A patient comes to see me because her periods are painful, heavy or unpredictable. Perhaps she has endometriosis, adenomyosis or PCOS. Perhaps she has been struggling with pelvic pain or debilitating periods for years.
And then I mention the pill, the hormonal coil or another hormonal treatment.
The response is sometimes immediate:
“But I’m not looking for contraception.”
And I completely understand why.
If you have come to a gynaecology appointment looking for an explanation or treatment for your symptoms, being offered contraception can sometimes feel like you are being fobbed off.
So why do gynaecologists seem to suggest contraception so often?
The answer is that we are not always thinking about contraception.
Sometimes we are thinking about hormones.
Contraception can be a treatment – even when you don’t need contraception
This is probably the most important distinction to make.
Some of the medications we call “contraceptives” have effects that can be very useful in treating gynaecological conditions.
For example, hormonal contraception can change the way you experience your periods. Depending on the method, it can make periods lighter, less painful, less frequent or stop them altogether.
That can be particularly helpful for women with conditions such as endometriosis, adenomyosis or heavy menstrual bleeding. Hormonal treatment is one of the options recommended for managing pain associated with endometriosis, for example.
So when I suggest the pill or a hormonal coil to a woman who isn’t trying to prevent pregnancy, I am not necessarily thinking:
“She needs contraception.”
I may instead be thinking:
“Can we reduce the hormonal stimulation and menstrual bleeding that is contributing to her symptoms?”
Those are two quite different conversations.
So why hormones?
The menstrual cycle is a hormonal process.
Every month, your ovaries produce hormones that cause the lining of the womb to grow and then shed when you have your period.
For some women, that cycle is associated with significant pain or bleeding. In conditions such as endometriosis and adenomyosis, hormonal activity can be closely linked to symptoms.
One way of treating those symptoms is therefore to alter what the hormones are doing.
Depending on the treatment, we might:
- reduce or stop ovulation
- make the womb lining thinner
- reduce menstrual bleeding
- make periods less frequent
- stop periods altogether
- reduce the hormonal stimulation associated with endometriosis
- reduce the cyclical nature of pelvic pain.
That is why something that was originally developed or is commonly used as contraception can also have a place in gynaecological treatment.
The contraceptive effect may simply be an additional effect that isn’t relevant to you.
“But I don’t want to take hormones.”
This is another conversation I have regularly – and I think it is an important one.
Some women are understandably reluctant to take hormones.
Perhaps you have had unpleasant side effects in the past. Perhaps you didn’t feel like yourself on the pill. Maybe you are worried about mood changes, weight gain, libido or other side effects. Or perhaps you simply don’t like the idea of taking hormones when you don’t feel that your body needs them.
Those concerns are valid.
And “I don’t want hormones” is not something that should simply be brushed aside.
Hormonal treatments are medicines, and like all medicines they can have benefits, side effects and risks. Different hormonal methods contain different hormones, in different doses and delivered in different ways, so your experience of one method does not necessarily tell us exactly how you will respond to another.
The conversation shouldn’t be:
“You have this condition, therefore you need hormones.”
It should be:
“These are the options available to us. This is why I think this treatment might help. How do you feel about it?”
That distinction matters.
Are we actually treating the condition – or just masking the symptoms?
This is probably one of the biggest concerns women have.
If the pill makes your periods less painful, does that mean the underlying problem has gone away?
Not necessarily.
Hormonal treatment can be very effective at controlling symptoms, but symptom control and treating the underlying cause are not always the same thing.
For some women, controlling symptoms may be exactly what they need. For others, we may need to investigate further, consider imaging, look for conditions such as fibroids, adenomyosis or endometriosis, or discuss other treatment options.
This is why I would never want a woman to feel that being offered hormonal treatment means that we are simply trying to make her symptoms disappear without finding out what is causing them.
Sometimes hormonal treatment is part of the answer.
Sometimes it isn’t.
And sometimes it is one step in a much bigger treatment plan.
What if I don’t want contraception or hormones?
This is where the conversation becomes particularly important.
There isn’t one treatment that is right for every woman.
For example, if you have heavy periods and don’t want hormonal treatment, there are non-hormonal options such as tranexamic acid or anti-inflammatory medication that may be appropriate, depending on your circumstances and the underlying cause.
The right treatment also depends on what you are trying to achieve.
Are you:
- trying to become pregnant?
- hoping to avoid pregnancy?
- wanting to keep your natural menstrual cycle?
- struggling with heavy bleeding?
- dealing with severe period pain?
- experiencing pain throughout the month?
- concerned about the effect of hormones on your mood or wellbeing?
- hoping to avoid medication altogether?
These are all important parts of the conversation.
And if you are actively trying to conceive, that obviously changes the treatment options considerably.
What are the non-hormonal options?
If you don’t want to use hormones, that doesn’t mean you are left without treatment.
The options will depend very much on what is causing your symptoms, but non-hormonal treatments can be useful for many women.
For heavy periods, for example, medicines such as tranexamic acid can reduce menstrual blood loss, while anti-inflammatory medicines such as ibuprofen or mefenamic acid can help with both pain and bleeding for some women.
There is also much more to managing gynaecological symptoms than medication alone. Depending on your symptoms and diagnosis, lifestyle measures such as regular physical activity, sleep, nutrition, managing stress and maintaining a healthy weight can all form part of a broader approach to looking after your health and managing symptoms.
For conditions such as endometriosis, adenomyosis or fibroids, treatment needs to be individualised. This might involve medication, non-hormonal approaches, lifestyle and supportive measures, monitoring, further investigation or, in some circumstances, a procedure or surgery. Sometimes a combination of approaches works best.
The important thing is that treatment should fit the problem – but it should also fit you.
If you don’t want hormones, tell your gynaecologist. It is a useful starting point for the conversation, not the end of it.
“I feel like I’m being fobbed off with the pill.”
If you’ve heard this before, you’re not alone.
I think sometimes the frustration comes from the fact that women have been told for years that the answer to period problems is simply “try the pill”.
If you’ve been having severe pain for years, you may quite reasonably think:
“Surely there must be more to it than that?”
And sometimes there is.
A hormonal treatment may be a perfectly reasonable treatment for your symptoms, but that doesn’t mean that your symptoms shouldn’t also be properly assessed.
Heavy or painful periods can have many causes, including endometriosis, adenomyosis and fibroids. The impact on your quality of life is also important.
So if you’ve been offered contraception and you’re wondering why, ask.
“What are we hoping this treatment will do for my symptoms?”
“Are you suggesting this because I need contraception, or because of the hormonal effect?”
“What are my non-hormonal options?”
“Do we know what is causing my symptoms?”
“What happens if I don’t want to take this?”
These are all completely reasonable questions.
And what about the word “hormones”?
I think we can sometimes forget just how emotionally loaded that word has become.
We talk about “taking hormones” as though it is one single thing.
But hormonal medicines are not all the same.
The combined pill contains oestrogen and a progestogen. Some treatments contain progestogen alone. A hormonal coil releases a progestogen within the womb. Other treatments used in gynaecology can work on the hormonal system in very different ways.
So if you’ve previously had a bad experience with one hormonal treatment, tell your doctor.
It doesn’t necessarily mean that every hormonal option will affect you in exactly the same way.
But equally, if you don’t want hormonal treatment, that is important information too.
Sometimes doing less is a perfectly reasonable choice
Not every symptom has to be treated with medication.
Sometimes symptoms are manageable and you may decide that you don’t want treatment at all.
Sometimes you may prefer to monitor things.
Sometimes you may want to investigate further before deciding on treatment.
And sometimes you may want to try a non-hormonal approach first.
As a gynaecologist, my job isn’t simply to find something I can prescribe.
It is to understand what is happening, explain the options and help you decide what feels right for you.
The bottom line
So, why do gynaecologists seem to recommend contraception so often?
Because some contraceptive methods are also very effective gynaecological treatments.
They can reduce bleeding, make periods less painful, suppress ovulation and alter the hormonal environment that contributes to certain conditions.
But that doesn’t mean contraception is the only answer.
And it certainly doesn’t mean you should feel pressured into taking hormones that you don’t want.
If a hormonal treatment is suggested, it is completely reasonable to ask why it has been recommended specifically for you, what it is expected to achieve, what the alternatives are and whether there are non-hormonal options.
If you feel that you are being offered the pill simply because your doctor doesn’t know what else to do, say so.
And if you don’t want hormones, say that too.
The best gynaecology consultations aren’t about persuading you to take a particular treatment.
They’re about understanding what is happening, explaining the choices and finding a treatment plan that makes sense for you.