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Risks of Birth Control Pills and Finding the Right One if You Have Endometriosis

by | Posted on April 12, 2021

Risks of Birth Control Pills and Finding the Right One if You Have Endometriosis

Endometriosis is a disease where tissue resembling the endometrium (the inner lining of the uterus) grows in other parts of the body. It is most commonly found in the pelvic region [1]. Like the endometrium found in the uterus, this tissue also responds to female sex hormones, estrogen and progesterone, which play an important part in the menstrual cycle [2].

Doctors often prescribe combined oral contraceptive (COC) pills to regulate the menstrual cycle as well as the symptoms of endometriosis [3].

Why are COCs not ideal for managing endometriosis?

Combined oral contraceptives (COCs) have been in vogue for many years for the symptomatic management of endometriosis despite the lack of concrete evidence of efficacy as they are inexpensive and are generally well-tolerated [4].

Endometriosis is an estrogen-dependent disorder [5]. Estrogen given unopposed (without progesterone) can promote the growth of endometrial tissue leading to inflammation and pain. The COC contains both estrogen and progestin (the synthetic form of progesterone), which counters the effects of estrogen. Although COCs may help with painful symptoms of endometriosis, it is thought that estrogen dominance (estrogen having a greater effect than progesterone) may still occur when taking COCs, thus not helping with regression of endometriosis lesions, and in some cases with continuing progression of the disease [4].

COCs are also limited in their applicability. They are not suitable for women over age 35 who smoke, women at increased risk of stroke, heart attack, and blood clots, and those taking certain medications [6].

Which birth control pill is more effective?

Research suggests that progestin-only pills are a better alternative to COCs to manage the symptoms of endometriosis as they do not contain estrogen [4].

The continuous administration of progestins at higher doses than the COC also stops regular periods and reduces the chances of breakthrough bleeds. Progestins also have anti-inflammatory properties, which is helpful in alleviating inflammation and pain associated with endometriosis [4].

Finally, another advantage of progesterone-only pills is that they can be used at any age to stop menstruation with few side effects and without the risk of internal clots [7].

Please note that the “mini-pill”, while progestin-only, is only a contraceptive pill that works by thickening cervical mucus and may not help to the same extent with pain symptoms and also does not suppress the menstrual cycle or stop ovulation. The mini-pill is at a dose that is 10 times lower than progesterone-only therapies for endometriosis.

What are some of the progestin-only treatments available?

Progestin-only treatments are available as pills, injections, and intrauterine devices.

Norethindrone and medroxyprogesterone are oral pills and medroxyprogesterone are also available as an injection.

Progesterone pills are usually taken daily and at the same time, every day whereas injections are given once every three months.

Levonorgestrel is another progestin that is available both as a pill and as a small, T-shaped intrauterine device. The device can release medication for up to five years [8].

What other hormone therapies are available?

Danazol is a synthetic male hormone or androgen that can also be used to manage endometriosis [8]. Danazol lowers estrogen levels and prevents the growth of endometrial tissue. However, it is not used commonly any longer as it comes with the risk of severe side effects including weight gain, changes in menstrual cycles, and other androgenic effects such as excess hair growth in a male pattern. 

Leuprolide acetate (leuprorelin, or Depo Lupron) is an injection that is given every one or three months to treat endometriosis. Leuprolide interferes in the signaling that tells the ovaries to make estrogen and thus lowers natural estrogen levels inhibiting the growth endometriosis [9]. Essentially, it tells the brain to stop sending messenger hormones (follicle-stimulating hormone and luteinizing hormone, FSH and LH) to the ovaries, thus creating a state of pseudo-menopause. However, the continuous administration of leuprorelin can lead to side effects such as hot flashes, vaginal dryness, and low bone mineral density with a risk of fracture [8]. Therefore, leuprorelin is often supplemented by hormonal “add-back” therapy in which a progesterone pill is administered alongside to offset the side effects and prevent endometriosis progression at the same time [10].


  1. Endometriosis: Symptoms, Causes, and Treatments, SECKIN MD
  2. Endometriosis, Mayo Clinic
  3. Modern combined oral contraceptives for the treatment of pain associated with endometriosis, Cochrane
  4. Progestin-only pills may be a better first-line treatment for endometriosis than combined estrogen-progestin contraceptive pills, Robert F. Casper, Fertility and Sterility.
  5. Endometriosis, Endocrine Reviews
  6. Combined pill, National Health Service, UK.
  7. All Birth Control Pills Aren't Created Equal In Managing Endometriosis, Say Experts,
  8. Medical treatments for Endometriosis, Brigham and Women’s Hospital.
  9. Leuprorelin as a Treatment for Endometriosis, The Embryo Project Encyclopedia
  10. Treatment with leuprolide acetate and hormonal add-back for up to 10 years in stage IV endometriosis patients with chronic pelvic pain,, Fertility and Sterility.

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