen in the Pill can potentially increase insulin resistance and the risk of developing Type 2 Diabetes - a particular concern in the setting of PCOS as the syndrome already pre-disposes to insulin resistance and Type 2 Diabetes. This seems to be dose dependent with lower dose pills (with 20ug rather than 30ug or even 50ug oestradiol) failing to demonstrate a statistically significant increase in the incidence of Type 2 Diabetes. The benefits of the Pill for women with PCOS are certainly well established (so called anti-androgenic progestogens in certain Pills address a whole constellation of issues arising from PCOS). What I would say to any patient concerned about the issues raised in this paragraph are to discuss them with their GP or gynaecologist and ensure a thorough understanding of the options and their pros and cons so that you make an informed decision.

So where does this leave us?

For me personally it was a useful exercise to explore the issues raised by the concept of PBCS. As I mentioned above, we all need more reasons to eat well and exercise more and, even if it is almost certain that most women will happily be able to take the Pill, cease it and not suffer marked health effects, a focus on the potential issues with the Pill and simple measures to guard against the same is not at all harmful.

And for those who are worried that they are at risk of developing PCOS because of the Pill? Please try to be reassured that there is no evidence to support such a link. I suspect that, as with many things on social media, someone has taken the concept of PBCS and run with it in directions its authors did not intend.

And as always, if you have any concerns about your contraceptive choices, or gynaecological healthcare in general, please do seek an appointment with your GP or gynaecologist.