Cindy: Inflammation related to use of birth control pills

Cindy consulted me at the age of 40 regarding general health. As a well-versed pharmacist, she wanted to know if she should consider changing her birth control pills to some form of bio-identical hormone therapy given her age. She had been using some form of birth control pill since the age of 28, and was pleased about the fact that they helped to control her acne, as well as reduced her previously 7-day menses to much lighter flow. Aside from a previous history of uterine cyst that was surgically removed years ago, she had also undergone lumpectomies for benign fibroadenoma tumors in her breasts as early as age 19. Overall, she felt well, exercised regularly, and felt that she was eating a healthy diet. Aside from dry skin and work-related chronic neck pain from strain, she did complain of low sex drive, sugar cravings, and periodic mood irritability. She had yearly physicals through her PCP with blood work, and was told that she was healthy.

Upon my initial exam, I discovered a fairly large nodule in her thyroid gland, which Cindy had not appreciated until I pointed it out. Her initial total cholesterol was also elevated at 253, with an abnormally high HDL at 141 (though she was uncertain of her previous baseline level), and she had other markers of inflammation, including a significantly elevated serum ferritin level at 250 ng/mL. Her blood sugar regulation was suboptimal, and she was pre-diabetic with HgbA1c of 5.8%, even though her weight was normal at 108 lbs, at a height of 5'1" tall. I also discovered her iodine and vit D levels were low, and even though her overall LDL was normal at 88 mg/dL, her LDL-Particle number was moderately elevated at 1400 nmol/L, placing her at increased risk for coronary heart disease. Her lipoprotein fractionation results also indicated increased fractions of the small and medium sized LDL particles, which are also correlated with increased coronary heart disease risk.

I requested a thyroid ultrasound on Cindy, which revealed "large, irregular partially solid and partially cystic mass within the left thyroid lobe measuring 3.4 x 2.1 x 3.5cm". She was referred to an endocrinologist, who recommended a fine needle aspiration biopsy. I asked that Cindy postpone the biopsy to see if it might change with my recommendations, including discontinuing her oral contraceptive, dietary changes, as well as normalizing several nutrients that were depleted. Cindy was also found to have a "2.9cm heterogeneous lobulated mass in the right breast" upon screening mammogram, which led her to a lumpectomy. The final pathology was read as "benign intraductal papilloma with florid ductal epithelial hyperplasia", which as I explained to Cindy, was one step away from breast cancer.

Because I suspected potential inflammatory effects of chronic oral contraceptives, I advised Cindy to stop them. I cautioned her that scientific research has linked oral contraceptives not only to deranged hormone receptor physiology, but also to significant alterations in the synthesis of numerous liver regulatory proteins, including thyroid and sex hormones, as well as reduced absorption of multiple nutrients. I was also concerned about its negative effects on proliferation indices within the breast tissue, especially given her recent diagnosis of precancerous breast tissue changes. I reviewed a detailed dietary plan to shift towards more of a plant-based diet, increasing fiber, as well as ways to help target her elevated blood sugars. I also advised proper supplementation of several nutrients that were deficient, which I felt were likely related to the ingestion of chronic oral contraceptives.

Slightly over a year later, I received an email from Cindy stating that her thyroid nodule completely disappeared. Her email went on further to say: "I do think that it has something to do with being off the birth control pills,as well as eating organic food almost all the time. I am very happy that you told us not to have it removed. Imagine if I had it done, what a waste of time (and pain) and money. I am so glad we have you as our doctor, Dr. Chen!!!! YOU ARE THE BEST!!! :-)" Follow-up blood work done since then also demonstrated resolution of previously elevated ferritin now down to 81 ng/mL, normalized blood sugar regulation with HgbA1c of 5.2%, repletion of all previously depleted nutrients, and reduction in overall cholesterol to 200 mg/dL (a 53 point reduction), with significant reduction in previously very elevated HDL to now 98 mg/dL. Cindy has remained off all oral contraceptives, and continues to try to live a healthy lifestyle, thus far without any recurrence of breast or thyroid lumps. She feels well, her acne has completely cleared up, sugar cravings resolved, and her husband reports that her previous mood irritability swings have also completely resolved.

Cindy's case illustrates the numerous potential metabolic derangements from chronic use of oral contraceptives, which led to chronic inflammation, sugar cravings, and mood irritability. And the fact that her large thyroid nodule spontaneously completely regressed after a period of time off the birth control pills and simultaneous diet/lifestyle changes also leads me to believe that the hepatic first pass metabolism of these oral contraceptives, plus the numerous well-documented nutrient deficiencies with chronic use, likely all contributed to the growth of her nodule. Although we cannot prove cause/effect of chronic birth control pill use with her precancerous changes in the breast tissue, oral contraceptives, especially the progestin component, are correlated with increased cellular proliferation within the breast tissue.