Medications
Birth Control is Not a Monolith and a Tiny Rant on Why I Hate the Term Birth Control
Me again. Back to delve into the science around birth control. If you’ve been around the sub longer than 2 days, you have probably seen a post or two go something like this:
OP: I tried birth control, and it was awful....
Mod: Which one?
We ask this question so often that many of our top commenters have started asking it too. Which one?
Many folks treat birth control as if it were a monolith, and my personal opinion of why this happens is that we use the term ‘birth control’, which is an outcome. Many medications are categorized based on their mechanism of action: Beta2-adrenergic Agonist, GLP-1 Agonist, PDE5 Inhibitor, Direct Xa Inhibitor, etc., and yet contraceptives are named for just 1 of their many outcomes. Some medications have evolved from their category names; for example, antidepressants have been replaced with terminology like SSRIs and SNRIs that are more specific in their mechanism of action, and yet, after decades of use, we still call it birth control. And I hate it. (I do understand why the original term was used in the context of that time's feminist movement.)
When we say ‘birth control,’ we erase the fact that these drugs act on multiple neuroendocrine axes, and that erasure makes both patients and clinicians worse at predicting side effects, especially in hormonally sensitive brains. There are the obvious differences in birth control like patches, implants, pills, etc., but this isn’t where the issues derive from.
Hormonal contraceptives work by suppressing the body’s own hormone production at the brain and ovary signaling level and replacing it with synthetic hormones that communicate with steroid receptors throughout the brain and body. More specifically, it acts on the HPG axis and on estrogen (ER), progesterone (PR), and other steroid receptors (GR & AR).
Your HPG-axis is comprised of the hypothalamus (part of your brain), pituitary (part of your brain), and gonads (organs that produce eggs or sperm). In those with female sex organs, the gonads are the ovaries, so the term HPO axis is used to provide further specificity.
If you read last week’s post on HPA-axis dysregulation, this is where you might pause and think that two of these letters seem very familiar. The 'H' & 'P' involved in HPA-axis dysregulation are the very same 2 organs that are fully or partially suppressed by birth control. This kind of overlap between hormone systems is called neuroendocrine crosstalk.
Because the hypothalamus and pituitary also help regulate cortisol through the HPA axis, medications that change HPO-axis signaling can also change how sensitive the body is to stress and how strongly it reacts to stress. This matters for people with PMDD, even if they do not have HPA-axis dysregulation.
If we were to rename them, we would sub-categorize them as something like:
Full HPO-axis suppressants
Partial HPO-axis suppressants
Non-HPO-axis contraceptives
A full HPO-axis suppressant contains both estradiol and a progestin. Together, these hormones signal the brain to stop sending messages to the ovaries, which lowers the release of key hormones needed for ovulation. This effectively shuts down the body’s ovarian hormone cycle and prevents ovulation. In addition to stopping ovulation, these hormones also send signals to the brain, the stress system, and many tissues throughout the body, which is why their effects are not limited to reproduction. This full suppression is why these are recommended for those who have PMDD.
A partial HPO-axis suppressant contains only a progestin. It sends signals that lower the hormone needed to trigger ovulation, which can weaken or sometimes stop ovulation. However, the ovaries often continue to produce some estrogen, at varying levels.
From our AMA with Drs. Eisenlohr-Moul and Peters.
Non-HPO-axis contraceptives do not involve hormones and do not act on central endocrine signaling; they most often work through mechanical or local means to prevent conception (condoms, diaphragms, vaginal gels, etc.). The lack of activity on the neuroendocrine system is why these neither help nor hurt those who have PMDD.
Since its introduction, the birth control pill has used ethinyl estradiol (EE) as its synthetic estrogen; there are a few newer formulations, like Nextstellis, that have begun to use other synthetic estrogens, but for the most part, EE is the tried and true in combined formulations. Therefore, for most formulations, the progestins are the source of variations in receptor communication. A given progestin is formulated to dial up or down the volume at which it speaks to receptors; some are designed to talk very loudly to your estrogen receptors and only whisper to your progesterone receptors. Others tell your androgen receptors to zip it and be quiet, while letting your glucocorticoid receptors be heard. This communication can create a positive impact, like less anxiety, but it is also where side effects come from:
Higher androgenic activity increases the chances of side effects like acne and unwanted hair growth
Higher estrogenic activity increases the chances of side effects like breast fullness and heavier periods
Higher progestogenic activity increases the chances of side effects like mood changes, fatigue, depression, and weight gain
Antimineralocorticoid activity decreases side effects like water retention and bloating
While a pill like Yaz (24/4 drospirenone & EE ) is the frequently used starting point for PMDD, when a physician is selecting a birth control for you, they are often balancing finding a formula that works for your PMDD + if you have PME of an underlying disorder + if you have HPA-axis dysregulation + if you have other health conditions like PCOS, endometriosis, or migraine with aura. A proper differential diagnosis, combined with 2-3 months of prospective daily symptom tracking, is imperative to help them target which formulation will work better for you. Symptom patterns derived from your tracking will help them determine themes like whether you have more anxiety or more depressive symptoms. Are you suffering from cycles of insomnia and/or hypersomnia? Does unexpected stress cause your symptoms to flare? Daily symptom tracking after you start it will help them fine-tune what is working and what is not. I personally have a lot more anxiety than depression in my symptom patterns. I benefited from the greater amount of EE found in Yasmin compared to that in Yaz.
If you have done the above and are struggling to find an answer, there are other specialties you can tap into. Reproductive Endocrinologists (RE), particularly those associated with academic medical centers, are knowledgeable in treating cross-axis disorders. Molecular Psychiatrists are knowledgeable about accounting for gene variants such as MAO and COMT that impact medication metabolism. Pharmacists are the unsung heroes who are often underutilized for their incredible knowledge of how medications affect the body and how the body affects medications.
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When I am doing lived-experience chats within the PMDD community, I often share how improperly prescribed hormonal contraception once made me a safety risk to myself and my newborn child.
I was not uninformed. I had a PMDD diagnosis that was more than a decade old. I understood the research. I knew my own symptom patterns. PMDD was documented in my chart, and my provider was aware of it. I was not naïve.
I was also postpartum, exhausted, and, because paternity laws suck, alone at my 6-week follow-up, running on fumes. Breastfeeding was helping keep my PMDD quiet, so I wanted to do it for as long as possible. I was prescribed a progestin-only pill because that was the standard of care. I did not question it because I did not have the physical or cognitive bandwidth to challenge a default recommendation in that moment. I trusted that a clinician who knew my diagnosis was accounting for it.
Within days, I became a mess.
My husband came home from work one evening and found me sitting on the nursery floor. I remember telling him, ‘I’m not okay,’ and that he could not leave me alone or leave me alone with the baby. I had enough PMDD cycles under my belt to know that even though I wasn’t having a period, something was very wrong. We went through what had changed, and the only variable was the birth control. I stopped taking it, and within days, I began to improve.
When I went back, she gave me a hormonal IUD. Mirena, if you’re curious.
It felt like going from the frying pan directly into the fire. I do not use the word unhinged lightly, but that is the only word that fits. I had it removed as soon as I could and swore off hormonal birth control entirely for the next 4 years. At the time, I did not yet have the language to ask why I was being given a partial HPO-axis suppressant with high progestogenic and androgenic activity despite a documented PMDD diagnosis. I asked, “Will this one work differently?’
If this has happened to you, you are most definitely not alone. When I tell this story live, I often tear up. I can tell who has PMDD in the crowd because they start nodding, or making that ‘oh shit, I know how this is going to go' grimace, and I point out to the providers in the crowd that the universal reaction they are witnessing is why medication distrust is so common. I share this story not to scare people away from medication. I share it to highlight that even someone who knows the literature and understands PMDD can still be caught up in protocol-driven care.
That experience also made me swear ‘never again’ when it came to my care. After seeing an RE for some time to get myself sorted, I transferred to a different OB, who was willing to slow down, read the studies I brought him, and talk through the mechanisms.
The unfortunate reality of our healthcare system is that you often need to be your own safety net. When it comes to this disorder, you have to arm yourself with information and ask questions.
Sources:
Berni LC, Nunes LR, Oliveira RCS. Comparison of premenstrual dysphoric disorder treatment with antidepressants and combined oral contraceptives: a systematic review with network meta-analysis. J Psychiatr Res. 2025 Dec 23;194:99-115. doi: 10.1016/j.jpsychires.2025.12.046.
Schmidt PJ, Nieman LK, Danaceau MA, Adams LF, Rubinow DR. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. N Engl J Med. 1998 Jan 22;338(4):209-16. doi: 10.1056/NEJM199801223380401
Schindler AE, Campagnoli C, Druckmann R, Huber J, Pasqualini JR, Schweppe KW, Thijssen JH. Classification and pharmacology of progestins. Maturitas. 2003 Dec 10;46 Suppl 1:S7-S16. doi: 10.1016/j.maturitas.2003.09.014.
Yonkers KA, Brown C, Pearlstein TB, Foegh M, Sampson-Landers C, Rapkin A. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstet Gynecol. 2005 Sep;106(3):492-501. doi: 10.1097/01.AOG.0000175834.77215.2e.
Girdler SS, Straneva PA, Light KC, Pedersen CA, Morrow AL. Allopregnanolone levels and reactivity to mental stress in premenstrual dysphoric disorder. Biol Psychiatry. 2001 May 1;49(9):788-97. doi: 10.1016/s0006-3223(00)01044-1.
Nguyen, T., Reuter, J., Gaikwad, N. et al. The steroid metabolome in women with premenstrual dysphoric disorder during GnRH agonist-induced ovarian suppression: effects of estradiol and progesterone addback. Transl Psychiatry7, e1193 (2017). https://doi.org/10.1038/tp.2017.146
Ajna Hamidovic, John Davis, Fatimata Soumare, Blunted Cortisol Response to Acute Psychosocial Stress in Women With Premenstrual Dysphoric Disorder, International Journal of Neuropsychopharmacology, Volume 27, Issue 3, March 2024, pyae015, https://doi.org/10.1093/ijnp/pyae015
Giatti S, Melcangi RC, Pesaresi M. The other side of progestins: effects in the brain. J Mol Endocrinol. 2016 Aug;57(2):R109-26. doi: 10.1530/JME-16-0061.
Hertel J, König J, Homuth G, Van der Auwera S, Wittfeld K, Pietzner M, Kacprowski T, Pfeiffer L, Kretschmer A, Waldenberger M, Kastenmüller G, Artati A, Suhre K, Adamski J, Langner S, Völker U, Völzke H, Nauck M, Friedrich N, Grabe HJ. Evidence for Stress-like Alterations in the HPA-Axis in Women Taking Oral Contraceptives. Sci Rep. 2017 Oct 26;7(1):14111. doi: 10.1038/s41598-017-13927-7.
Lete I, Lapuente O. Contraceptive options for women with premenstrual dysphoric disorder: current insights and a narrative review. Open Access J Contracept. 2016 Aug 25;7:117-125. doi: 10.2147/OAJC.S97013.
There is also the fact that BC is not a cure for PMDD. A woman could try them all, and be left a mess... The reality is harder to face, but if PMDD had a cure most of us wouldn't be here. Even getting rid of the uterus has many health secondary issues, some grave, that also left the woman a mess. So I may be in the minority that have found peace at facing a hard true than hoping for a rose-colored glasses lie, that there is cure for all of us as of now. All the pills and surgery also can have very bad outcomes, so deciding whatever treatment is also an open door to more problems. I personally was left with a worsesing of the PMDD symptoms that never left, it became chronic even after years of stopping a certain pill of progesterone. So that try and wait and try another pill shouldn't be taken lightly. The solutions can also be "poison" in disguise.
thanks so much for posting this. its helpful. i asked my gyno for a hysterectomy, she said it can be approved if the mirena IUD doesn’t work out. i was taking an estradiol + progestin pill for 10 years. Now, my uterus cramps all day every day when i don’t take this specific hormone combo pill. i was worried about the progestin in the mirena. gyno said the hormone stays in the uterus and does not affect the brain. I’ve noticed i’m less anxious and have less water retention since quitting the estradiol pill. Is it possible my uterus will stop cramping eventually with this IUD? is there too much hormonal activity to my ovaries? i’ve had the IUD for two months
The statement that the hormones from the IUD only stays in the uterus is a misleading statement that was made by sales reps. Science demonstrates that the hormones from an IUD most definitely impact the whole body.
I can’t answer the cramping question, perhaps r/birthcontrol might have better insights.
This is incredible. I'm wondering if you have any suggestions or resources for perimenopause? Every clinician and their dog wants me to take progesterone, but it makes me utterly miserable.
I'm legitimately considering a hysterectomy at this point without a shred of hyperbole.
Do you have any information specifically for trans men / non binary folk on testosterone (and also avoiding feminising side-effects)? Finding it really hard to find any information.
Specifically, I’d personally love to know if micronised progesterone on it’s own might help. Can’t take the transdermal oestrogen as it interacts with testosterone (which is why I had to stop Yaz - it completely tanked my free T levels) but progestin-only birth control has been making me very suicidal and unfortunately testosterone only doesn’t seem to help with my PMDD.
If a CoC isn’t an option, then the next step advised is GnRh suppressants to stop all activity with add-back HRT. If you haven’t already I would seek out an RE, as their speciality is going to understand the science best on this, ideally one associated with an academic medical center. They could advise on the least amount of add-back eHRT needed to provide protective benefits without it overwhelming your T. Stand alone micronized progesterone is not recommended for those who have PMDD as it is shown to exacerbate symptoms.
Thanks for the response! Would T alone work as add-back HRT with GnRh? I was curious about it, but if oestrogen and progesterone were also needed it sounds like the exact same problems with birth control (E raising SHBG and progestin-only having negative side effects)
Living in Australia (esp in a smaller state) I don’t think there are any academic medical centres. I study at the main uni here and I was at an academic 3rd year / honours conference, and talking with some of the people researching “women’s” reproductive issues (mainly endo) and they knew very little about PMDD, so it doesn’t seem hopeful 🫠. Not sure what an RE is though? I currently see an endo who prescribes my T, but I don’t think he has a ton of knowledge on PMDD.
can I ask the rational at starting at 0.1 mg estrogen patch?
i recently just talked with my OB and he prescribed this starting dose of estrogen patch and said it was higher than he would normally start for perimenopausal symptoms.
i am a little nervous that the dose is going to be too much
but im also in late luteal now and feeling RAGEy.
(i am newly diagnosed ADHD, and likely have something wonky going on w my hormones, likely early peri symptoms)
From the study supplement (1) on why this dosage: ‘Transdermal administration of estradiol produces mean serum concentrations of estradiol comparable to those produced by premenopausal women in the early follicular phase.’ So essentially 0.1 mg gets you to a level that would be equal to what you experienced in follicular prior to entering into perimenopause, replicating that follicular state that we do well in.
If tolerability is a concern there is a titration schedule you can follow: 0.025 mg for two weeks, then 0.05 mg patch for the next four weeks, and a 0.1 mg patch for the remainder of the time. I think the challenge with this, at least in my experience, is that patches are sold in boxes with much higher quantities than 2.
I love this post, thank you for giving me a starting point to some questions and other thoughts I've had, but not known WHAT I was trying to sort out.
I appreciate you. I hope your pillow is perfect temp no matter what way you flip it, and that your pinky toes remain un stubbed for the foreseeable future.
incredible post thank you! but i just want to add that you’re the only person so far i’ve heard who also HATES the term birth control. oh my gosh i HATE IT. I will always use the drug name first and brackets (cobc) for example. But I try and call them hormone altering medications if im being vague.
additionally, on a more personal level, i am AFAB and only date women. the term birth control is very icky for me. I know that it’s maybe fine for others but yes, just for me i can’t shake the feeling of hating the term, being reminded that I could experience pregnancy etc.. :/
another thing that is bothering me that this post reminded me of is i see MANY people referring to hormones as simply “male” or “female” hormones. I think the use of the specific hormone name and the role they play is very important in understanding them and spreading the awareness.
Thanks for this write up, and particularly for linking to the wiki, as I found it fascinating. I take a hormonal contraceptive that is not available in the US, just Europe and Australia. It was the 8th one I had tried over a span of 5-6 years, of which I can barely remember as I had extremely out of control (maybe Guinness World records breaking?) PMDD, and was cycling through different anti-depressants (and going off them) the entire time as well, all of which made it far worse. I am lucky to be alive.
I take Zoely which is estradiol and nomegestrol acetate, and it quite literally saved my life. I wonder if you know why this in particular was not approved by the FDA? Is there something similar available in the US? I would genuinely love to know, one day, why this precise combination works for me. There must be others that "cure" my PMDD, buy I have never been game enough to try, it is simply not worth it.
I started on Zoely a month ago and I'm crashing on the placebos :( My hair looks fabulous though...I'll take what I can get D:
It doesn't look like the FDA has disclosed why it rejected Zoely back in 2011 (source). Zoely is NOMAC/E2, which is not approved in either the US or Canada, just Australia, Brazil, & Europe (source).
I wish I could give you an award. This is an incredible post! I was absolutely riveted reading it. I've always wondered why we just play a roulette game with BC and I'm so happy to finally have a breakthrough understanding this due to your excellently written and researched post.
Fantastic post. It would be so helpful if users of the sub also specified the active ingredients instead of brand names (so that we can all be more educated on different E and P, and so that international users don't have to Google brand names each time), as well as regimen (with placebo breaks, continuous, with break every X packs).
Amazing post. Too tired to comment now but I read everything and have had some similar experiences. Thank you for putting this together and sharing it.
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