The Birth Control Pill Doesn't Mask PCOS

What some naturopaths don't want you to know

Some naturopaths claim that the birth control pill “masks” polycystic ovarian syndrome (PCOS), and instead of “masking” PCOS with the pill doctors should be looking for the  “root cause” and then treating this “root cause”. 

“Masks” and “root cause” are in quotations because these terms are never defined in any medically meaningful way.

This naturopathic insistence on a “root cause” for every medical condition is not compatible with most chronic conditions, which are typically multifactorial, meaning they are a complex mix of genetics and environment, but it is hard to sell a supplement geared to fixing those issues! Better to boil it down to “one simple thing” that “they” (meaning medicine) doesn’t want you to know, such as a “hormone imbalance” or “inflammation” or “toxins”. 

PCOS Basics

PCOS involves disturbances in hormones produced by the ovary and the pituitary gland and is very often associated with insulin resistance. It’s the most common endocrine-metabolic disorder among reproductive aged women and people with ovaries. You can read more about how it isn’t caused by birth control pills here.

There are three classic features of PCOS:

1. Elevated androgens, such as testosterone. This is called hyperandrogenism or HA. This is typically diagnosed clinically by the presence of excess body or facial hair in a so-called “male” pattern, but sometimes it is diagnosed with blood work. 

2. Infrequent ovulation, meaning 36 days or more between menstrual periods. This is called oligo-anovulation or OA. This is also diagnosed clinically, meaning we health care providers ask if cycles are regular or irregular and how often they occur?

3. Polycystic ovaries on ultrasound, known as polycystic morphology or POM.

To be diagnosed with PCOS a person must have two of these three hallmark features, which are also used to subtype PCOS. So a person can have elevated androgens and irregular ovulation (HA and OA) or irregular ovulation and polycystic ovaries on ultrasound (OA and POM) etc. The overlapping portions of the Venn diagram make up four subtypes of PCOS. 

I asked Dr. Lucky Sekhon, a board certified OB/GYN and reproductive endocrinologist (meaning an expert in reproductive tract hormones), about the criteria for diagnosing PCOS and she agreed, telling me that it is “based on irregular ovulation, the appearance of polycystic ovaries on ultrasound, and having biochemical and/or clinical signs of hyperandrogenism.” And she confirmed, you can check hormone levels and do an ultrasound to evaluate the ovaries “on or off the pill.” BTW Dr. Sekhon is a great follow on Instagram, you can find her account here. 

Many people with PCOS also have insulin resistance, meaning the cells in their body don’t respond to insulin as well as they should. With insulin resistance the body responds by increasing insulin production, but with PCOS the ability to increase insulin production is impaired. This increases the risk for type 2 diabetes. People with PCOS are also at increased risk of metabolic syndrome, which also increases the risk of type 2 diabetes as well as the risk of heart disease.

Obesity can be an additive factor for people with PCOS, meaning people with obesity may have more symptoms or more severe symptoms. The reasons are not fully known, but there are a variety of metabolic issues in adipose tissue of women with PCOS that favor inflammation and insulin resistance. Obesity does not cause PCOS. 

Let’s tackle the “root cause” concept first.

There isn’t a single process that can explain all of the biological phenomena with PCOS. 

What we do know is PCOS is genetic, but researchers still don’t know all of the potential genetic contributors. There are many candidate or potential genes that appear to be involved, including genes that govern gonadotropins (hormones released by the pituitary that trigger follicle development and ovulation), genes that affect how the follicle develops, genes that affect how the body handles sugar, and genes that affect ovarian growth.

I asked Dr. Sekhon what she thought of the “root cause” hypothesis and she replied, “the root cause of PCOS from the REI perspective is an underlying genetic predisposition which can be aggravated by environmental factors.”

Researchers know enough about PCOS to know that some of the genes associated with it have been around for 60,000 years. They know about many of the complex endocrine and metabolic interactions. For example, that with PCOS excess insulin acts synergistically with a hormone released by the pituitary (LH or luteinizing hormone) to stimulate the follicles to make extra androgens. They know that there are defects in the production and action of glucose transporter 4, a protein that transports glucose into cells. Basically, a lot of puzzle pieces have been identified, but how they all fit together to bring about PCOS is not yet understood. I want to acknowledge that is frustrating, but the answer to that frustration is most certainly not to invent some fantasy “root cause”.

If the naturopathic community has solved this puzzle and discovered the “root cause” or the single thing or the exact chain of events that causes PCOS, why don’t they publish this incredible scientific breakthrough? Why have I not read about this in the New England Journal of Medicine or JAMA? I think we all know the answer here. 

And what about the naturopathic PCOS supplements? If they are so effective, why haven’t these regimens been published? Don’t naturopaths want everyone studying PCOS and everyone with it to benefit from these discoveries? I won’t hold my breath for any credible study, because it is highly likely the results would make it much harder to sell their “hormone balancing” promises for $69.99 a month. 

Instead, these folks market the concept of a “root cause” modeled after conspiracy theories. They tout nebulous medical and scary sounding explanations, like “inflammation” or “estrogen dominance” and talk about how the mysterious “they”, meaning medicine, don't want you to know about the secret solution because “they” are in the pocket of Big Pharma. And they push these theories and their supplements by demonizing the birth control pill, not by showing their ideas are scientifically valid or that these supplements work. 

And the biggest irony of all is naturopaths who frequently sell supplements in their online stores, some even with branded supplements, are somehow not in the pocket of the completely unregulated Big Natural who never perform high quality studies backing their claims?

I mean. 

What about “masking”?

Management of PCOS for those not trying to get pregnant involves several cornerstones, such as:

• Getting the correct diagnosis and sub-type.

• Ruling out other conditions masquerading as PCOS, for example thyroid disorders or a tumor that produces testosterone. 

• Treating high androgens, if that is a concern (e.g. acne, excess hair growth, and balding).

• Regulating menstruation or reducing heavy flow if needed and desired. 

• Preventing cancer of the lining of the uterus, which is much higher for people with PCOS.

• Screening for other health conditions associated with PCOS, for example diabetes and lipid abnormalities.

• Improving metabolic disturbances and preventing complications from metabolic disturbances.

When we use the term masking in medicine we typically mean something that interferes with our ability to make a diagnosis. For example, acetaminophen lowering a fever so you mistakenly believe your patient doesn’t have a fever, when in reality they do.

It’s important not to confuse masking with therapy. For example, a 49-year-old taking the birth control pill won’t know if they are in menopause or not as hot flashes and irregular bleeding, signs of the menopause transition, are treated by the pill. You could say that the menopause transition is masked by the pill. And I would reply, that is often the point of being on the pill during the menopause transition! We sometimes give the pill to treat the bothersome symptoms. We have criteria for stopping the pill in this situation, so it doesn’t interfere with medical care in any way.  

The pill doesn’t mask PCOS, because the diagnosis can still be made when someone is taking the birth control pill. We can look at hair growth and see if it is there or ask about laser hair removal. We can ask what periods were like before the pill was started. And an ultrasound will still show polycystic ovaries, whether someone is on the pill or not.

Tests to rule out other conditions, such as a testosterone producing tumor, congenital adrenal hyperplasia, and thyroid dysfunction can all be done while taking the pill. We can screen for diabetes and check blood pressure and lipid levels when people are on the pill. 

There is on caveat here. If there are no reliable signs of increased androgens (such as excess hair growth) or it is unclear and the diagnosis is in question, then blood tests to check testosterone and other androgens may be needed to help with the diagnosis. In this situation, the birth control pill should be stopped for three months before testing as it will affect the levels of these hormones.

In short, we can do everything we need to do for PCOS whether someone is taking the pill or not. And if additional tests are needed, the pill can be stopped.

What About “Temporary PCOS”?

That isn’t a thing. I’ve heard some people claim that the pill can cause temporary PCOS, but I found no data for this. I asked Dr. Sekhon and she confirmed.

The pill can raise LDL and triglycerides for some people. This is not PCOS.

The pill can raise blood pressure. This is not PCOS.

It is possible this very real metabolic syndrome, discussed earlier, is being confused with PCOS. Metabolic syndrome is diagnosed when there are three of the following five criteria:

• High blood glucose

• Low levels of HDL

• High levels of triglycerides

• Waist circumference of > 35 inches for women and > 40 inches for men.

• High blood pressure

If you are on the pill and develop high triglycerides and/or high blood pressure, the pill should be stopped. If your blood pressure and triglycerides revert to normal then hopefully you no longer have metabolic syndrome. This does not mean you had temporary PCOS, you had known side effects from the pill.

As metabolic syndrome increases the risk of cardiovascular disease, the estrogen containing birth control pill should be stopped regardless of triglycerides and blood pressure.

There are many treatment options for PCOS

The estrogen-containing birth control pill is not the only therapy for PCOS. For example some other therapies (not an exhaustive list) include the following:

• Exercise, which can help the metabolic dysfunction

• Low carbohydrate diet, admittedly based on weak evidence.

• Acne can be treated with topical therapies as well as with antibiotics, spironolactone and Accutane.

• The medication metformin can help reduce androgen production by the ovaries (although not as much as the birth control pill) and it can help with metabolic disturbances.

• The levonorgestrel IUD (like Mirena) can treat irregular bleeding and help prevent cancer of the lining of the uterus. 

• Excess hair growth can be treated with spironolactone, shaving, waxing, or eflornithine HCL, 13.9% solution.

The best treatment depends on many factors including the subtype of PCOS, pregnancy goals, the need for cancer prevention, desire for regular periods, the presence of metabolic dysfunction (insulin resistance) and desire to treat androgen excess.  

The birth control pill is the most effective of all the therapies at reducing androgens and so it treats acne, reverses excess hair growth, and can stop hair loss (balding). It also regulates periods (or takes them away if you want to take the pill continuously), and is very effective at preventing cancer of the lining of the uterus. And if contraception is desired, it also provides that benefit. 

The pill is recommended as first line therapy for PCOS because it can treat so many things, not because doctors are colluding to put generations of women on oral contraceptives. If people prefer to try metformin to lower androgen levels, or spironolactone for acne, or to see how exercise and diet can effect changes that is all fine. With the caveat that if someone is at high risk for cancer of the lining of the uterus that they have made aware of that concern and that preventative therapy exists 

None of what the pill does is “masking” PCOS, it is treating. When a naturopath tries to scare someone away from the pill based on the fantasy of “masking” it sounds to me like they want that person to suffer, often so they can sell a supplement they aren’t willing to test in a clinical trial to prove it actually works.

But until we understand the actual genetic and environmental causes of PCOS and design other therapies, no one needs to suffer from acne or irregular periods. No one needs to be at risk of cancer of the lining of the uterus. All therapies for PCOS that are appropriate for the medical situation should be offered, with their benefits and risks, and then an informed decision made.

I know some people get stuck on the idea that the pill doesn’t cure PCOS, but managing symptoms and preventing complications is a huge part of medical care. When we treat high blood pressure with medications, we aren’t making the high blood pressure magically disappear forever. We are lowering blood pressure so it doesn’t damage the kidneys or blood vessels and cause a heart attack, stroke, or kidney disease. That doesn’t mean people can’t also make lifestyle changes, such as exercise and diet. But if the blood pressure is high enough, letting the kidneys get damaged while waiting to see if exercise and diet help would be malpractice. 

It is true that many people are offered the birth control pill for PCOS without having an adequate discussion about what it can or can’t do, about the risks, or about other options. But none of those very valid points mean the pill masks PCOS.

It is true that some people have side effects from the pill and dislike taking it. That also does not mean the pill masks PCOS. 

It is true that some people are offered the pill when they are 14 or 15 and are suffering with irregular periods. (Irregular periods are very common at the beginning of the menstrual life because ovulation is irregular in the first three years of menstruation). This doesn’t mean these people have PCOS, but it is possible they could be diagnosed later on when their menstrual cycle has matured. But if you are 14 or 15 and bothered by the irregular nature of your periods, the only treatment option currently available is hormones. Being dissatisfied with that option does not mean the pill masks PCOS. 

It is true that for people with PCOS that symptoms may go away on the pill and when the pill is stopped those symptoms may return because they still have PCOS. The pill treats many issues related to PCOS, but it does not cute PCOS. That also does not mean that the pill masks PCOS. 

And it is true that we still do not know all that we need to know about PCOS and that we need more options. And that still does not mean the pill masks PCOS. 

When I hear a naturopath say that the pill “masks” PCOS, what I hear is they do not understand the physiology of PCOS or do not care to understand it. It also sounds to me like they want people to take unproven, untested supplements that they often sell in their online store. And I also hear the lie that mainstream medicine is hiding the truth about the “root cause” of PCOS. And conveniently, this “truth” and studies showing the efficacy of these supplements, while supposedly revolutionary, will never be published in a peer reviewed journal of even middling repute. 

This post has been updated to clarify the testings where evidence of increased androgens is uncertain

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