Women's Health Matters

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In December 2008, our guest expert in Le Club's Ask the Expert segment was Dr. Rebecca Herman, a physician at the Bay Centre for Birth Control, Women’s College Hospital.

Dr. Herman attended medical school at the University of Western Ontario, completing her post-graduate residency training in family medicine at Toronto East General Hospital. She has worked in a variety of clinical settings, including hospitals, community and student health centres, and women's health clinics.

Dr. Herman currently runs an office-based family medicine practice and works at the Bay Centre for Birth Control, Women's College Hospital. At the Bay Centre she provides care in the areas of contraception, identification and treatment of sexually transmitted infections, and early pregnancy counselling and management. Dr. Herman has a special interest in adolescent medicine, health education and promotion, and sexual health.

Here are Dr. Herman’s answers to your questions on Contraception:

Q: I am 41, have never had children, and have some pain and bleeding during cervical smears (Pap tests). I am considering getting a Mirena IUD and was wondering if the risk of pain is higher for me?

A: Every woman is different, and it is impossible to predict the level of discomfort you may (or may not) experience during IUD insertion. Generally speaking, women who have had uncomplicated vaginal deliveries often tolerate IUD insertions very well. Having said that, many women in your position have no difficulties with the procedure whatsoever. I don’t believe your experience with Pap smears should be relevant. It’s recommended that women come during their menses (because the cervix is more open) and take two ibuprofens one hour prior (assuming you can tolerate this medicine). If your doctor sees fit, he or she may also give you tablets to insert into your vagina prior to insertion of the IUD to help open up the cervical canal.


Q: I recently read an article in the Toronto Sun about The Scent of Desire, a book that talks about birth control pills affecting a woman's sense of smell related to her selection process for mating. As a sexual health counsellor, I had not heard of this before. Is there any scientific data about this?

A: I have not heard about this either – interesting question.

Editor’s note:
While we cannot comment on the scientific data, we can tell you that Rachel Herz, PhD, the author of the book, is a visiting professor at Brown University who specializes in the psychology of smell. Dr. Herz is regularly interviewed on radio and television, and in print media.

According to an article about the book in the Seattle Times, evolutionary biology dictates that we choose a lover’s scent that is very different from our own, but birth control pills, in mimicking pregnancy, might cause a woman to desire a different ‘odourprint.’

Amazon.com quotes good reviews from Publisher’s Weekly and Kirkus Reviews. However, the journal Evolutionary Psychology published a negative review, saying that the book ‘contains misrepresentations of evolutionary theory, unsupported claims, lack of appropriate citations, and gross oversimplification throughout.’


I would like to know what side effects the Depo-Provera shot may have and whether it is healthy to go long periods of time without having a period.

A: Depo-Provera is a medication containing the hormone progestin that is given by intramuscular injection every 12 weeks. If taken on schedule, it is over 99 percent effective at preventing pregnancy. Major side effects of Depo-Provera include irregular or prolonged vaginal bleeding or spotting after receiving the shot (usually this decreases over time, but it is very unpredictable). After one year of Depo-Provera administration, half of women will stop having their periods altogether. This is completely safe.

Other side effects include headaches, weight gain, breast tenderness, depression and slow return of fertility after stopping (most women regain fertility by nine months, but this could take up to 18 months after receiving the last injection).

Studies have demonstrated that Depo-Provera users do have lowered bone mineral density scores (a measure of bone strength), but it is now generally accepted that this loss is regained once the medicine is stopped. When we look at previous Depo-Provera users, we don’t see any increase in bone fracture risk. All women using Depo-Provera should try to increase their calcium and vitamin D intake, minimize smoking, alcohol and caffeine, and exercise regularly to help with their bone health.


Q: I took the Diane-35 pill for four years, and I stopped taking it three weeks ago. Today, I have about 10 pimples on my back, which I did not have before. Is it possible that this has something to do with stopping the pill? Is it going to stabilize itself? I need another method of contraception, because I always forget to take the Pill, but I have no idea where to turn.

A: Diane-35 is a medication containing two compounds: cyproterone and ethinyl estradiol. This medication is primarily prescribed as an acne treatment, with the ‘side effect’ of excellent contraception (like the regular birth control pill) if taken as prescribed. Cyproterone is an anti-androgen that works very well to fight acne, and it is not found in any other birth control pill on the market. Certainly, stopping Diane-35 could be associated with new pimples and worsening acne. This might ‘stabilize’ itself – I would generally recommend waiting three pill-free months to reassess and see how your skin is doing without the hormones. If, at that time, the acne is still a problem you should speak to your doctor about various other topical (cream) or oral treatments that are available.

If you have difficulty remembering to take the pill on a daily basis, there are a lot of other choices out there for effective contraception. Without going in to too much detail, options include:

  • the Evra Patch (worn on the skin, changed every week)
  • the NuvaRing (inserted into the vagina for 3 week cycles)
  • Depo-Provera (injection given by nurse or doctor, every 12 weeks)
  • IUD/IUS (inserted by a doctor into the uterus, staying in place for a maximum of five years)
  • barrier methods (male condom, female condom, diaphragm, sponge)


Q: Is weight gain one of the side effects of the Mirena IUD? Are there any other side effects that I should be aware of?

A: The Mirena Intrauterine system (IUS) is a small T-shaped plastic device that releases small amounts of the hormone progestin into the uterus once inserted. Overall, the amount of progestin released daily is very small. The progestin circulates locally, so most of the side effects are limited to the reproductive system, with only minor effects occurring throughout the body. Although not common, there have been reports of minor weight gain, slight change in mood or depression, some headaches, breast tenderness and acne – although these usually subside within the first three to six months.

Many women experience irregular, unpredictable bleeding during the initial six months after insertion. The vast majority of time this subsides, and many women (20 percent by one year) stop menstruating altogether (which is completely safe). The Mirena IUS is 99 percent effective and can be left in place for five years. 


How long should a pre-menopausal woman in her early 50s continue to use birth control? Is there a risk of pregnancy at that age if you continue to have your periods?

A: It is completely safe to continue taking the birth control pill right into menopause. In addition to offering excellent contraception, this is also a very good way to manage unpredictable and irregular bleeding that often accompanies the perimenopausal time. Be sure to speak with your doctor about your choices. Once menopause has occurred, the birth control pill is no longer indicated.

Although significantly reduced, there is always a chance of pregnancy at any age so long as menstruation is still occurring. Contraceptive measures must always be used until menopause has occurred (no period for one year and discussed with your doctor).


Q: My friends have talked about the 'patch.’ What birth control method is that and what are the side effects?

A: The Evra contraceptive patch contains the same two hormones present in the birth control pill (estrogen and progestin). This small square patch sticks to the skin (usually on your buttocks, abdomen, upper back, shoulder or on the outside of your upper arm) and is changed weekly for three cycles, then removed for one week (during which time menstruation occurs). If used correctly, it is 99 percent effective at preventing pregnancy.

Side effects, much like the birth control pill, include breast tenderness, nausea, headaches, and a very small but serious risk of blood clots in the legs or lungs. Specific to the patch, some skin irritation at the site may occur and the patch may be somewhat less effective for women weighing more than 90 kg.


Q: Am I at risk of becoming pregnant if I often forget to take the pill? I sometimes forget take it three times during the month. Am I at less risk if I have been taking The Pill for eight years? At what time of the month is a woman most likely to become pregnant?

A: Yes. The birth control pill is very effective at preventing pregnancy-but ONLY if taken exactly as prescribed (i.e., no missed pills).  Even if you’ve been on the pill for a very long time, you are still very high risk for getting pregnant if you miss pills without using any back-up contraception (e.g., condoms). A woman is most likely to get pregnant if she misses pills at the beginning or end of her pack, although conception can occur anytime through the cycle if pills are missed. In your circumstance, you should use condoms for every act of intercourse from now on, and take a home pregnancy test to ensure that you are not pregnant.


Q: What do you think of the new birth control pill Seasonale that results in having a period every three months? I am 45 years old, so I'm peri-menopausal. Is it safe? Are there any side effects or unknown problems?

A: Seasonale is a very safe option for women who wish to menstruate on a 91-day cycle. This birth control pill contains exactly the same hormones and dosages as the ‘standard’ 28 day pill, but is merely marketed differently (and, accordingly, costs more). When taking Seasonale, you take 1 active tablet per day for 84 days, followed by 1 inactive tablet for 7 days (when you will have your bleed). This is very appealing to many women, and is a great option for those with heavy menses, PMS symptoms or schedules that don’t accommodate a bleed every 3 weeks. An equally safe and effective alternative is to use the standard birth control pill (some are better than others, so speak to your doctor first) and use the active pills back-to-back to ‘skip’ a bleed.


Q: I have heard that some pharmacists refuse to give the emergency contraceptive pill over the counter. Can you still get it without a prescription? Also, how does it work?

A: The emergency contraceptive pill (‘morning after pill’) is available without a prescription and is either behind the counter or on the shelf. Unfortunately, some pharmacies have their own policies whereby they do not provide this. This is at their discretion, but generally speaking, the pill is widely available at most branches.

The ECP (emergency contraceptive pill) is meant to be used when another method of birth control has failed (e.g., broken or slipped condom) or when none has been used. The ECP is good at reducing the chance of getting pregnant, but it is not perfect and it is not as good as trying to prevent pregnancy with other methods of contraception. It will not stop or harm an existing pregnancy.

The ECP may either stop an egg from being fertilized or alter the uterus lining so that the pregnancy cannot implant. The ECP can be used for up to five days (120 hours) after an act of unprotected intercourse. The sooner it is taken, the more effective it is. Generally speaking, the ECP will reduce the chance of pregnancy by 75-85 percent. Most women will have a regular bleed within three weeks of taking the ECP. If this doesn’t occur, a pregnancy test should be taken.

Always remember that the ECP does not protect against STIs (sexually transmitted infections), so if no contraception has been used you must also think about your risk of infection and get tested and treated if concerned.


Q: Is it dangerous to continue taking the Pill when you're pregnant? In the situation I'm referring to, the woman is ignoring the fact that she's pregnant and is still menstruating.

A: The birth control pill has not been shown to have any detrimental or dangerous effects on an existing pregnancy. The bigger concern, however, is why a woman who is pregnant would still be taking the Pill. Once pregnancy is confirmed (by a urine or blood test), the birth control pill should be stopped, and the woman needs to visit her doctor to discuss her options. A woman requires special medical attention even early on in pregnancy (no matter what her personal decisions and choices may be), and these issues need to be addressed to best serve and care for her and her pregnancy. 


Q: At what age can a teenager legally get birth control without having to tell her parents?

A: A teenager does not need her parents’ permission to use contraception. Any conversation between a teenager and a medical doctor is absolutely private and confidential, and can’t be shared with anyone else (like a parent) unless the doctor is concerned about the teen’s, or someone else’s, safety. A teenager should feel very comfortable talking to her doctor about these issues and very proud for taking such responsible action. So long as the doctor can be sure that the teen is safe, I hope most doctors would be comfortable talking about, and prescribing, birth control if appropriate.


Q: Is it true that the Copper-T IUD can be used as emergency contraception? How would this work, and how does it compare to using the ‘morning after pill’?

A: Yes, the copper IUD can be used as emergency contraception up to seven days after having unprotected intercourse (sooner is better, preferably within five days). The copper IUD is a device that must be inserted into the uterus (through the vagina and cervix) by a physician. The copper IUD primarily acts to prevent implantation of a fertilized egg in the uterus. It is approximately 97 percent effective. Although the IUD is more effective as post-coital contraception than the morning after pill, it is also more expensive, and requires insertion that carries its own specific risks (i.e., pain, bleeding, complication, risk of infection).

Once in place, the IUD can be left for five years – but it must be remembered that condoms must still be used for STI prevention.


Q: My daughter had a reaction to birth control pills: she developed painful bruised lumps on her shins. The nurse diagnosed her with a condition called erythema nodosum and told her that she can never take estrogen-based birth control pills because she is at increased risk for blood clots. What birth control method should she use instead?

A: Erythema nodosum can occur from a variety of causes, and the birth control pill can be one unlikely cause. Another, more common cause is a bacterial infection (like Strep).

The difficulty for your daughter lies in trying to decipher what triggered her erythema nodosum, and if it was merely a coincidence that she developed it when she happened to be on the Pill. Unfortunately, you’ll probably never know for sure.

I would encourage you to speak with your doctor, because there are many other options available (and, quite possibly, the birth control pill might be one of these). I’m not aware of any confirmed associated link between an increased risk of clotting and erythema nodosum due to birth control.

Non-estrogen options include: Micronor, Depo-Provera, condoms (male and female), IUD/IUS, diaphragms.


Q: When should a girl start getting Pap smears?

A: Females should begin getting Pap smears (which screen for cervical cancer) within one to two years from their first sexual intercourse. You do not need to have a Pap smear to be prescribed the birth control pill or any other form of contraception.

An STI check (which tests for sexually transmitted infections) can be done at any time, and is certainly encouraged if a woman has any concerns or questions.


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