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Polycystic ovary syndrome—aka PCOS— is the most common endocrine disorder, but we still don't fully understand why it happens. It predominantly affects women of reproductive age, and it manifests in the form of chronic inflammation, irregular menstrual cycles, weight issues, fertility problems, acne, and excess facial and body hair.
Ob-gyn Felice Gersh, founder/director of the Integrative Medical Practice of Irvine and author of PCOS SOS! A Gynecologist's Lifeline to Naturally Restore Your Rhythms, Hormones and Happiness, says that PCOS is a normal variation of women that's been exacerbated by the endocrine disruptors we're exposed to on a daily basis. Back in ancient times, she says, slightly elevated levels of testosterone would have been a survival mechanism. But now, women who have this underlying tendency find that it manifests in much more severe ways because of our environment.
Meet the Expert
Felice Gersh, M.D, is a board-certified OB/GYN and Integrative Medicine practitioner in Irvine, CA. Since founding the Integrative Medical Group of Irvine, Gersh has won countless accolades including the Orange County Medical Association’s Physician of Excellence Award.
That's what makes choosing a birth control when you have PCOS so complicated. You're dealing with a hormonal system that is irregular. While there's no one-size-fits-all approach to the best birth control for PCOS, some methods are better than others. Keep scrolling to arm yourself with knowledge of how hormones play a role with PCOS, as well as how the most common contraceptives interact with the disorder.
Hormones and PCOS
First, it's important to understand the role of hormones in women with PCOS. "Estrogen is the master hormone that regulates all the female body," Gersh says, adding that contrary to popular belief, women with PCOS actually have a reduced amount of estrogen—not an elevated amount. And, when their body tries to create more estrogen, it ends up making more of the hormone LH, which stimulates testosterone production. In essence, the balance of hormones is off.
Another thing that contributes to increased levels of testosterone is inflammation. Gersh says studies have shown that women with PCOS have an impaired gut barrier function, which messes with everything from the immune system to inflammation levels, and drives metabolic dysfunction and high levels of insulin. These elevated insulin levels drive testosterone production and can also lead to weight gain.
Birth Control Pills
If you have PCOS and you want to go on birth control to either treat your symptoms or prevent pregnancy—or both!—choosing your method can be tricky. Gersh says you might want to stay far away from birth control pills. "The common remedy is birth control pills. That's a very poor choice," she explains. Since women with PCOS don't have proper estrogen, she explains that they're more prone to blood clots. One of the risks of some birth control pills is also blood clots, and combining the two is a "recipe for potential disaster," according to Gersh. She also notes that women with PCOS have higher rates of anxiety and depression—two other risk factors of the pill.
However, there’s a caveat. According to the Open Access Journal of Contraception, combined hormonal contraceptives can offer a silver lining for people with PCOS. CHCs combine estrogen and progestin which help to reduce testosterone levels, create lighter periods, decrease cramping, and even improve skin clarity. What’s more, they’re proven to reduce hyperandrogenism symptoms (like excess face and body hair), as well as the risk of endometrial cancer. It’s worth noting, however, that with these positive benefits also comes the chance of metabolic shifts which can lead to weight gain or loss, mood swings, nausea, and occasional spotting.
If, for some reason, your doctor says you’re unable to take CHCs, there’s still light at the end of the tunnel. Progestin-only pills, while lacking estrogen, are able to increase progesterone levels and effectively regulate periods and prevent against endometrial cancer. Check with your ob-gyn to see if these might be a fit for you.
As with most birth control, there are high and low concentrations of these pills, giving you the option to further tailor them to your symptoms and needs.
Gersh also doesn't typically recommend implants or IUDs, because they foster hormonal imbalances. She emphasizes that reproduction isn't a tacked-on feature of the female body. It's integrated into the whole and should be treated as such.
However, Gersh says that a copper IUD (which doesn't contain hormones) is an option for women with PCOS looking to prevent pregnancy. There are limitations to this method, though. While a copper IUD is highly effective at preventing pregnancy, copper is inherently inflammatory, and women with PCOS are already dealing with high levels of inflammation. Plus, according to the OAJC, they can lead to weight gain, though less than if you were to have a depo-provera shot (more on that below).
Contraceptive Rings and Patches
If you’re looking for an option outside of oral contraceptives but can’t get behind IUDs, you may want to try a contraceptive ring (like NuvaRing) or patch. According to Planned Parenthood, these transdermal patches and small, flexible rings regulate periods and prevent pregnancy by releasing hormones (estrogen and progestin) into the body.
Like other aforementioned contraceptive methods, birth control rings come with a side of clearer skin, lower cancer risk, and reduced bloating and cramping; though it’s balanced out by dizziness, nausea, and even fatigue (which is already a symptom that some people with PCOS experience).
Otherwise known as medroxyprogesterone acetate, the Depo-Provera shot is a progestin injectable that is recommended for both birth control and to regulate menopausal hormones, and is injected every three months. While many people swear by the shot, the OAJC points out that it’s associated with a reduction of HDL levels which can lead to cardiovascular risk. What’s more, it’s known for the highest weight gain after two years of use in comparison to copper IUDs and hormonal IUDs like Mirena. Additionally, according to Mayo Clinic, the shot can be harmful to those with a history of depression, liver disease, breast cancer, heart attack, or stroke. In other words, while it’s applauded by some, it's certainly on the riskier side of things, and it's best to consult a doctor before deciding to opt for the injectable.
Condoms and Diaphragms
At the end of the day, Gersh recommends methods like condoms and diaphragms above all else for people living with PCOS. Unlike their oral and internal counterparts, these products don't come with a side of negative side effects like weight gain, spotting, and mood swings. Though, they also don't come with hormones to help regulate the lack thereof, either. Regardless, like all contraceptives, these need to be used correctly to prevent pregnancy. If you're unsure how to do so, click over to Planned Parenthood for a helpful run-down.
How to Further Relieve Symptoms of PCOS
Certain lifestyle changes can help manage the symptoms of PCOS. Gersh recommends changing up your eating habits and trying the ProLon intermittent fasting diet, which she says has been shown to help reduce inflammation. She also recommends resveratrol supplements. Resveratrol is an antioxidant that has been shown to help lower testosterone. And because women with PCOS often have reversed circadian rhythms, she says supplementing with melatonin can be beneficial.
The Bottom Line
Gersh says treating PCOS with hormonal birth control is just a way to cover—not treat—the underlying issues. And you can only cover them for so long. "The optimal birth control doesn't exist," she says. But for now, we have to work with what we have—especially because an unwanted pregnancy isn't an optimal outcome, either. She advocates for more research into better birth control options for women, and we're wholeheartedly on board.
Cleveland Clinic. Polycystic ovary syndrome (PCOS). Updated November 3, 2014.
de Melo AS, Dos Reis RM, Ferriani RA, Vieira CS. Hormonal contraception in women with polycystic ovary syndrome: choices, challenges, and noncontraceptive benefits. Open Access J Contracept. 2017;8:13-23. doi:10.2147/OAJC.S85543
Planned Parenthood. Birth control patch.
Mayo Clinic. Depo-Provera (contraceptive injection).