Remy sprang forward in her chair. “Wait. No coffee? Really?”
“I’m sorry, yes.”
“A hundred percent no caffeine?” Remy looked visibly distressed. She sighed. “Oh, gosh. Okay.”
“Yeah, alcohol’s iffy, but caffeine’s a big one. There was a study that showed even under thirty milligrams of caffeine a day affected outcomes.”
“Alcohol’s not a problem. Giving up this”—Remy held up her smoked rosemary latte—“is going to be the problem.” She paused. “But I’ll do it.”
—
By the time another nurse came in for the final portion of the appointment, Remy’s head was spinning. “So much paperwork! So many different scenarios that might happen,” she said, wide-eyed, looking at me sitting rather deflated in the other chair. She sat up and arched her back against the chair, her long legs stretching out in front of her. The stack of forms in her lap was mounting. She was glad she’d remembered to move her crystals from the pocket of her scrubs, where she normally carried them, to the pocket of the shirt she’d put on that morning. She had four with her today: moonstone, helpful with transitions and new beginnings, supports all stages of pregnancy, childbirth, and fertility; elestial amethyst for empowerment; black tourmaline to feel grounded amid change; and fossil ammonite, evolution of the body and soul. A happy fertility combo pack—that’s how Remy thought of them. The moonstone was roughly the size and shape of an ovary. She carried the crystals on her body most days and meditated with them most nights. Tactile and cool to the touch, they gave her something concrete to feel, to focus on.
An hour later, the nurse had walked Remy through the medications, demonstrating how to prepare and inject the hormone shots into her abdomen. Syringes, needles, vials. There was so much to remember—and she’d gone to medical school, for goodness sake! She told me she couldn’t imagine a person who’d never before administered a shot going through this, and, honestly, I had to agree. We both felt drained, overloaded with information. The last part of the morning’s appointment was more blood work down the hall. Remy took a deep breath and brought her hands to her head, pushing her hair back. She glanced over at me. “This is a completely overwhelming process,” she announced, her tone both declarative and resigned. Then she quickly stood up from the chair before the fatigue could settle in.
The Pill’s Power—and Unintended Consequences
A common question many potential egg freezers ask is, “What if I’m on birth control?” Beyond the surface-level pragmatic answer—most IUDs don’t need to be removed; users of the Pill will simply stop taking it before freezing—is a more important matter: the relationship between hormonal birth control and fertility. Understanding this relationship required a working knowledge of something I knew very little about: hormones.
If there were a class called Egg Freezing 101 (there should be), hormones would be covered in the first week. That’s how fundamental a role they play in a person’s health, including fertility. Many women know something about hormones only in the context of their choice of birth control, which makes sense, because taking hormonal contraceptives is a common way women change up the balance of hormones in their bodies—to prevent pregnancy, to combat acne, to make painful periods more bearable. Artificially altering the mix of chemical signals in a woman’s body, however, often masks the effect of those alterations, which makes it nearly impossible for her to understand how her hormones operate in a natural, non-synthetic state.
Around the end of the nineteenth century and the beginning of the twentieth, scientists began to discover the chemicals that regulate various functions in the human body, including reproduction. The word “hormone” was coined in 1905; in the 1920s, human chorionic gonadotropin, or hCG—a hormone found in high concentrations in pregnant women—was identified. Hormones are chemical messengers that travel through the bloodstream to different parts of the body. Hormones fluctuate, increasing and subsiding, and in so doing they influence the body in far-reaching and powerful ways, regulating heart rate, appetite, mood, reproduction, sleep cycle, growth and development, and more. You are your hormones. It sounds trite, but it’s no exaggeration. Of the fifty or so hormones in the human body, estrogen and progesterone—the predominant sex hormones for women—are two of the most important ones connected to reproduction. To explain them, I need to go back to ovaries.
Ovaries are organs and part of the female reproductive system. An ovary is most similar in size and shape to a small walnut. At birth, you’ll recall, ovaries contain around one million to two million immature egg cells, or oocytes, all held within follicles—those tiny, fluid-filled sacs—and after puberty a single follicle from the group of available follicles is “selected” as the dominant one each month and recruited for ovulation. A view inside a woman’s ovaries reveals follicles, resembling a honeycomb, with their enclosed microscopic egg cells, in every stage of resting or growing. Zoom in closer and there are the granulosa cells, a halo of even smaller cells surrounding each egg that are essential to its development.[*4] In addition to housing oocytes, ovaries also direct several key operations—most notably, menstruation. The menstrual cycle is more than just a woman’s period; it is her reproductive system’s rhythmic changes. This cycle is like having an additional vital sign, similar to blood pressure or pulse. All the changes that occur throughout her menstrual cycle are governed by hormones. And where are the two crucial fertility hormones, estrogen and progesterone, produced? In the ovaries.
Let’s start with estrogen. There are three main naturally occurring estrogens—estradiol, estriol, and estrone—that play an important role in growth and reproductive development. Estradiol is the most common type of estrogen in reproductive-age women (and the one people are usually referring to when they talk about estrogen) and the one I’m going to tell you about. It’s produced primarily in the ovaries, specifically within the follicles, and is involved in reproduction, menstruation, and menopause.
If estrogen is a woman’s superhero sex hormone, then progesterone is its trusty sidekick, helping to regulate her monthly cycle and prepare her uterus in case of pregnancy. Estrogen is primarily secreted in the first part of a woman’s cycle, peaking around ovulation. Progesterone picks up where estrogen leaves off, alerting the uterus that an incoming fertilized egg may be on its way. In a normal menstrual cycle, the hypothalamus works with the pituitary—a pea-sized gland at the base of the brain—to send a signal to the ovaries to start making estrogen and progesterone and stimulate follicle growth. Then, as I mentioned earlier, a single follicle is selected to grow a mature egg for fertilization. The anointed follicle begins to secrete estrogen. The brain waits for the estrogen level to be high enough for long enough, which is its sign that there’s a dominant follicle containing a mature egg. Once the brain is alerted to the fact that there’s a mature egg, it sends out another signal to the ovaries, triggering ovulation. The follicle bursts. The egg breaks free, and its journey toward the uterus begins. The other, non-dominant follicles begin to break down, and the uterus starts readying itself for the possible arrival of a fertilized egg.
It’s amazing, really, how every month a woman’s body readies itself for a potential pregnancy. There’s a flurry of activity going on there pretty much all the time. I imagine a symphony: My reproductive system is one section of the orchestra and my brain the conductor, eliciting every note that’s played by way of hormones.[*5] The music that results from this feedback loop between my brain and ovaries (well: ovary) is determined by the cyclical changes in my hormones—especially estrogen and progesterone—which control which of my follicles are selected and develop, the release of my eggs, and my uterus primping and preparing to perform its duties as hostess in case a fertilized egg cozies up there. The orchestra could not play, would not be, without its conductor’s ability to wave its baton.[*6]
Human sexual reproduction is exquisitely complex. It’s truly remarkable that any of us gets born. This is not part of the messaging of grade school sex ed classes, which more or less scare young people into thinking that sex equates to unwanted pregnancy every time clothes come off. The reality is, while all I’ve described above is happening, the story becomes even more intricate. A sperm has to make a long and difficult journey to meet a woman’s ripe egg, which has made its own shorter but equally arduous trip. Millions of sperm battle to reach and penetrate the egg. After beating out its other sperm competitors, only one will break through the egg’s outer layer—think of a pea going into a basketball—and this is the magic moment: fertilization.
But we’re talking about what happens if there is not, in fact, a magic moment. If the star-of-the-show egg hasn’t been fertilized by the sperm and there is nothing to implant in the endometrium, the egg dissolves and the uterus begins to shed the lining that it has been developing to receive a fertilized egg. A woman’s period, or monthly bleeding, is the shedding of the endometrial lining. That’s why the arrival of a woman’s period is usually a sign she’s not pregnant.
As we’ve just seen, virtually every part of this delicate symphony is run by hormones. And so no matter what she is using it for, hormonal birth control transforms the regulatory systems in a woman’s body in a sweeping way, which can have all kinds of intended and unintended consequences.
One of those unintended consequences, it turns out, is why I’m here telling this story.
—
After my first emergency surgery, doctors told me that while it was unusual and unfortunate that I’d needed to have an ovary and fallopian tube removed, my chances of becoming pregnant naturally weren’t affected by my loss of one ovary. Once I began menstruating, about a year later, my periods were more or less regular; in a miracle of compensation, my other ovary took over, popping out an egg each month. Life resumed, and I happily went back to sports, friends, and my adolescence. Years later, though, trying to piece together my particular situation and the chain of events that caused me to almost lose my remaining ovary became an important pit stop on my journey to make a decision about egg freezing.
The summer after my sophomore year of college, a boy I adored and I broke up. We’d dated on and off for a year. There were nights staying up until dawn talking about music and sharing playlists and days spent draped on the couch together reading books like Moby-Dick for a favorite literature class. We enrolled in the same astronomy course only to get in the bad habit of skipping most of the early morning classes; I loved stars, but I loved staying in bed with him more. Once, after one of our “off” periods, he asked my roommate to let him into our apartment while I was out and I came home to rose petals scattered throughout my room, a love note on my pillow. He was a dreamer and I was in my Kerouac phase, enthralled by sensitive hearts and sharp minds like his. I was pretty sure we were in love, pretty sure I’d never felt so alive with anyone, and then we went home for the summer. Suddenly, all the miles between us made communicating feel like a chore; our intense connection seemed like a fire that burned too bright too fast. The relationship sputtered until, for reasons I’m not sure either of us understood at the time, it was over in the same whirlwind way it had begun.
Back on campus in the fall, I found myself thinking about him every morning when I took my birth control pill. The constant reminder that he and I were no longer having sex grew more and more frustrating until one day I chucked my pink pack of pills in the trash. No reason to continue taking the Pill if I’m not having sex and not at risk of getting pregnant, I figured. I’d soon be leaving to spend a semester abroad in Ghana, and so, with some degree of petulance, I decided not to bother going to the trouble of filling a prescription of several months’ worth of pills to take with me.
When I was prescribed the Pill at my college’s student health center, several months before that breakup, I didn’t have a conversation with the nurse practitioner about its possible side effects—mood swings, bloating, spotting—and I didn’t know to ask. I knew the Pill helped protect against pregnancy; that was why I wanted to go on it. But I didn’t understand how it prevented ovulation by interfering with the natural balance of hormones in my body. And I definitely didn’t know that it suppressed the formation of ovarian cysts.
This would turn out to be something I really wish I had known.
Until I understood what it was, the word “cyst” made me think of tumors and cancer. But “cyst” is a generic term for a fluid-filled structure that can form almost anywhere in the body. And most ovarian cysts, it turns out, are common by-products of ovulation; they’re actually part of the follicle that the egg comes from. These functional cysts, as they’re called, are found in nearly all women who have a normal menstrual cycle—except those who are on hormonal birth control. So, just to be clear, premenopausal women who are ovulating and are not on hormonal birth control tend to develop ovarian cysts.
Quick recap: Ovaries contain follicles. Follicles hold eggs. At any given time, there are follicles at all stages of development in a woman’s ovaries. Ovulation occurs when a follicle releases an egg, every month or so. After a complex series of interactions between the brain and the hormones in the ovaries, the follicle housing the egg bursts and the egg is released.
Once the egg has vacated the premises, the left-behind follicle seals itself off and morphs into a yellow, fatty-looking structure known as the corpus luteum. So this mass of cells has a new name, and it has a new job as well. If pregnancy occurs, the corpus luteum continues making progesterone, a hormone that stimulates the uterus to thicken in preparation to receive the incoming fertilized egg. If pregnancy doesn’t occur, the corpus luteum stops producing progesterone, begins to break down, and, after about fourteen days, disappears. As progesterone levels drop, the uterus gets the message that there’s no need for lining this month, and a woman gets her period. But sometimes, instead of shrinking away, the corpus luteum lingers and grows, filled with light yellow fluid. This buildup causes a corpus luteum cyst. This is one type of functional ovarian cyst; the other, a follicular cyst, forms when the follicle stays intact, instead of rupturing and releasing its egg. Sounds a bit aggressive, but functional ovarian cysts are usually harmless, rarely cause pain, and often go away on their own within a few months of forming.
It’s when one of these normally-not-a-big-deal cysts swells up with too much fluid and becomes abnormally large, doesn’t shrink away, and/or bleeds into itself that there starts to be cause for concern. That’s where, in my case, things got tricky. For a long time after my second surgery, I wondered why an overgrown, blood-filled cyst had developed on my ovary and if there was any definitive explanation for the medical emergency it led to. There isn’t. But as I learned more about how the Pill works, I grew suspicious. I’d been told that my abruptly going off the Pill several months before I landed in the emergency room very likely had something to do with why I almost lost my remaining ovary. I accepted this as fact when my doctors explained it to me in my post-surgery haze. I was still in a considerable amount of pain. I felt very, very grateful I still had my ovary. At the time, I didn’t really want to fully understand what had transpired to land me there. Now, though, I’m able to explain.
I talked earlier about the considerable impact the Pill has had in the more than sixty years it’s been around. On a more micro level, it’s also had a tremendous impact on the biology of every person who has taken it. The Pill—which, in case you haven’t seen one lately, is about half the size of an Altoid—doesn’t just block sperm from reaching an egg; it changes the entire internal landscape of a woman’s body. Tens of thousands of studies have explored how hormones influence behavior, and there’s evidence that the Pill impacts several bodily systems, affecting everything from sexual behavior to appetite to emotion regulation to whom we’re attracted to.[*7] Members of my generation are among the first to be on long-term birth control for the majority of our adult lives; from the minute we’re sexually active until we decide to start trying to become pregnant, many of us are “on” hormones. Birth control pills are used today by roughly 20 percent of the country’s women using contraception. It took some time for reproductive biologists to figure out what the Pill was best used for, and for that reason it has a colorful history of off-label uses. Before Enovid received government approval to be sold as a birth control pill, for example, it was marketed as a cure for irregular menstrual cycles. But while doctors puzzled over the precise explanations for the Pill’s effects, all that the over half a million women who started taking it “off-label” needed to know was that it prevented pregnancy.
Here’s how it works. The Pill relies on synthetic hormones to prevent ovulation and thus pregnancy. “Synthetic” hormones, those produced in a lab, are modified to imitate natural hormones. Women’s bodies, you’ll recall, make estrogen and progesterone on their own. In a normal menstrual cycle, levels of these sex hormones fluctuate up and down. When you take the Pill, these fluctuations stop and levels are kept stable. Hormones, as I’ve said, are chemical messengers, facilitating communication between cells throughout the body. The Pill alters the normal feedback loop between the brain and the body. The ovaries don’t get the message from the pituitary gland to make estrogen and progesterone, and the brain, in turn, isn’t told by the ovaries to continue the cycle, so it stops directing the ovaries to select and develop a dominant follicle and release an egg. That’s why women who take hormonal birth control don’t ovulate. (You’re neither killing off nor “saving” the extra eggs; you’re just not using them.)
Most birth control pills contain a synthetic estrogen, usually ethinyl estradiol, and a synthetic progesterone, called progestin. These synthetic hormones, taken in the form of the Pill, do some pretty heavy lifting to stop a woman’s ovaries from releasing eggs and make the uterus inhospitable. They thicken her cervical mucus, which makes it difficult for sperm to reach the egg in the first place. They also keep the lining of the uterus thin, which discourages a fertilized egg from implanting there.[*8] So, there’s no egg in the tube, the sperm’s already treacherous journey becomes nearly impossible, and the uterus becomes a far cry from a cozy, safe cocoon. When the egg and sperm can’t get together, pregnancy can’t happen. (And if, against all odds, they somehow still managed to connect, they wouldn’t last long in such an inhospitable meeting place.)
The Pill does all this by suppressing the release of two other naturally occurring hormones: follicle-stimulating hormone (FSH) and luteinizing hormone (LH), both produced in the brain’s pituitary gland. Remember how the brain sends signals to the ovaries to develop follicles and release eggs? FSH and LH are those signals. FSH stimulates follicle growth and tells the ovary to recruit and mature an egg. LH is the surge that indicates ovulation is about to occur; it sets ovulation in motion by telling the ovary to release the mature egg. So, the Pill’s synthetic estrogen suppresses FSH, preventing a dominant follicle from developing, and the Pill’s progestin suppresses LH, blocking ovulation. And no ovulation means not getting pregnant.
In short: When used correctly, the synthetic hormones in hormonal birth control prevent a woman’s ovaries from developing follicles and releasing eggs (ovulation), which in turn prevents the growth and shedding of her uterine lining (the natural period). The Pill in essence short-circuits the brain and stops a few key aspects of the body’s usual hormonal cycling, typically a delicately controlled equilibrium. The symphony has stopped, the music replaced by an entirely different composition of the powerful chemicals the Pill contains.
Bye, natural hormones. Tag, you’re it, synthetic hormones.
There are hundreds of brands of birth control pills on the market, and new ones come out often. Most women take their doctor’s recommendation for which kind to take and usually try a few different brands before finding one to stick with. The variety can be daunting. It’s not all that easy to find the right hormone dosage, especially considering that birth control pills use different types and varying potencies of synthetic progesterone and/or estrogen. Women are encouraged to experiment with different brands of the Pill, which makes it sound fun even though it’s not. The Pill’s positive side effects are great ones: For many women, it eases cramps and PMS, clears up acne, and makes periods lighter and more regular. (The Pill’s negative side effects, which plenty of women are familiar with, are not so great; more on that shortly.) A “period” while on the Pill, by the way, is actually called withdrawal bleeding—it’s not a real period. But even though the Pill effectively puts a woman’s natural hormone rhythm into sleep mode, her body still reacts when her hormone levels drop, which happens when she takes the placebo pills at the end of the pack.[*9] In the case of both withdrawal bleeding and a period, the decrease in hormones causes the mucus and lining of the uterus to shed and exit through the vagina. So this fake “period,” while typically lighter and shorter than the real thing, can still cause PMS symptoms in some women, including headaches, nausea, mood swings, and sore breasts. These are more common in the first few months of being on the Pill and usually—but not always—go away, or a woman simply gets used to them.
No ovulation means no egg to be fertilized. It also means follicles don’t grow; they’re hibernating, so to speak. And no mature follicles means no corpus luteum—and no functional ovarian cysts. Ah. This very small fact—that, in addition to everything else it does, the Pill helps reduce the size of ovarian cysts and sometimes prevents them from forming at all—is, for me, a crucial piece of information that I did not have when it mattered most.
Decades ago, doctors learned that women taking birth control pills had fewer cysts, since the hormones in the Pill typically stop follicles from developing. Here’s the bit I really wish I’d had some inkling about: that going off the Pill and waking follicles from their deep slumber can lead to a functional cyst growing too large, which in turn can cause the ovary to twist (remember that kinked garden hose?). Ovarian torsion, an uncommon but serious condition, must be treated quickly. If it’s not, in rare cases it can result in the loss of an ovary—because the twisting cannot be undone.
I certainly didn’t know any of this when I was in college and going on, and then suddenly off, the Pill. But I believe I should have. I prided myself on being an informed and self-aware young woman, attuned to matters of body and health. But when it came to hormones, my reproductive system, and birth control, I was mostly clueless.
