How do you address patients' concerns about hormonal contraception being unnatural?

Highlights

• Explore what a patient means by “natural,” as even non-hormonal options like a copper IUD are foreign devices in the body.
• Frame hormonal contraceptives as therapies that can reduce ovarian cancer risk, manage painful periods, and help treat conditions like endometriosis.
• Explain that frequent menstruation is a modern norm; hormonal use can mimic the more evolutionarily natural state of infrequent periods.
• For patients considering natural family planning, clarify that its 70% effectiveness rate comes with a 30% risk of unplanned pregnancy.
• Hormonal contraceptives use synthetic hormones, not bioidentical ones, to manipulate hormone levels and achieve a desired health outcome like preventing pregnancy.

Article

Deconstructing the Patient's Definition of "Natural"

When patients express concern about hormonal contraception being "unnatural," the initial step is to explore their specific definition of the term. Dr. Catherine Leclair, an OBGYN, emphasizes the importance of this clarification. "When I hear 'natural,' I assume she means something identical to what the body makes," she notes. This opens a dialogue about bioidentical hormones versus the synthetic estrogens and progestogens in most hormonal contraceptives. Dr. Leclair explains that while these agents are not identical to endogenous hormones, they effectively manipulate hormone levels to achieve a desired physiological state, such as anovulation. She also points out the ambiguity of the term, noting that even nonhormonal methods may not meet a patient’s definition of "natural." A copper IUD, for instance, is a foreign device, and the only methods without a device or medication involve fertility awareness or barrier methods. Understanding the patient’s underlying premise is critical to providing care that aligns with their values while addressing their medical needs.

Framing the Conversation Around Goals and Risk Tolerance

Once the patient's perspective is understood, the conversation can be reframed around their reproductive goals and tolerance for risk. Dr. Melinda Lukens, an OBGYN, begins by discussing the patient's desire for or avoidance of pregnancy and the regularity of their menstrual cycles. She provides a thorough explanation of natural family planning techniques, including their efficacy of approximately 70% for a patient with a predictable cycle. For many, this efficacy is a critical factor. "I tell patients that if they’re uncomfortable with a 30% chance of unplanned pregnancy, we have safe, effective medications that can stop ovulation," says Dr. Lukens. This approach transitions the conversation from a philosophical debate about "naturalness" to a practical, evidence-based discussion of risk management.

Highlighting the Non-Contraceptive Therapeutic Benefits

A key strategy is to broaden the patient's understanding of hormonal contraception beyond pregnancy prevention. Dr. Lukens frames these medications as a form of hormone therapy with significant health benefits. "While not taking anything is considered 'natural,' that doesn’t necessarily mean it’s better for your health," she explains. She highlights strong scientific evidence that hormonal contraceptives reduce the long-term risk of ovarian and uterine cancers. Furthermore, they are effective tools for managing conditions such as endometriosis, dysmenorrhea, and menorrhagia, which in turn can lower the risk of iron deficiency anemia. Presenting these therapeutic advantages helps contextualize hormonal intervention not as an unnatural imposition but as a potential health-promoting therapy tailored to the patient’s overall situation.

"While not taking anything is considered 'natural,' that doesn’t necessarily mean it’s better for your health." Dr. Melinda Lukens

Offering an Evolutionary Perspective on Menstrual Cycling

A compelling method for reframing the concept of "natural" involves an evolutionary perspective, as articulated by Dr. Deborah Bartz, a specialist in Complex Family Planning. She points out the significant disparity between modern reproductive patterns and those of our ancestors. "A modern woman has about 400 periods during her reproductive life, whereas our ancestors had about 40," Dr. Bartz observes. Historically, women spent most of their reproductive years pregnant or lactating, experiencing infrequent menses. She posits that the modern state of near-constant menstrual cycling constitutes a repetitive "trauma to the uterus, to the tubes, and to the ovaries," which may be associated with the rise in conditions like endometriosis and chronic pelvic pain. From this viewpoint, using hormonal contraception to suppress ovulation and reduce the frequency of menses can be framed as a way to restore a physiological state more aligned with our evolutionary history. Dr. Bartz states, "Whenever I have a chance to flip the script and tell people that being on hormones can be beneficial and more natural, I do." This counter-narrative effectively challenges the preconceived notion that uninterrupted cycling is the only "natural" or healthy state for the female body.

"A modern woman has about 400 periods during her reproductive life, whereas our ancestors had about 40." Dr. Deborah Bartz