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Birth Control

Birth Control Unlocked – now available for $8.99!

Posted by on Oct 18, 2013 in Birth Control, Blog | 2 comments

Birth Control Unlocked – now available for $8.99!



Today is October 18! This is exactly 365 days from the day I first released PCOS Unlocked! It is also my own birthday – so I am swimming in celebration and contemplation and symbolism this week.

To that end, since I recently finished writing and uploading Birth Control Unlocked, I figured why not go ahead and release it on the birthday of PCOS Unlocked.  Now I get to have three birthdays this week, which might call for more tequila and dancing this weekend than I had initially prepared for.*

To that end, you can now purchase the ebook Birth Control Unlocked: Your Body, Your Options, Your Guide here on this website, @, which is one of the pages listed in the navigation bar “Birth Control.”  The sales page not a fancy sales page. It’s not designed to entice you. It just is. Birth Control Unlocked is a map to the world of birth control, and while charting all of the territory, I also highlight the best tools you can have on your journey (for example, liver health!) of choices, wellness, fertility, and kickass womanhood.

It’s only sale now for $8.99. That might change in the coming months – I have listed its value elsewhere on the web at $14, but for now I am going to sell it for $8.99.

Below is the table of contents, and below that I have attached the introduction to the book to give you a feel for how it reads.



table of contents






Welcome to birth control unlocked! My name is Stefani Ruper, and I am the author of PCOS Unlocked: The Manual as well as the forthcoming Sexy by Nature: The Whole Foods Solution to Radiant Health, Life-Long Sex Appeal and Soaring Confidence. I also write at, and I have been working in the field of women’s health for several years. Throughout those years, I have traversed the landscape of birth control options more times than I could count. I haven’t done any serious experimentation on a personal level.  Aside from a few brief forays into hormonal birth control for health reasons, I haven’t used anything other than prophylactics. I have made these choices entirely on the basis of my extraordinary depth of knowledge in the field, my allegiance to natural womanhood, and of course the particular needs of my own sexual activity (which is not, to be fair, all that great.)


If my need for serious birth control increased, I would probably re-consider my current path. But I would not share my decision with you in this format. Birth control is an entirely subjective matter and needs to be treated as such. Each of us has different psychological needs, different physiological needs, and different negotiations to make with her partner – as well as differing financial needs. I do not delve into the finances of different birth control options here, nor do I discuss any psychological factors that may go into decision making. This is a guide that focuses on the physiological implications of all of the different options available to you, so that in the context of the rest of your life (on which you are a much better resource than I), you are empowered to use the information as best you see fit.


While none of the birth control options I discuss here are 100 percent effective – none of them are – they are largely effective and supported by all the major health institutions. It is also important to note that the majority of the ineffective cases are due to human error, not to faulty product design. Faulty product design exists, again, of course, but it is far and away more important that you act realistically and choose a birth control method that fits with your psychological and logistical needs. If you can remember to take a pill every day at the same time, great. If you cannot, I highly recommend looking elsewhere to meet your birth control needs.


My knowledge of the depth and breadth of birth control practices comes from years of helping women try to optimize their health in the context of their birth control choices. To that end, I share with you a significant depth of knowledge regarding different birth control options, but perhaps more importantly, I share with you the best theories I know out there on why birth control has certain effects on women while on it and while coming off of it. Many women wrestle with significant side effects, the least of which being infertility, after coming off of the pill. Why does this happen? What organs in your body are affected by birth control? What can you do while on the pill to mitigate damage, and what can you do afterwards to regain your fertility and hormone balance as soon as possible?


I wish you all the best moving forward with this information. This guide is not meant to share everything about diet, everything about birth control, or everything about how you need to make this decision with you. It is, instead, just one tool in your pocket. It’s the one for knowing your body, knowing your options and the risks, and doing your best to be as healthy as possible no matter which option you choose.


Go to to purchase the guide for $8.99, or click the button below!


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*This is a rhetorical device. I almost never drink alcohol.

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On the fertility awareness method, getting intimate with your cervix, and how long a sperm can set up camp in your vagina

Posted by on Oct 22, 2012 in Birth Control, Blog | 29 comments

On the fertility awareness method, getting intimate with your cervix, and how long a sperm can set up camp in your vagina

Writing about birth control these past few months, I’ve covered a wide variety of options.  The thing is, however, that nearly every one of them interferes in the process of a woman’s natural hormone signalling.  Those that don’t, such as the copper IUD, still as yet pose serious health concerns.

Smaller side effects such as headaches, nausea, weight gain, acne, mood changes, and sleep disturbances are nothing to laugh at.  Scarier risks such as blood clots, heart palpitations, muscle weakness, and sudden death even less so.  Some hormonal options of birth control are rightfully scary in the eyes of women concerned with natural, healthful womanhood.

So a lot of women turn to the fertility awareness method.  FAM has a bit of a bad rep.  It’s regarded in many circles as inconsistent and unpredictable, and therefore subject to high failure rates.  In other circles, it’s disregarded as that silly thing overly religious people do.  Neither of these could be farther from the truth.  Yes, some people practice FAM for the sake of their religious beliefs.  And yes, some people mess up and get pregnant.  But when practiced properly, FAM has success rates that equal and even surpass some of the conventional birth control methods.  1 percent is about the going rate.

So what is fertility awareness, and how does it work?

FAM is the practice of avoiding unprotected intercourse during the period in which a woman can become pregnant.   For this reason, the whole trick of FAM is identifying physiological markers of ovulation.  Ovulation is the time in which a woman’s ovaries release an egg, and so it is around ovulation that women need to step carefully.

The first day of a menstrual cycle is the first day of bleeding, and ovulation generally occurs ~two weeks later.

There are many significantly advanced methods for detecting ovulation.   Hundreds of dollars can easily be spent on costly and precise methods such as analyzing saliva for ovulation-indicative molecules, or monitors that track changes in electrical resistance in vaginal fluid.   This makes sense.  Lots of people are trying very hard to conceive children.  Yet more natural, and mostly free, methods also exist, and are quite effective.

1)  OPK Urine tests

Luteneizing hormone spikes in the urine around ovulation, so increasing LH levels can predict fairly accurately when a woman is on the precipice of ovulation.  Most test strips predict the onset of ovulation within 12-36 hours.   If you are interested in FAM but are either not quite comfortable with touching your cervix or enjoy confirmation that comes from computers and scientific tests, this might be a good method to have in your arsenal.

2) Basal body temperature

One way to detect ovulation is to monitor basal body temperature levels.   Tempreatures rise with progesterone levels, and will spike about 24 hours after ovulation.  They should remain this high until your next period.

The way to do so is to check your temperature (in your mouth is fine– just always be consistent with where and how you do it) the moment you wake up.  Chart your temperature over time, and notice the spike that occurs just after the middle of your cycle.  It should be between .4 and 1.0 degrees F.   You won’t feel the shift, but you can detect it by using a basal body temperature (BBT) thermometer.  BBT thermometers are just more precise than others, but still they come as cheap as ten dollars.

You are most fertile in the two or three days before your temperature hits its high point. A few experts think you may have an additional 12- to 24-hour window of fertility after you first notice the temperature creep up, but most say that at that point, it’s too late to make a baby.  At the very least, however, it becomes statistically less likely.

For this reason, it is best to chart your temperature for a few cycles, and start counting ovulation as the two days or so previous to your spike.  You can also use other ovulation-detection methods to confirm.

3)  Cervical mucus release

The appearance of cervical mucus and vulvar sensation are generally described together as two ways of observing the same sign.  In a menstrual cycle, it’s appearance, or thickening, marks the start of ovulation.

The production of fertile cervical mucus is caused by estrogen, the hormone that also prepares a woman’s body for ovulation.  Cervical mucus is produced by the cervix, which connects the uterus to the vaginal canal. Fertile cervical mucus promotes sperm life by decreasing the acidity of the vagina, and also helps guide sperm through the cervix and into the uterus.

By observing her cervical mucus, and paying attention to the sensation as it passes the vulva– that is, as you can actually feel it coming out of your vagina, a woman can detect when her body is gearing up for ovulation, and also usually when ovulation has passed.  This is because when ovulation occurs, estrogen production drops slightly and progesterone starts to rise. The rise in progesterone causes a distinct change in the quantity and quality of mucus observed at the vulva.

For some women, cervical mucus persists throughout the following week and its hard to tell precisely the difference.  Regardless, the start of ovulation has now become quite clear.  Your most significant discharge is your ovulatory period, and the start of it is the start of ovulation, which lasts 12-36 hours.

Your libido may also spike at this time (!).

4) Cervical position

The cervix changes position in response to the same hormones that cause cervical mucus to be produced and to dry up–estrogen and progesterone.

When a woman is in an infertile phase of her cycle, such as the first two weeks, the cervix will be low in the vaginal canal; it will feel firm to the touch (like the tip of a person’s nose, says Wikipedia); and the opening in the cervix will be relatively small, or ‘closed’.  As a woman becomes more fertile, the cervix will rise higher in the vaginal canal; it will become softer to the touch; and the opening surface will become more open. After ovulation has occurred, the cervix will revert to its infertile position.

The only way to track this is to feel around and see what’s up for a whole month.  It may take longer.  But as estrogen levels rise and drop, the whole vaginal environment changes, and– really, I can’t describe it nearly as well as you can interpret it as you feel it yourself– you can really sense the difference in your cervix.  The trick is to find it, but basically you just press as far back and up into your vaginal canal as it goes until you feel a change in tissue.   If the cervix is too high up there when you try, check again in a few days– perhaps you were ovulating or your estrogen levels were spiking.  If you cannot reach your cervix, ever, then it’s entirely possible you just have a high cervix, and you’ll have to rely on the other three methods discussed here.

5)  Your sex drive may rise during ovulation.

This point is self-explanatory, I think.


These are the primary methods by which women detect ovulation in their cycles.   One by one, you may be worried that they are inaccurate or you are reading the signal improperly, but together, you have pretty powerful evidence that ovulation is occuring in your body.   And over time, as you become more and more used to this method, you become more and more familiar with the shape of these feelings and fluctuations, and become more and more intune with yourself and accurate with your predictions.

These are wonderful ways to avoid the problems of hormonal birth control.  This is why FAM is so widely practiced by naturalistic and paleo-oriented women.   When done correctly, it really does prevent pregnancy.  You cannot get pregnant unless a sperm has met the egg in the fallopian tubes.

But how long can a sperm survive inside the vagina?

So a woman can only conceive once her egg has dropped into her fallopian tubes, and met with sperm there– and the egg is only there for 12-36 hours, yet ovulation is not the only time of having sex that she can get pregnant.    This is because sperm usually die off between 1 and 2 days after release into the vagina, but they can actually survive up to 5 (or on the safe side, 7) days. (!)

Human sperm travels at the staggering rate of up to 4 millimeters per minute, but many are as slow as 1 millimeter per minute.  You have to put this into perspective; human sperm are only 55 millionths of a millimeter or 55 microns in length, so a millimeter is a pretty big deal to the mini-me’s.

The average length of the journey to the fallopian tubes is 175 millimeters, which means the Road Runners of the team can get there in 45 minutes, but in practice the journey takes anything up to 3 days if they can make it that long.

For this reason, marking back from ovulation, women need to stop having unprotected sex 7 days beforehand, then count two whole days for ovulation, and then give it as many as seven days afterwards.  If she feels a bit risky she can push it on the edges of fertilization, but most women do not.

In this period, some women abstain from sex.  Others use barrier type birth control such as condoms, diaphrams, or sponges.

Unfortunately this blocks out about half of the woman’s cycle.  It is, however, the only way to have unprotected sexwhile being certain to prevent pregnancy.

Your chances of getting pregnant

A perfectly fertile and healthy couple statistically has a 1 in 4 or 1 in 5 chance of conceiving with every given act of intercourse during a woman’s fertile period.  This means that the vast majority of these couples conceive within a year.

That’s actually a pretty high statistic, so many women are very serious about the boundaries of their fertility awareness practices.

STI’s, etc.

And as a final caveat– note that all birth control methods outside of the condom do not prevent STIs.  They only prevent pregnancy, so get tested!  Both of you.

And best of luck moving forward figuring this out.  It’s a lot of fun–and a lot of women really love–getting in touch with your body and your cycle.


What’s your experience?!  Your hopes?  Your doubts?  Your concerns?  Share away!  FAM is such a diverse and widely / differently practiced art.  I am super excited about hearing more about your personal experiences.



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The Birth Control Series V: The IUD

Posted by on Oct 1, 2012 in Birth Control, Blog | 49 comments

The Birth Control Series V: The IUD

Before jumping into the IUD, a couple of brief notes:

You may have noticed I have sort of dropped a bit off of the map in the last couple of weeks.  Nothing too drastic, just less rapid posting on less complex topics and a decreased social media presence.   But that’s all about to end, and very soon!  Thank goodness.  It’s because I’m almost done with my Big Project, and releasing it in less than three weeks!

PCOS Unlocked: The Manual is a package:

it includes a book with a capital B, a series of how-to and self-diagnosis guides, an audio, and a video, and an email consultation with me… all designed to help you not just understand PCOS in general, but to understand your own PCOS, and what precise steps to overcome it are particularly well-suited to your personal situation.  More about that and giveaways and sneak peaks throughout the next two weeks!  Huzzah.

Then I get to tackle menopause and pregnancy and calorie restriction and high intensity interval training and male libido.  All exciting topics I’ve been scheming on but unable to get around to.

Plus the birth control series is wrapping up!  Today, the copper IUD.   Remaining are sponges and diaphrams and female condoms, and the fertility awareness method.



IUD stands for intra-uterine device.  An IUD is a small, T-shaped bit of plastic that a trained doctor inserts into the uterus, and which can be inserted at any time a woman is not pregnant.  An IUD implant can run as high as 1000 dollars, but it can last up to 12 years.

As of 2002, says the WHO, the IUD was used by as many as 160 million women worldwide.

There are two types of IUDs, and their benefits and side effects vary widely: one is the copper IUD, and the other is a low-dose progesterone IUD.

The progesterone IUD (name brand Mirena)

The progesterone IUD is a small ‘T’-shaped piece of plastic, which contains a synthetic progesterone-variant, levonorgestrel.

The progesterone IUD is coated with a membrane that regulates the release of levonorgestrel. It releases levonorgestrel at an initial rate of 20 micrograms per day and declines to a rate of 14 micrograms after 5 years, which is still in the range of clinical effectiveness. In comparison: birth control pills can contain as many as 150 micrograms of levonorgestrel, all of which feed right into the bloodstream.

The progesterone IUD releases the levonorgestrel directly into the uterus. Most of the hormone stays inside the uterus, and only a small amount is absorbed into the rest of the body. This is unlike the NuvaRing, which is also a hormonal vaginal insert, but which deposits hormones into the bloodstream, and can therefore cause fluctuations in hormone levels all over the body.

The progesterone IUD is inserted by a medical professional in a brief procedure, after making sure the woman does not have sexually-transmitted infections.  If she does, the device can exacerbate the infection.

The progesterone IUD is perhaps the most effective of all forms of birth control, with early year failure rates of .2 percent, and later year failure rates of .7 percent.  This IUD can be used for up to 7 years.

The progesterone IUD works by inhibiting fertilization.  Cervical mucus thickens, sperm are killed, the endometrium is suppressed (since progesterone is antagonistic to endometrium growth), and ovulation is impeded.  Some women ovulate on the progesterone IUD, but many others stop ovulating while on it.  This entirely depends upon how sensitive they are to the progesterone input, and whether or not the low dose of progesterone contained in this IUD is enough to derail hormone signalling.

Because this IUD can derail hormone signalling, it also has the power to decrease menstrual flow, to decrease cramping, and even in some women to end menstruation altogether.   These are some lovely and tempting side benefits for many women.

On the other hand, the small hormonal disruption can be a nuisance to many women, too.  Side effects of the progesterone IUD include:

Irregular bleeding: This is common in the first 3-6 months of use, as the body adjusts to new hormone levels.  After 1 year, however, 20 percent of women stop menstruating, and most women resume normal, lighter menstrual periods.

Expulsion: Sometimes the IUD can slip out of the uterus.  In this case, it needs to be re-inserted.

Perforation: Sometimes the IUD can move into uterine walls, and in this case needs to be extracted via surgery.  This occurs in less than .1 percent of women.

Pregnancy: A super small risk, but nonetheless, ectopic pregnancy and miscarriage occurrences increase when pregnant on this IUD.

Infection: Infections are somewhat associated with starting the IUD, but this is largely due to co-occurrence with sexually-transmitted infections, and should not be a problem with sexually healthy women.

Ovarian cysts: Ovarian cysts have been diagnosed in about 12% of women using the progesterone IUD. Most of these follicles are asymptomatic and do not cause problems or harm, although some may be accompanied by pelvic pain. In most cases the enlarged follicles disappear spontaneously after two to three months of use, and surgical intervention is not usually required.

The copper IUD

The copper IUD is one of the only non-hormonal–and is the only long-term non-hormonal–birth control method available outside of fertility awareness.  It’s the same little T shape as the hormonal IUD, and made out of plastic, too, but with copper wires wired inside it.

The way the copper IUD works is by acting as a spermicide within the uterus.  This makes it’s failure rate quite low– varying between .1 and 2.2 percent, depending upon the brand used and the amount of copper contained in the particular IUD.  The efficacy of each copper IUD is based on how much copper is in it: the most efficient IUD has been shown to have at least  380 mm of copper wiring.

The copper IUD is effective immediately upon insertion–which means it can also be used as an emergency contraceptive–and fertility usually returns within three months of removal.   This is a much safer option for hormonal regularity and fertility than hormonal birth control methods such as the pill.

The presence of copper in the uterus increases the levels of copper ions, prostaglandins, and white blood cells within the uterine and tubal fluids.

Many women have adverse reactions to proposals to use the IUD because of a myth about the IUD: that it works by “irritating” the uterus so much that it cannot get pregnant.  This is not really true.  The copper acts as a spermicide–actively killing sperm–and this is the reason it prevents women from getting pregnant.

The increase in prostaglandins, however, can in fact lead to increased inflammation during the menstrual cycle.   The menstrual cycle already contains bouts of prostaglandin secretion– as the endometrium is shed and surrounding muscles contract– though in a woman sensitive to increased inflammation, an IUD can make cramping and blood flow worse.

It has also been shown that the copper IUD increases blood flow and cramping significantly in the initial months: in the first 3-6 months, blood flow increases on average between 25 and 50 percent.  For many women this drops off after several months, and they enjoy many peaceful years of safe sex.  For others, it does not.  Discomfort is the number one reason for removal of the copper IUD–and again, this is largely because of the copper ions and prostaglandins.

Other side effects of the copper IUD include:

Expulsion: sometimes the copper IUD can be spontaneously expelled from the uterus.   Explusion rates can range from 2.2% to 11.4% of users from the first year to the 10th year, and this varies by the brand.  Unusual vaginal discharge, cramping or pain, spotting between periods, spotting after sex, or the absence or lengthening of the strings (there to assure a woman the IUD is still in place) can be signs of a possible expulsion.

Perforation: Very rarely, the IUD can move through the wall of the uterus. In this case, surgery must be performed in order to remove it, just like with the progesterone IUD.

Infection: The insertion of a copper IUD poses a transient risk of pelvic inflammatory disease (thanks to the copper ions and prostaglandins) after being inserted, though, also like the progesterone IUD, this is usually because of sexually transmitted infections, and not the IUD itself.

Irregular Bleeding and Spotting: For the first 3 to 6 months after insertion for most women, and for a small percentage far longer, the copper IUD can cause irregular periods and spotting between periods.

String problems: A small portion of men report that they can feel the strings during intercourse. In this case, strings can be trimmed.

Pregnancy: Although rare, if pregnancy does occur with the copper IUD in place there can be serious side effects.  Risks of ectopic pregnancy and miscarriage increase.   In this case, the IUD should be removed immediately.

Copper toxicity: One aspect of the copper IUD not often discussed in the medical community is copper toxicity.  If a body receives more copper in it than it can handle– and this is particularly the case if zinc is not supplemented or consumed in high quantities while using the IUD– a woman can experience crippling side effects.   Amalia, one of our community members, has written to me and kindly acquiesced to share her story with us.  My hope in sharing this with you is to a) empower you to take your health into your own hands and b) demonstrate to you the symptoms and pathology of copper toxicity, in the case that you may be experiencing something similar.

Amalia’s experience with a copper IUD

Before my health problems began around my 24th birthday, I was the that annoying person who could eat whatever I wanted and never gain weight. I never thought about dieting, was happy with my body, and simply ate when I was hungry. I was always naturally very thin (5’8″ and about 115-120lbs). I’ll also note that I was raised in a very health-conscious, vegan household, but could eat whatever I wanted (i.e. ramen, doritos, bagels, and cookie dough straight from the tube) once I left for boarding school at 13. During college and in the years after, my diet improved but wasn’t great (salads, rice, pasta, Chinese, Mexican, Japanese take out, and sweets).

All of my symptoms began rather suddenly after a period of intense emotional stress. I put on 10 pounds in just one month, which turned into 30 pounds at my heaviest. I’ll be the first to admit that I wasn’t fat, but I looked puffy and unhealthy. I stopped getting my period but had constant PMS symptoms (extreme bloating, cramps, skin breakouts, irritability) and my gynecologist told me that everything was normal and not to worry. After being on various birth control pills for 8 years, I had gotten a copper IUD about a year before all of these symptoms began. I had chosen the Paragard because I wanted a hormone-free birth control option. My gynecologist assured me that the IUD could not be responsible for my problems because it doesn’t contain hormones. In addition to the PMS symptoms, I was experiencing depression (for the first time in my life), anxiety, extreme fatigue, insomnia, some mild hair loss, and intense and uncontrollable sugar cravings. My eating quickly became disordered, as I binged on anything sweet and tried to hide it from the people around me. It felt like I was in a downward spiral and couldn’t get out. I went to many doctors – western, eastern, natropathic, etc. – and no one could tell me what was wrong with me. Acupuncture and Chinese herbs helped a little but weren’t getting to the root problem. I was miserable and my declining health was all I could think about. Finally, in May 2010 one year after this all started, I saw another gynecologist who told me that the copper IUD could possibly be at fault. I researched more online and stumbled upon a forum of thousands and thousands of women all around the world who were all suffering from the same symptoms as I, all with the copper IUD. I finally felt like I had found the answer and immediately got my IUD removed. Within a couple of months, my periods were back to normal and I was starting to feel a little better. However, a few months later I was still suffering from the majority of symptoms and sent a hair sample to a natropathic doctor who focuses on copper toxicity. He put me a on a diet (80% cooked veggies, 20% animal fats and proteins), gave me a slew of supplements to support adrenal fatigue, liver detox, and sluggish thyroid, and insisted on lifestyle changes to limit stress and focus on sleep. After a year, I felt better but my progress was very slow, especially since I still struggled with sugar addiction – even if my binges were gluten and “sugar” free.

In May of this year, I decided to take my health into my own hands and approach my sugar addiction in a new way. I researched ways to get off sugar, which led me to Dr. Lustig, which led me to the Paleo/Weston A Price world. I’ve been listening to all of the major paleo/real food podcasts I can find and learning so much. I’ve been playing around with my diet within this framework to find what’s right for me and, along with finally being able to do away with the sweets, I’m starting to really feel like myself again. I have much more energy, better body composition, have the energy to work out, and have been sleeping better. I started drinking bone broth, taking the Green Pastures FCL/BO, and got an Earthing sheet for my bed, all three of which I believe have been immensely helpful. I have also been focusing on the emotional aspects and seeing a therapist has been an important component of my recovery. I still struggle with overeating, gut issues, and my periods have stopped in the last few months (corresponding precisely with when I started to feel much better), but I am continuing to make progress.

I hope that my story can alert women to the possible dangers of copper overload from the copper IUD, which for me started a chain reaction of health problems. I realize that it does not affect everyone in the same way, but I want women to be aware of the side effects, many of which are not recognized by the medical community.

Amalia’s Resources her book, Why Am I Always So Tired? (she points out copper IUD link) (this is the natropath I worked with. he mentions copper IUD as well) I found of women with same copper overload symptoms from copper IUD)


What’s your story?  History, concerns, ideas about the IUD?


More on the birth control series:

Part I: Birth control pills: How they work, benefits, and risks

Part II: The Drosiprenone Pill Warning

Part III: Which Birth Control Pills are Which?

Part IV: The Implant and NuvaRing


The PfW donation drive is marches on!  Our community needs support to keep running, and this website thrives off of your support and love.  Whatever you might want to donate– 1, 2, 3, 6,000,000 dollars–would be a huge help to all of us.

Thank you so much for your love.

Choose an amount and follow the button through to paypal below to support us.


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The Birth Control Series IV: The Implant, The Patch, and The NuvaRing

Posted by on Sep 19, 2012 in Birth Control, Blog | 13 comments

The Birth Control Series IV: The Implant, The Patch, and The NuvaRing

The implant, the patch, and the NuvaRing are all hormonal birth control methods.   One is a thin rod implanted into the arm by a medical professional, another is a patch attached to the skin, and the final is a flexible plastic ring inserted into the vagina.  Each of them gets hormones into bloodstream.  The only real difference between these methods and birth control pills is the method of ingestion.  They are marketed as hassle-free birth control methods, and that’s true, more or less.   They require less mindfulness than birth control pills do.  Whether or not that’s something you desire is completely up to you.

Each of the methods varies slightly by use by and by hormonal content.  There are also some specific health concerns related to each method, so they are worth noting.

The Implant

The implant, under the two brand names Implanon and Nexplanon, is a small rod inserted under a woman’s arm.
The implant is made of medical plastic that is sterile and soft. This contraceptive rod is 40mm (1.5 inches) long and 2mm (0.08 inches) in diameter. The implant, once inserted, is effective for a maximum of three years.   The implant is the only of these three methods to be a progesterone-only method.

Once the birth control implant is inserted, it begins releasing small doses of the synthetic progesterone etonogestrel. Implanon contains 68 milligrams of etonogestrel, and it is released slowly and steadily over the course of the three year period.

Since the implant is a continual dosage of a progestin, the implant does not include a regular cycle the way most other birth control methods do.  For the majority of women on the implant, their periods become light but unpredictable.  For 30 percent of women, menstruation stops completely within one year of use.  For this reason, the implant might be a convenient and relatively risk free option.  I call it “relatively” risk free because it is estrogen-free.  It is usually estrogen-based pills–such as the methods below–that have the potential for scary side effects such as thrombosis and heart attacks.

The patch

The patch in the form of Ortho Evra was first released in 2002.   Because of it’s supreme convenience and relatively low cost, it became a best-seller in two short years, selling nearly 400 million dollars worth.

However, Ortho Evra is a progesterone-estrogen combination pill, and it turns out that the patch generated much higher levels of estrogen in the blood of users than pharmaceutical companies had anticipated.  This results in a greater risk of blood clots– and shortly thereafter lawsuits began piling up.   In 2005, Ortho Evra, under an agreement with the FDA, added a black-box warning to its packages stating that patch users are exposed to roughly 60 percent more estrogen than the typical pill user, resulting in a potential “approximate doubling of risk of serious blood clots.

That risk remains fairly low, and there are warning signs that can be heeded in order to save women at risk:

  • a new lump in the breast
  • a sudden very bad headache
  • achy soreness in the leg
  • aura — seeing bright, flashing zigzag lines, usually before a very bad headache
  • bad pain in the abdomen or chest
  • headaches that are different, worse, or happen more often than usual
  • no period after having a period every month
  • trouble breathing
  • yellowing of the skin or eyes
It is also of course known that women with health problems, even ones as common as diabetes or pre-diabetes, should step cautiously around high doses of estrogen.  Risks are low, but the costs are high.
Using the patch

The patch is another birth control method that works in cycles.  The pattern is three weeks on, with one patch applied each week, and then one week off.  The “off” week is when menstruation occurs.

The patch is applied to a woman’s upper outer arm, buttocks, abdomen or thigh on either the first day of her menstrual cycle or on the first Sunday following that day, or for an amenorrheic woman on any random day, whichever is most appropriate for this woman. The day of application is known by the companies from that point on as patch change day. Seven days later, when patch change day comes again, the woman removes the patch and applies another to one of the approved locations on the body. This process is repeated again two more times.  And then one whole 7 day period is taken off for menstruation, starting the whole cycle again on the following patch change day.

Continual use of the patch has been studied, but is not recommended considering the relatively higher estrogen dose of the patch.

All that being said– while higher estrogen levels are associated with risk of cardiovascular problems, women who suffer from low estrogen levels may benefit greatly from estrogen input.  The appropriate amount of estrogen varies by the individual, so it is worth discussing these issues with your doctor if you are interested in how much estrogen you should be (daring to) take.

The NuvaRing

The NuvaRing is a flexible, plastic ring inserted into the vagina one each month.  It is inserted by the individual at the start of the menstrual cycle and left for three weeks, and then removed for one week while a withdrawal bleed occurs.  A new ring is then inserted for the following month.

Back-to-back use of the NuvaRing–that is, without a withdrawal bleed–have been studied.  They do not seem to be alarming, though have not been officially approved by any government agencies.   This is presumably because the estrogen levels from the NuvaRing are low enough to tolerate consistent dosages.

The NuvaRing emerged on the market after the birth control patch, and was instantly popular because it offered an easy contraception method without as much risk of blood clots as the patch.   People still leapt up in arms over the NuvaRing, claiming that it had increased side effects, but several statistical analyses have shown that it carries the same risk as other birth control options.

The NuvaRing is also a combination pill, and delivers 120 µg of etonogestrel, a synthetic progesterone, and 15 µg of ethinyl estradiol, a synthetic estrogen, each day of use.

This is less estrogen than both the patch and other combination pills, which makes the NuvaRing desirable with women who have predispositions to estrogen dominance or who have a history of problems with breast tenderness, PMS, nausea, or cramping.   The NuvaRing also has a lower incidence of breakthrough bleeding, despite how low it’s estrogen dosage is.

Many women believe that the NuvaRing is a more gentle form of birth control than others–that it won’t cause hormonal disturbances–because it sits in the vagina, and therefore acts locally, rather than universally in the body.  This supposedly mitigates the side effects.  But I have yet to be able to find any evidence that this is the case.   So far as I can tell, the reason the NuvaRing may have fewer side effects than other methods is simply because it releases a lower dosage of hormones.

All that being said, some researchers argue that third- and fourth-generation contraceptives — including those that contain desogestrel like the NuvaRing — raise the risk of blood clots without adding any benefit.   Third and fourth generation contraceptives contain synthetic estrogens, which may or may not be more problematic than original formulations and bio-identical forms.  No significant statistical evidence, so far as I can tell, exists to support these claims.


So those are alternative methods of taking hormonal birth control!   The implant contains progesterone only, and reduces menstruation, the patch contains higher levels of estrogen, and the NuvaRing is a late-generation combination pill with as low a dose of hormones in it as possible.   The side effects and risks of each of these methods is approximately the same as oral birth control pills — except perhaps in the case of the patch, and also in the case of late-generation estrogen consumption.

Coming up are IUDs, sponges and condoms, and fertility awareness!   And menopause!


Also see:

Part I: Birth control pills: How they work, benefits, and risks

Part II: The Drosiprenone Pill Warning

Part III: Which Birth Control Pills are Which?


The PfW donation drive is marches on!  Our community needs support to keep running, and this website thrives off of your support and love.  Whatever you might want to donate– 1, 2, 3, 6,000,000 dollars–would be a huge help to all of us.

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The Birth Control Series Part III: Which Birth Control Pills are Which?

Posted by on Sep 5, 2012 in Birth Control, Blog | 5 comments

The Birth Control Series Part III: Which Birth Control Pills are Which?

There are nearly 60 varieties of birth control pills.  They are, as I mentioned in the first post of the series, grouped by whether they are progesterone-only or progesterone-estrogen combination pills, by which kinds and amounts of progesterone and estrogen they use, by being mono, di, tri, or quadri phasic, by lasting one month before a withdrawal bleed, or by lasting three months before a withdrawal bleed. Below is a table I use for reference that details the phase and drug type of each type of birth control.



Alesse-28 ethinyl estradiol levonorgestrel
Apri ethinyl estradiol desogestrel
Aviane ethinyl estradiol levonorgestrel
Brevicon ethinyl estradiol norethindrone
Demulen 1/35-21 Demulen 1/35-28 Demulen 1/50-21 Demulen 1/50-28 ethinyl estradiol ethynodiol diacetate
Desogen ethinyl estradiol desogestrel
Genora 1/35 ethinyl estradiol norethindrone
Genora 1/50 mestranol norethindrone
Levlite 28 ethinyl estradiol levonorgestrel
Levlen 21 Levlen 28 ethinyl estradiol levonorgestrel
Levora 0.15/30-21 Levora 0.15/30-28 ethinyl estradiol levonorgestrel
Loestrin 21 1/20 Loestrin 21 1.5/30 Loestrin FE 1/20 Loestrin FE 1.5/30 ethinyl estradiol norethindrone acetate
Lo-Ovral 28 Ovral 28 ethinyl estradiol norgestrel
Low-Ogestrel 28 Ogestrel 0.5/50-28 ethinyl estradiol norgestrel
Microgestin 1/20 Microgestin 1.5/30 Microgestin FE 1/20 Microgestin FE 1/5/30 ethinyl estradiol norethindrone acetate
Modicon ethinyl estradiol norethindrone
Necon 0.5/35-21 Necon 0.5/35-28 Necon 1/50-21 Necon 1/50-28 Necon 1/35-21 Necon 1/35-28 ethinyl estradiol norethindrone
Nordette 28 ethinyl estradiol levonorgestrel
Norinyl 1/50 mestranol norethindrone
Norinyl 1/35 ethinyl estradiol norethindrone
Nortrel 0.5/35 Nortrel 1/35 ethinyl estradiol norethindrone
Ortho-Cept ethinyl estradiol desogestrel
Ortho-Novum 1/35 ethinyl estradiol norethindrone
Ortho-Novum 1/50 mestranol norethindrone
Ortho-Cyclen ethinyl estradiol norgestimate
Ovcon 50 Ovcon 35 ethinyl estradiol norethindrone
Tri-Norinyl 28 ethinyl estradiol norethindrone
Yasmin 28 ethinyl estradiol drospirenone
Zovia 1/50E Zovia 1/35E ethinyl estradiol ethynodiol diacetate
Jenest 28 ethinyl estradiol norethindrone
Mircette ethinyl estradiol desogestrel
Necon 10/11-21 Necon 10/11-28 ethinyl estradiol norethindrone
Ortho-Novum 10/11 ethinyl estradiol norethindrone
Estrostep 21 Estrostep FE ethinyl estradiol norethindrone
Ortho-Novum 7/7/7 ethinyl estradiol norethindrone
Ortho Tri-Cyclen Ortho Tri-Cyclen LO ethinyl estradiol norgestimate
Tri-Levlen 21 Tri-Levlen 28 ethinyl estradiol levonorgestrel
Tri-Norinyl 28 ethinyl estradiol norethindrone
Triphasil 28 ethinyl estradiol levonorgestrel
Trivora 28 ethinyl estradiol levonorgestrel
24-4 PREPARATIONS (24 days of hormone pills and 4 days of placebo pills)
Yaz ethinyl estradiol drospirenone
Lo Estrin 24-4 ethinyl estradiol norethindrone acetate
Seasonale ethinyl estradiol levonorgestrel
Seasonique ethinyl estradiol levonorgestrel
Micronor norethindrone
Nor-QD norethindrone
Ovrette norgestrel

Table from Medicine Net.

For more on the birth control series, see:

Part I: Birth control pills: How they work, benefits, and risks

Part II: The Drosiprenone Pill Warning


And finally, we are in the midst of a support drive.  The Paleo for Women community costs a fair bit of money to run, and we can use all of the help we can get.   Any amount of money you’d like to donate would be a huge boost and enormously appreciated. !

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The Birth Control Series II: The Drosiprenone Pill Warning

Posted by on Sep 3, 2012 in Birth Control, Blog | 0 comments

The Birth Control Series II: The Drosiprenone Pill Warning

Yaz and Yazmin (as well as Gianvi, Ocella, Syeda,Zarah, Beyaz, and Safyral) are popular birth control choices for women who have PCOS or other hyper-androgen disorders.

This is because the progesterone that comes in these pills is Drosiprenone.  Drosiprenone acts much in the same was the drug spironolactone does in the body, which is to say, as a testosterone blocker.  This is why women with PCOS and/or hormonal dysregulation love this pill.  However: blocking testosterone is not the primary intention of these pills.  They are, first and foremost,  potassium sparing diuretics.

The drug Spironolactone is ordinarily proscribed to lower blood pressure while simultaneously preserving potassium levels.  This is good for people with kidney disease.  It also has, however, as I just mentioned, the “added benefit” of interfering with adolsterone production.  This, in turn, appears to have an anti-androgen, specifically an anti-testosterone effect.  For this reason, Spironolatone and Drosiprenone decrease and in many cases completely eliminate problems with acne, male-pattern hair growth, and male-pattern hair loss.

Drosiprenone has the same testosterone-fighting and potassium-sparing effects.

Women on these drugs must get their potassium levels regularly checked, and must make sure that they are not dehydrated while on these drugs.   And when they do, they are normally quite fine.

The level of Drosiprenone in the pill is less than women normally take when on Spironolactone, but that does not change the importance of this warning.

A build-up of potassium in the blood can lead to sudden death.  I am not joking.  Early warning signs include muscle weakness, shortness of breath, and heart palpitations. 

Dehydration can lead to a wide variety of medical problems, including

  • Dry, sticky mouth
  • Dry skin
  • Headache
  • Constipation
  • Dizziness or lightheadedness
  • Low blood pressure
  • Rapid heartbeat
  • Rapid breathing
  • Insomnia
  • Anxiety
  • Fever
  • In the most serious cases, delirium or unconsciousness

I took Spironolactone for five months and experienced anxiety, heart palpitations, and insomnia due to combined potassium-imbalance and dehydration, not just while on the drug, but for several months afterwards.  Unfortunately, I did not know it at the time, so I did not know how to fix it.  It continued to worsen until I checked myself into the ER with severe heart palpitations.   I share this information with you NOT to scare you off of these drugs–millions of women use them every year to happy effect–but rather to share with you the reality of the situation, and to let you know that if you experience any changes or negative side effects once going on one of these pills, this may be why, and a reason for you to consider other options more appropriate to your personal biochemistry.

Potassium rich foods include avocado (the richest), banana, potato, sweet potato, tomatoes, all leafy greens, and salmon.  Most other vegetables and fruits are rich in potassium relative to the rest of foods.    It might be best to avoid these foods while on drosiprenone-containing birth control pills.



Birth Control Series I: Birth Control Pills, How they Work, Benefits, and risks

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Birth Control Pills: How They Work, Benefits, and Risks

Posted by on Aug 29, 2012 in Birth Control, Blog | 50 comments

Birth Control Pills: How They Work, Benefits, and Risks

Today we are going to kick off the Kick Ass Birth Control series by talking about America’s most popular method: the pill.

The thing is, the pill is so complicated and comes in so many different forms, it’ll have to be broken down.

This post focuses on how the pill works, and what this might mean for health and fertility.  The next installment will cover all the various types of pills, explaining and weighing pros and cons of each.

And briefly, beforehand, the world’s quickest announcement: the T shirt contest has been closed!  We got dozens of awesome designs.  Beautiful, fierce, simple, explicit, exquisite… so thank you, thank you so much, all of you, for caring about and loving this community. So I am sitting on some ideas and going through sketches with my artistic pals.  The T shirts and the giveaways will be revealed as soon as we have that done, definitely within the month.  !


The normal menstrual cycle and getting pregnant

In order to understand how birth control pills work, it is crucial to first understand the menstrual cycle.

In super brief:

The menstrual cycle is a complex interplay between hormones secreted from the pituitary gland, and the hormonal responses of the reproductive organs over the course of approximately one month.

In moderately brief:

 In a normal menstrual cycle, FSH is secreted by the pituitary gland, which stimulates follicular development, then the ovaries respond with rising estrogen levels.  These estrogens then trigger an FSH decrease and an luteinizing hormone (LH) spike, which induces ovulation, and then progesterone levels rise.  Progesterone peaks and then falls, and the falling of progesterone triggers the shedding of the endometrium in blood flow during what we commonly call week 1.  Then the cycle begins anew.

In details: 

The first day of a menstrual cycle is the first day of bleeding.  During this period, the lining of the uterus is shed.  This bleeding constitutes the first 3-8 days of the first half of the menstrual cycle, which lasts about two weeks and is called the follicular phase.

During the follicular phase, levels of estrogen rise and make the lining of the uterus grow and thicken. Detecting elevated estrogen levels, the pituitary gland increases its production of follicle-stimulating hormone throughout the follicular phase.  This hormone stimulates the growth of 3 to 30 follicles.  Each follicle contains an egg.  With time, the levels of FSH decrease, so only one of the follicles continues to grow.  It produces estrogen, and other stimulated follicles break down.

Detecting this shift, the pituitary now releases luteinizing hormone.  This makes the follicle bulge and rupture, releasing its egg.  This is ovulation.  During ovulation, testosterone, which is otherwise constantly produced at low levels by the ovaries, surges, and estrogen drops.

After ovulation comes the luteal phase.  Here the ruptured follicle closes and forms the corpus luteum.  This thickens the endometriums, which in turn produces progesterone.  But if the egg is not fertilized within about two weeks, progesterone levels fall, which triggers shedding and bleeding.  Here the cycle begins again.  Cycles are generally “known” to be 28 days long, but the length of a regular, healthy cycle can vary from ~20 to ~35 days.

How a woman gets pregnant

A woman gets pregnant when a sperm is implanted in the egg in the dates immediately preceding, during and following ovulation (as much as a few days earlier if the sperm hang around long enough, and 1-2 days later, when the egg dies).   When this is the case, progesterone levels never fall.  Because progesterone levels never fall, menstruation never occurs.  This is why missing periods or “being late” is often the first sign a woman guesses she may be pregnant.


What birth control pills are

Birth control pills are streams of hormone supply.

They come in either a) progesterone-only forms, or in b) progesterone-estrogen combination pills.

They can be monophasic, diphasic, triphasic, or now quadriphasic, meaning that there can be a) a steady stream of a low dose, or b) a fluctuating amount of hormones.  This fluctuating, cyclical type of pill is thought to approximate a more natural cycle.

Usually birth control pills are taken in monthly cycle, and they deliberately induce menstruation, though now some formulations last for up to three months.

When to take the pill 

A woman takes a pill every single day for a given period of time, and usually at the exact same time.  This is important, because the level of hormones in the blood must be sufficient at all times in order to prevent a cascade of hormones further down the line.

Think of it like this: if you are late in taking your progesterone pill, your pituitary gland might get excited and send an LH signal.  You might later get the progesterone into your system, say 6 or 12 hours late, but by that time the LH has already been released, and ovulation has already occurred.  It is supremely important to take the pills on time.

How it works

Progesterone-only pills were the first pills ever designed.  The idea is simple, and the effect, profound.

Progesterone in the system– as we saw in the review of the normal menstrual cycle– prevents the release of FSH and LH in the brain.   In sum, that means that when a woman takes a daily progesterone pill, FSH and LH do not get secreted.  FSH and LH are responsible for ovulation taking place, so without them, the woman does not ovulate.

In greater detail, that means: in step 1) Progesterone inhibits FSH production.  Step 2) Low FSH levels prevent estrogen levels from rising, and prevent development of the endometrium.  3) Estrogen maintains a baseline low, and that fact, coupled with the high levels of progesterone, prevent LH from being triggered.  And finally, in 4) because there is no LH, no ovulation takes place. Because there is no ovulation, the woman does not get pregnant.

Combined oral contraceptives

Recently after the progesterone pill was developed, estrogen was added to several formulations to create the combined oral contraceptive. The reason estrogen was tacked on (a decade or so after the original development of the pill) was because doctors thought it would stabilize the endometrium and sort of prevent breakthrough bleeding.  Which it did.  What doctors found, however, was that the estrogen also helped prevent ovulation.  This is important to take note of for women who suffer from estrogen dominance and are trying to conceive.

The effect of adding estrogen to pills, then, is to prevent breakthrough bleeding.  It can also be helpful for women who struggle with low estrogen levels (often from low body fat or stress) or from high testosterone levels.  This is because estrogen helps balance testosterone in the bloodstream.  Women with PCOS, for this reason, are proscribed estrogen-containing pills much of the time if they are trying to manage their testosterone-dominant symptoms.

Other ways pills work

Birth control pills also have physiological effects that prevent pregnancy.  Progesterone decreases the amount of and increases the viscocity (thickness) of cervical mucus.  This makes it near impossible for sperm to penetrate through the cervix.

The timing of the pill

Most pills are designed to mimick as much as possible the natural menstrual cycle.    The reason for this is not quite clear, and leans heavily on the psychological.  When they were designing the pill several decades ago, doctors seemed to think women needed to menstruate regularly in order to feel normal or comfortable in their own skin.  That has changed in recent years, though that bias remains somewhat strong.

This fact means that the most common pattern is for progesterone to be taken for 21 days, and then either a placebo or no pill for the next 7 days.  By day 21 of the cycle, ovulation has already been inhibited long past.  This means that progesterone can be dropped of by day 21 with no worry of ovulation taking place, while simultaneously being enough of a drop to induce menstruation.

Another model is to change the 21-7 day cycle to 24-4 days, which can shorten and lighten the periods.

It is also physiologically somewhat important to have a withdrawal bleed, since it is possible that the endometrium will build up too thick without menstruation, which can lead to certain physiological complications such as cancer.  However, those occur on long time scales, and this effect varies widely depending on how much estrogen is in a woman’s system and how much her endometrium grows over time.

However, in general, the pill decreases endometrial thickening, so this is in fact a benefit of the pill–reducing the risk for this type and source of cancer– rather than a negative.

So is it necessary to have a withdrawal bleed every month?

No, in fact, it isn’t.

Some pills extend the cycle to three months long

Though the thing is, we can hardly call a three month long stasis a “cycle.”  It isn’t.  What happens in three-month long pills such as Seasonale is that progesterone continually inhibits LH and FSH without end.  No menstruation or cyclic pattern occurs.

Finally after three months– a somewhat arbitrary number decided on by pill manufacturers and the medical community, a withdraw bleed is induced by taking a few placebo pills. In theory, you could just keep taking progesterone and not menstruate for as long as you desired. But again, because it is nice to “reset” and also to clear up the endometrium, especially if on a pill that contains estrogen, withdrawal bleeds should happen occasionally.

Positive effects of the pill?

Reduction in cancer risk of female-specific cancers–endometrial, ovarian, and colorectal.

If this is true, it is probably in my personal opinion because of the dampening effect progesterone has on estrogen, which itself plays a role in feeding tumors.  However, other studies demonstrate increased breast cancer risk with pill consumption.

Increased vaginal lubrication?

Alleviation of PMS

Decreased Acne

Negative effects of the pill?

Increase in cancer risk (not yet known)

Weight gain

Decreased libido

Decreased vaginal lubrication



Psychological disturbances such as anxiety, insomnia, or rage


Pill acclimatization and amenorrhea

Another affect of going on the pill is that the body might become overly-dependent upon it. Hormones run off of negative feedback loops.  What this means is that detecting certain levels of a given hormone in the blood tells the appropriate glands to stop producing that hormone.  This makes sense, right, in light of the fact that the body wants to maintain proper hormonal balance.

This has negative implications for women who supplement with estrogen or progesterone (ie, take the pill) during their reproductive years, however.  Because the hormones are being eaten or injected into the bloodstream, the body often stops making them. And then after the pill, the body still does not make them. Some women might go several months or up to a year before they begin ovulating and menstruating again.

This is of course not usually the case.  Most women are just fine off of the pill.  Just as with the side effects.  60 percent of women report not having any side effects on the pill.  Most of the rest have some side effects, but bear with them. Others find that the side effects are unbearable, and choose other fertility methods.

Why the pill has both positive and negative effects

Each woman’s body is different.  This means that adding estrogen to the bloodstream might help her symptoms, but in other cases adding estrogen to the bloodstream could do a lot of harm.  The same of course goes for progesterone.  Adding these hormones to the bloodstream has the potential to either increase or decrease the levels above what is natural for a woman– and in fact it is almost certain that they will be differently balanced.

Upsetting the natural balance between estrogen and progesterone, as well as between those hormones and the rest of the sex hormones, particularly testosterone, can have serious effects on a woman.  Estrogen and testosterone need to be specifically and well balanced in order for a woman to have a properly functioning sex drive.  Estrogen and progesterone need to be well-balanced for clear skin.  And so on and so forth.  The list is long.

It is worth noting, moreover, that estrogen and progesterone act as “antagonists” to one another, meaning that progesterone has the power to reduce estrogen’s effects, and vice versa.  This is partly why combination pills are desirable for many women, though it is also why estrogen-dominant women might choose a progesterone-only pill.

That being said…

The pill is complicated!  In my personal experience, it’s just not worth it.  But the negative health effects of the pill are all specific to the individual.  As are the positive effects.  And long term health impacts are not well-understood.  For that reason, it is entirely specific to your body and your needs whether or not getting on a hormonal regimen is “worth it” for you.

As a final note…

As a result of the pill, women are excreting more hormones than usual, which are making their way into the water supply.  This has significantly disrupted the reproductive cycles of some fish.  It is also questionable how much these products make it into the water supply.  Most studies seem to show that small percentages of it do (between ten and twenty percent), but that water treatment plants are mostly effective at filtering them out.


What I listed above are well-known and popular effects of the pill.  What was your experience?  Did you have any side effects?  Any unusual side effects?  Let us know!  The Pill can do a whole lot more than it is commonly accounted for.

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