Hair loss Treatment Center

PARTICIPANTS Steven D. Spandorfer, MD New York Presbyterian Hospital - Weill Cornell Medical College

Joining me are two experts.  Doctor Steven Spandorfer is here.  He's a reproductive endocrinologist at New York Presbyterian Medical Center.  Thanks for joining us today.

STEVEN SPANDORFER, MD:  Thank you for having me.

CHERYL WILLS:  Doctor Margaret Polaneczky is also here. She's a gynecologist, also at New York Presbyterian Medical Center.  Thank you.

MARGARET POLANECZKY, MD:  You're welcome.

CHERYL WILLS:  Okay, let me start with you Doctor Polaneczky.  The pill is as much a part of our culture as, I think, anything now.  What is the pill, and how does it work?

MARGARET POLANECZKY, MD:  The pill is a hormone that prevents pregnancy in a number of ways.  It prevents the egg from being released from the ovary, so it prevents ovulation.  But it also thickens the mucus at the opening to the cervix, which is the entrance to the uterus.  That's an important mechanism a lot of people forget about.  It also may effect the motion of the Fallopian tube and the uterine lining in ways that discourage pregnancy.

CHERYL WILLS:  Doctor Spandorfer, what's inside that little pill women take every day?

STEVEN SPANDORFER, MD:  Well, there are several types of pills, but the most common formulation of birth control pills has a component of estrogen in it.  And it also has a component of a progestin in it.  And the two are formulated together in different variations.  But, a pill will have each of those, every day.

In most birth control pills, that you take for 28 days, you'll take active pills, which have the estrogen and the progestin in it, for 21 days.  Then there'll be seven days that are generally the sugar pills, or the placebo pill. They're really utilized so that the patient remembers.  You take a pill every day, that way you don't forget.  If some packages only come with 21 active pills, you skip a week, you then start the next week.  The thought is that maybe the patient would be more likely to forget.

CHERYL WILLS:  It helps keep women keep their periods regular, is that right?

STEVEN SPANDORFER, MD:  Well, one of the many different reasons to utilize birth control pills besides the contraceptive benefits is it definitely keeps women's periods regular.  They can pretty much like clockwork guarantee knowing when they're gonna get their period.

It also has other advantages to the period, though.  If you look at women who are on birth control pills, they're going to have much less bleeding.  And importantly, along with that, they're gonna be much less likely to be anemic or to have low blood counts.  They are also going to be more likely to have less severe pain with their periods.  There's a whole host of things that, in my eyes and in most of my patients' eyes, are really improvements on the cycle itself.

CHERYL WILLS:  Doctor Polaneczky, estrogen in the pill is very important.  The fact that estrogen is inside that tiny little pill.  Why?

MARGARET POLANECZKY, MD:  Actually, the progesterone is enough to keep a woman from being pregnant.  In fact, there are birth control pills – and we like to call them "mini-pills" -- that just contain the progestin component.  The estrogen is primarily there for cycle control.  Without it, the periods can be a little irregular.  There can be some spotting or, we call it, "breakthrough bleeding".  The estrogen is there to keep the menstrual cycle regular.

CHERYL WILLS:  Now, how does one take the pill?

MARGARET POLANECZKY, MD:  The pill is taken every day, once-a-day.

CHERYL WILLS:  Is morning is better, or nighttime?

MARGARET POLANECZKY, MD:  I tell my patients to take it in the evening because the estrogen component, in some women, can lead to a little bit of nausea, particularly if it's taken on an empty stomach.  But again, the most important thing is to find the time of day that you know you're gonna remember to take the pill.  So, if that's the morning for you, then that's the best time.

CHERYL WILLS:  How effective, Doctor Spandorfer, is the pill?

STEVEN SPANDORFER, MD:  The birth control pill is one of the most effective methods that we have of reversible contraception.  In a very well-motivated couple, you can have an efficacy of like, 98, 99 percent; probably even closer, approaching a hundred percent, or as close to that as we can get.

CHERYL WILLS:  Sure.  And that's as long as you take it on schedule, every day.  Now, what happens when you miss a day?  When you're on vacation, you're excited, and you forget about it?

STEVEN SPANDORFER, MD:  Right.  Very commonly, people will miss pills.

CHERYL WILLS:  Sure.

STEVEN SPANDORFER, MD:  And missing one birth control pill, generally, you just take two the next day, and continue on with your package.  And you're actually fairly well covered.

CHERYL WILLS:  So, what does taking two do?  With many medications, they say if you skip, just continue, don't double up.  Why do you have to double up with the pill?

STEVEN SPANDORFER, MD:  The pill basically, once you miss one -- particularly today's pills, because they're such low level of the hormones in them, the estrogen and the progestin -- doubling up on it is a way of trying to let the patient not escape into an area where they may develop a follicle and lead to ovulation.  Along with that, really the most important pills to try not to miss are going to be the first pills of the pack.  If you miss too many of you early pills, a follicle may be selected.  Inside the follicle is the egg.  And one of the major methods of this working is by preventing ovulation.

CHERYL WILLS:  Doctor Polaneczky, there are different doses in some brands, different doses of every single little pill.

MARGARET POLANECZKY, MD:  Right.

CHERYL WILLS:  It's not just a bunch of little pills all the same dose, right?

MARGARET POLANECZKY, MD:  Some of them are.  Those pills are called "monophasic."  When all of the doses are the same it's called monophasic.  The triphasic pills have been developed in an attempt to get the different doses of medication as low as possible, without causing pregnancy to occur, or irregular bleeding.  Some women may have some mild, or nuisance-type, side effects from the estrogen or the progesterone.

The thinking is that if we can get the doses low as possible, we can minimize those side effects.  By changing the dose of progesterone throughout the cycle in different ways, different pill manufacturers are hoping to get rid of some of the irregular bleeding, or bloating, or mood swings, that some women might have with birth control pills.

CHERYL WILLS:  Doctor Spandorfer, the safety of the pill has been debated, I think, for 40 years.  If the pill is 40 years old, I think people have been discussing its safety for just about that long.  Let's discuss the risk of cancer because it's a topic that never seems to go away.  You have studies that come out that say there is no link to breast cancer.  Then you'll have another study that sort of disputes that, but it's never conclusive.  What is the final word on the pill and breast cancer?  Is there a link?

STEVEN SPANDORFER, MD:  The most important thing we can say is, there is no final word at this time.  In fact, most of the studies today are really analyzing data of patients that were on birth control pills that had much much higher dosage than what we're utilizing now.  So therefore, we're inferring some of this information from methods of birth control and contraceptive doses that we just don't use today.

So, that sort of aside, it appears when you look overall at cancer -- and breast cancer is clearly one that comes up -- it doesn't appear that there's an increase in lifetime risk of breast cancer.  Maybe, perhaps there's a small subset of people who are actually using the birth control pill in the age group of 30 to 40 who may have breast cancer diagnosed more often.  But there doesn't seem to be an increase in their overall lifespan or death rates from breast cancer.

I think along with talking about cancer, it's also very important to mention that there have been some very nice studies that have shown that people who take birth control over the years have a decrease in the ovarian cancer, as well as endometrial cancers.

CHERYL WILLS:  True.  And studies have proven that.

STEVEN SPANDORFER, MD:  There are some things that are positive.  Those are positive associations.  The fear of cancer and the birth control pill, there is some worry about breast cancer, but there is also some other very important, positive associations in decreasing cancer risk.

CHERYL WILLS:  Would you like to add to that, Doctor Polaneczky.

MARGARET POLANECZKY, MD:  I think when you look at cancer in general among birth control pill users, they have less cancers than women who don't use birth control.  That's because there really is, as Doctor Spandorfer said, a very profound effect on the risk for ovarian cancer, particularly now we are finding, in women with a family history of ovarian cancer.  The pill with actually lower their risk down to that of the general population.  We now have a pill that prevents cancer.  And it's been with us for 40 years.  And we're not using it enough in that way.  But if you combine all the cancers together, women on birth control pills die less of cancer than women who don't take the pill.

CHERYL WILLS:  When we talk about the difference in doses, say in the last ten years, compared to 40 years ago, how big is that difference?

MARGARET POLANECZKY, MD:  Forty years ago, doses were anywhere from 50 to even 100 micrograms of estrogen.

CHERYL WILLS:  Wow.

MARGARET POLANECZKY, MD: Now, most pills go between 20 to 35 micrograms.  Manufacturers are trying to get them even lower.  But the lower you take the estrogen dose, the higher the chance you'll have some nuisance, irregular bleeding.

CHERYL WILLS:  Doctor Spandorfer, is blood clot a possible risk or side effect with taking the pill?

STEVEN SPANDORFER, MD:  One thing you counsel patients about before taking it is that perhaps there's an increased risk.  The segment of the population that appears to be the highest risk for any type of blood clotting problems are going to be smokers, particularly older women who are smokers.  In general, it's not recommended if you're over 35 and you smoke, that you should take birth control pills.  That's clearly the population that probably has the largest problem.  Also, patients that have sort of inherent risk towards blood clotting problems may not be the best patients to use the birth control pill, as well.

I guess if you compare using the birth control pill to pregnancy itself and the risk of blood clots, it's probably actually lower with the birth control pill than it is with pregnancy, and maybe it's safer as a safer option.

CHERYL WILLS:  Sure.  What about nausea, Doctor Polaneczky?

MARGARET POLANECZKY, MD:  Nausea is a side effect we see in probably about ten percent of women who take the pill.  I advise my patients to take it with food in the evening if nausea becomes a problem.  There are some tricks you can do.  If you find that you become nausea with the first pill in a new pack, what I advise my patients to do is rather than wait seven days before you start into your next pack of pills, wait five days, then start taking a half a pill a day.  And wean yourself back onto the pill.

CHERYL WILLS:  And it's still effective?

MARGARET POLANECZKY, MD:  Absolutely.  Absolutely still effective.  There are some newer pills out that actually have shorter placebo days, and then go back in with these lower doses of estrogen.  It hasn't been studied yet, but we're trying to use it in these kinds of women to see if it helps a bit.

CHERYL WILLS:  Some women experience breast tenderness with the pill.

MARGARET POLANECZKY, MD:  Sure.

CHERYL WILLS:  Why would that happen?

MARGARET POLANECZKY, MD:  Estrogen, as well as progesterone, has effects on the breast.  This symptom usually resolves within about three months.

CHERYL WILLS:  And what about moodiness?

MARGARET POLANECZKY, MD:  Moodiness.  Many women are moody, and I'm not sure that it's always fair to blame the pill.  I think we'd like to find something to explain our moods.  That aside, there are some women who will find when they take the pill, they're just not themselves.  For those women, that's where barriers and other forms of birth control become important.  It's important to have a wide variety of methods, because every woman is different, and every method is gonna be different for her than for, perhaps, her friend.

STEVEN SPANDORFER, MD:  Interestingly, I think what you were mentioning before, if you can convince a patient to sort of hang in there with the birth control pill, give it the first three months, you'll find that a lot of those nuisance sort of side effects really dissipate.  They're just not as evident to the patient.  Either they learn to live with it, or maybe they actually just acclimate themselves to the medication itself.  But I think sometimes a little bit of encouragement to the patient goes a long ways.

CHERYL WILLS:  Doctor Spandorfer, is there a link between weight gain and the pill?

STEVEN SPANDORFER, MD:  Well, that's always been said.

CHERYL WILLS:  Yeah.

STEVEN SPANDORFER, MD:  Most patients will come in, and if I mention birth control pills they say, "I don't want it, I don't want to gain those five pounds."

CHERYL WILLS:  And it's water retention they talk about?

STEVEN SPANDORFER, MD:  Well, it's interesting.  When you look at the studies that have been very well done, and have looked at weight very carefully, those patients actually really don't gain weight.  Some studies would suggest maybe a pound or two here and there.  I really try to encourage patients to not think of it as "It's going to put 5, 10 or 15 pounds on you just by being on the birth control pill."

CHERYL WILLS:  Doctor Polaneczky, some pills can control acne.

MARGARET POLANECZKY, MD:  All pills.

CHERYL WILLS:  Oh, all of them?!

MARGARET POLANECZKY, MD:  All estrogen-containing pills have effects that will decrease testosterone levels,  which in some women will help keep their skin clear.  Some manufacturers have actually done the studies to prove this about their pill, and are able to market their pill as an anti-acne pill, which is great because it gets more women to use the pill.  But the truth is that all estrogen-containing birth control pills probably would be helpful for your skin because all of them decrease testosterone levels.

CHERYL WILLS:  Now, what I didn't know is it could help migraines.  That was news to me when I was researching this.

MARGARET POLANECZKY, MD:  There is a two-sided edge to this sword.  For some women, the pill might precipitate a migraine.  For other women, particularly those who have migraines around the time of their period, taking the pill without a break -- going through weeks on a pack of pills, right into another pack of pill -- skips their period and skips their migraine.  The trigger for the migraine is often the ups and downs in the woman's hormonal levels.  So for those women you want a monophasic pill, a pill with the same hormone level in each pill in the pack.  You can suggest that they skip their periods, and thus skip their migraines.

CHERYL WILLS:  This may also help women who have painful ovulations.  Is that right?

STEVEN SPANDORFER, MD:  Birth control pills by nature suppress or prevent ovulation.  So it is a way to prevent the ovulation.  And also, I think, prevent painful, crampy periods that a lot of women get.  The birth control pill definitely helps with that, and in fact, it's probably one of the first nice treatment for really painful periods.

CHERYL WILLS:  Can it also prevent ovarian cysts?

STEVEN SPANDORFER, MD:  Because you are preventing someone from ovulating it can, I guess, prevent ovarian cysts.  There have been some people who had used it before in women that had cysts and put them on birth control pills to control those cysts.  Although, I think later studies have shown that that's really not an effective way.  Really, what you're doing is just buying time by doing that.  Clearly there are women on birth control pills over long periods of time who will have less cysts than women not.

CHERYL WILLS:  Last issue.  The seven day placebo is not entirely necessary.  You can continue taking the pill, if you choose, and not have a period at all.

MARGARET POLANECZKY, MD:  Exactly. Those seven days off were designed to let the woman have a regular menstrual cycle.  And for many women, this is very important.  They need to see that period every month so they know that they are not pregnant.  So for those women, having a period every month is the way to go, and taking the placebos is the way to go.

But for women who perhaps have very painful periods that don't really get better with regular birth control pill use, women with migraine headaches, some women who have severe PMS, by taking the pill for three weeks, and then going right into another pack of pills, it's safe and it's effective.  There is no risk to your health for doing it.  The only reason those seven days are in there is to mimic the normal cycle.  There is no medical or health-related reason why a woman on the birth control pill has to have a period every month.

CHERYL WILLS:  Here's a question.  What if a woman is pregnant, doesn't know it and she's on the pill.  She's just taking them every day?

MARGARET POLANECZKY, MD:  The bad news is that that's happened a lot.  But the good news is we have a lot of data now from all of these women who took the pill mistakenly, and we've found that there really is no increased risk over the background rate of malformations or congenital anomalies in the children of the women who take the pill every day.

CHERYL WILLS:  Eventually they will realize they're pregnant.

MARGARET POLANECZKY, MD:  Sooner or later they, hopefully, will.

CHERYL WILLS:  Doctor Polaneczky, Doctor Spandorfer, thank you both for joining us.  And thank you for tuning in to our webcast.  I'm Cheryl Wills.