The pill, your periods, and sugar

Dear Doctor Ninja,

You know how there are sugar pills in contraceptive pills? Recently, I learned that it’s not necessarily unhealthy to have skipped periods. Does it mean I can skip the sugar pills and continue to take the non-sugar pills to stop periods altogether? My husband and I are not planning on children and I’ve always felt that having periods are kind of a pain.

What is the story?


Confused 40 Something

The history of the birth control pill is amazing. It’s not only a story about discovery, but also one of medicalization, society, religion, sex and marketing. Whole books have been written about all of this. But you’re not here to read a book; just some quick advice from a ninja in pyjamas.

The typical set of birth control pills comes in a “monthly” set. 28 pills. Twenty-one of those pills have hormones in them—usually a combination of some form of estrogen and progesterone, which are the hormones that are responsible for signaling ovulation (release of an egg from an ovary) as well as for signaling thickening of the lining of the uterus (the organ also known as “the womb”). Twenty-one pills with hormones, but 28 in a pack. So what’s up with the 7 remaining pills?

These are the “sugar pills”; they’re pills that have no hormones in them, though probably not much sugar.

Why are they there?

In order for the birth control pill to prevent pregnancy, it has to be taken every day. The daily dose of estrogen prevents ovulation. The dose of progesterone thins the lining of the uterus, making it difficult for a fertilized egg to implant there.

However, two competing stories about menstruation figure into why these sugar pills are there at all:

1) that not having a period causes build up of “bad things” (dating back to some cultural beliefs about the “uncleanliness” of menstrual blood); and

2) periods are also a signal that one is indeed, not pregnant.

In the time of the introduction of the birth control pill, both of these stories figured prominently in both the minds of the inventors as well as the public. In order for the birth control pill to be accepted by the public, and thus for it to be successful at the goal of preventing unwanted pregnancies, periods still needed to happen.

Today, women have much more choice when it comes to controlling this aspect of their body. It is, however, a choice under constant threat of being taken away, both from a policy/interest group point of view as well as an accessibility point of view (with regards to costs, but also the intersection between cost and ideas about the “rightness” of birth control in general).

While there is some risk in taking the birth control pill (most famously, blood clots), there does not seem to be any evidence to suggest that not having a period puts you at any higher risk than that. The risk of having a blood clot ranges from 0.03 to 0.09 percent (3-9 in 10 000 people taking the pill). That you are already taking a birth control pill suggests that you are at least okay with the baseline risk that comes with this. Not having a period does not make this number higher.

There are longer term options available on the market; ranging from having a period just four times a year, to not having one at all.

In the end, deciding which option is best for you depends on how much you think of a period as being a sign that you aren’t pregnant, and also the associations you have with having a period and feeling like “things are okay”. For some, this association is very strong, and never having a period can cause distress even though they know the current facts about risk.

The “sugar pills” were never about what we know; they’re about how we feel.


Dear Doctor Ninja,

I’m a trainer in California and one of my new clients is a trans-woman who has completed her surgical affirmation. She is dieting and wants to continue losing weight without gaining muscle and wants to “tone”. I’m wondering if any of the exercises we might use could mess up her hormones somehow, and in particular her testosterone?


H. Ormonal

The process of affirming one’s gender happens in stages, but I think the short answer to your question is no, none of the exercises you might use would “mess up” hormones, regardless of what stage your client could be in. If your client is following the WPATH (World Professional Association for Transgender Health) process, then she would have had to been taking estrogen for at least a year before her surgeries, and depending on which surgeries she decided to have, may have had her testes removed, thereby essentially removing testosterone from the picture moving forward.

However, all of this is relatively moot.

From an aesthetic point of view, it sounds like your client would like to look thinner and leaner. “Tone”, as most trainers know, is achieved through having some muscle bulk, so that the “thin” doesn’t look “bony”, or starved; but also through body fat loss as well, so the fullness that covers the bony bits doesn’t look “soft”, which appears more fat-like to the eye.

It seems like you have the fat-loss part down. Your client is already losing weight and would like to continue. But you’re worried about how to build muscle mass without over-building it and somehow the trans- part of this client has your mind spinning in directions that you wouldn’t have if this client had been cis-gendered.

The arguments that some women have against progressive resistance training is that they will look too bulky. And perhaps, in some people, this could be an issue. But given the effort it takes for most cis-men (with typical male testosterone levels) to put on muscle mass, it’s unlikely that your client (even if they’ve retained their testes) is going to radically change her appearance within a period of time that you couldn’t adjust things in time. Even with the increases in testosterone that are seen with resistance training in cis-men, the time it takes to build enough muscle mass to make an aesthetic difference is high for most people.

Given that we know muscle mass is built by progressively increasing workload, and is lost by inactivity or decreasing workload, the solution is to respond to changes as they appear. There has to be enough muscle mass to hide things like ribs and sharp shoulder angles. So your client can’t just diet/train down to “thin” if she also wants “toned”. At some point, that muscle mass might start to look bulky. And regardless of what hormones are at play, the fix at that point would be to dial down the workload.

I suspect this is the approach that you would use for a cis-woman. You already have the tools to bring this client success. Don’t let the trans part get in your way here.