Dr. Stephanie Lam returns for an episode on contraception. In this episode, she explains the discussions that gynecologists have with patients on contraception, including choosing the right type of birth control, the symptoms that contraception can alleviate, and protection against STDs.
Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. Steph Lam, welcome back to the “Healthful Woman” Podcast. It’s so nice to see you.
Steph: I was waiting for you to call me back for this. I could not wait to do my next podcast.
Dr. Fox: Yeah, Lam has been just knocking down my door. Just really just please let me get on again. Please, please.
Steph: Well, actually, this topic, in particular, is actually one that I like to talk about. And we spent all day doing contraception so this is gonna be exciting actually.
Dr. Fox: It is. I mean, even though, you know, Stephanie is like one of the most personable outgoing people on earth, she is not yet the podcaster deep within. We’re getting it.
Steph: You’re converting me.
Dr. Fox: Yeah, we’re good. I’m just driving into you like…
Steph: You’re a natural, I’m not. So I would say…
Dr. Fox: Like a nail and a hammer. right.
Steph: Right. I’m trying to be like Fox when I grew up.
Dr. Fox: We’re in the month of January in 2021. You and I both received our second dose of the COVID vaccine in the past week.
Steph: Very excited. Really excited.
Dr. Fox: So yeah, here we go, back ends of this hopefully.
Steph: One can only dream that everyone can get access to this vaccine soon enough and that we can start to turn the corner because we need to move on. So yes, I was excited to get my second dose.
Dr. Fox: Yeah, my mother in law got her dose, her first dose yesterday. My father got his first dose yesterday.
Steph: Oh, good.
Dr. Fox: My mother has not yet gotten her first dose because they’re in Illinois my parents and my dad got it through the hospital because he’s a doctor. My mother hasn’t gotten hers but it’s starting slowly.
Steph: My parents are going tomorrow.
Dr. Fox: It’s great. It’s great. A little bit too slow, I would say, but better slowly than not at all.
Steph: Correct.
Dr. Fox: Excellent. So as you said before, we’re gonna talk about contraception today, which is clearly a topic that gynecologists talk about all the time. I mean, this is like pretty much everybody.
Steph: Bread and butter. This is what we do.
Dr. Fox: Unless you’re actually pregnant right at the time, at some point we’re talking about contraception. Is that a conversation that you just bring up or is everyone talks to you about it when it’s already happening or do you address it every visit?
Steph: Patients come in for all different reasons. And usually, when they’re scheduling an appointment, we get a little bit of a clue as to what they’re coming in for. Sometimes they’re coming in specifically because they want to go on birth control. We have a good number of very young patients who are considering birth control for several reasons. We give birth control to prevent pregnancy but I would say it’s something that I try to bring up in conversation at most of the visits like the topic of so where are you at? Are you thinking or trying to get pregnant? Are you looking at holding off pregnancy? And it will come up most of the days, for most of the patients.
Dr. Fox: Right. It’s interesting because there is some conflating of this because, on the one hand, contraception is specifically talking about…
Steph: Anti…
Dr. Foxx: Right. Things people can do to not get pregnant, hence the word contraception, it’s like conceive, against that. But one of the more common forms of contraception that we’re gonna talk about, which are, you know, hormonal, like pills are used for many other reasons like you said, or cycle control, sometimes for pain. There’s a lot of reasons. So there’s frequently times when we’re talking about, we call it contraception or birth control, but that’s not the reason it’s being used for, you know, either women who are…
Steph: Going through perimenopause.
Dr. Fox: Right. They’re not sexually active even or for teenagers, young girls who are not. And I was curious…and this is really sort of an aside, but I thought we can address it now. When you’re talking about that with, let’s say, teens. And how do you sort of talk about okay, we’re gonna do this and then sort of jump into well, are you sexually active? Are you thinking about it? Is that something that you decide person by person or do you say like, I’m always gonna talk about that? How do you navigate that? Because I imagine it could be tricky based on the age.
Steph: Depending upon the age of the patient, we usually…we’ll have a parent or a support person, or somebody who’s basically coming with the patient, depending upon their age. Now, in the world of COVID, it’s been a little tricky having that kind of visitor in the office kind of experience, but that parent…
Dr. Fox: Just turn off the Zoom for 10 minutes.
Steph: Correct. Will be either via Zoom…
Dr. Fox: I’m muted, I’m muted. What happened?
Steph: I can’t hear you. What are you talking about? What do you mean you’re sexually active?
Steph: So usually, depending upon the age of the patient, we will try to include someone in their family, to be part of the conversation. I do not believe in the taboo of not talking about sexuality. I think, are you sexually active? Do you have a male or female partner should be a question that we’re asked, and we shouldn’t feel uncomfortable with it. And I think it makes the patients happy.
Now, do they want to necessarily answer honestly all the time in front of their mom? That’s a trickier discussion. But yeah, I usually will bring it up with the 15s because they’re having sex. Not all of them, but there’s a lot that out there sexually active. And I think if you assume that they’re not or you don’t want to talk about it, then you cannot pick the right form of birth control for that patient.
Dr. Fox: Many of the forms of birth control will not protect against…
Steph: Sexually transmitted diseases.
Dr. Fox: Sexually transmitted infections and diseases. Some will but many won’t. And so again, if let’s say, you know, a girl’s coming, she’s like, “Oh, I’m gonna get the pill for cycle control and now I’m okay.” Like, if you don’t have that conversation, she may not know it, or she may end up being a risk for getting certain infections and it’s important to talk about that.
Steph: I mean, I have a daughter now who’s 11 and who’s very…she’s just young in lots of different ways. But I eventually one day…[inaudible 00:05:19] having the conversations easily now but you have to prepare them. Because if they think that they’re taking birth control for cycle purposes, their periods are crazy, they’re heavy, they’re so uncomfortable, the pediatrician sends them into me. And I don’t say to them, “Well, you know, this will protect you for your cycles, but it may protect you also for pregnancy, but if you don’t use that condom, you’re gonna come back to me with some sexually transmitted disease, “I’m doing her a huge disservice. So I usually try to do the conversation in a little way, at least once.
And then usually, if we’re starting, most people on birth control I try to touch base with them within a couple of months to see how they’re doing on the pill, or IUD or whatever it is.
Dr. Fox: I’m curious, in your practice, again, just because we’re in this topic, when this does come up and let’s say it’s the parent, you know, the mother who’s with her, is that something that when it comes up, most of the time the mother is like on board like, yeah, we need to discuss it, this is important, or most of the time mother’s like, what the hell are we talking about here? Why are we talking about this? This is insane. Because I imagine it could go either way.
Steph: This sexual activity perspective?
Dr. Fox: Yes. Sexual activity, and contraceptives, all these things.
Steph: I think most of them actually may get a little uncomfortable, depending upon where the patient’s from, you know, how savvy they are, that type of thing, if they have a boyfriend or don’t have a boyfriend. But usually, the patient, if they’re coming in and they’re sexually active and they’re looking for a birth control option from that perspective, not just bleeding, their mom’s been informed that they’re coming in for that reason. If they’re coming in for bleeding, I feel like you may have to navigate the conversation in a way.
And the patient’s parents, or whoever’s coming with them is usually fairly receptive. And I usually say to the patient, am I free to ask questions with your mom present, if you feel like there’s some answers that you want to describe in other ways? Usually, the mom will say, “No, no, I understand. I can step out or you can ask her privately.” They’re usually receptive.
Dr. Fox: Yeah, I would think that there’s obviously some parents who would just be so, you know, shock and horror over this, that they just, you know, collapse. But I think…listen, I’m a parent and I have teenagers. I think the vast majority of parents are like, please, God can you handle this instead of me?[crosstalk 00:07:16.495]
Steph: Take this off. Please unload this off of my plate. I don’t want to talk about this.
Dr. Fox: Right. If I can outsource that whole part of, you know, child rearing to somebody else, thank God. That’s unbelievable. And I think a lot of people are relieved.
Steph: They’re relieved. And I always say to the patient, you know, I’m always here for you to call me and to have discussions on any of the different topics. And the moms usually, or whoever’s coming with them is also very relieved, like, okay, you can now reach out to your gynecologist and I support you please, you know, lots of different questions. You don’t have to come to me. But yeah, the parents are usually fine.
Dr. Fox: Getting back to the general topic of contraception or birth control, when you’re approaching this topic with somebody or they’re approaching it with you, in terms of all the options, how do you even begin? Because there’s a lot of options, and so how do you begin that conversation?
Steph: Sometimes, and when patients come in and they say that they want to talk about birth control, I always ask them, is there a particular type of birth control that you came in thinking that you were interested in? So I always kind of have an open-ended question like, guide me as to where you think you’re going.
I usually break it down that there’s hormonal and non-hormonal forms of birth control. So there’s just two categories to start out with. And then there’s the most effective going down to the least effective. Obviously, the most effective form of birth controls are the IUD, there are sterilization and there are implants like the Nexplanon. And depending upon which way the patient says like, I have no interest in hormonal birth control, then it cuts my conversation down by more than 50% and I guide it that way.
If patients come in and they say, I’m interested in an IUD per se, which social media has blown up the IUD topic. In general, it’s one of the most popular forms of birth control in this country. Then it’s easy, because there’s four different choices, and I narrow down that way. But I usually will incorporate the conversation a little bit on everything. But I start out with, “Are you looking for some hormones or no hormones?” and I also guide it based upon age and what their symptoms are.
If patients come in and they have very heavy periods, they’re very uncomfortable, they would benefit from a hormonal form of birth control. It will make their periods much lighter, it will protect them from, you know, getting pregnant, and it’s just kind of becomes this thought process of how I could break it down based upon what they’re thinking.
Dr. Fox: Right. And I think there’s also the idea of what is their goal. Like for some people…
Steph: Short term, long term.
Dr. Fox: The goal is I need three months, I need six months, I need the rest of my life. Other people it’s, I’d be okay if I got pregnant, but I don’t want to get pregnant versus like I cannot get pregnant.
Steph: Right. And we see patients here, like I said, from the very young to the perimenopausal to menopause. We see patients at postpartum visits and exactly why they’re coming to us. Everyone’s completely different. So for someone who’s thinking very short term, I would lean against an IUD because that would really be ideally meant for more longer term.
If they want no hormones, then it breaks it down into a different way. So I think the conversation doesn’t have to be more than five minutes. It’s actually pretty quick that you can get an idea of what they’re looking for, but we do try to tailor it right to the individual patient. Like there’s no two forms of birth control that are right for the same person.
Dr. Fox: Exactly. And I think we’re gonna go through each of the forms and sort of what are the…
Steph: Pros and cons.
Dr. Fox: Pros and cons, how effective, not effective, what does it mean, which is really helpful. And then sort of, based on all those, you have to take, you know, what exactly are we looking for and what’s the situation and decide which one would be the right thing for that particular woman. Okay, so let’s start. So obviously, not having sex is one way to not get pregnant. That works.
Steph: It works.
Dr. Fox: It definitely works unless you’re going to an IVF doctor, in which case you can get pregnant all the time without having sex, that’s… But other than that…
Steph: They’ll appreciate the plug on that one for sure. Go ahead.
Dr. Fox: Yeah, that tends to be the most expensive form. Okay, so let’s start with things… I just sort of put them down…things that don’t work so well. So what is called the in Latin, the coitus interruptus, which is a really fancy medical term that is odd, basically pulling out.
Steph: The withdrawal method.
Dr. Fox: Right. The withdrawal method. And why does it not work so well?
Steph: Every single month, every single patient can ovulate at different points. And so, if you try to either time and withdraw at a certain point, thinking that you’re going to not get pregnant, there’s still a certain amount of ejaculate that may actually get inside the vagina, and you could still conceive on your own.
So the withdrawal method, the pull and pray, however you want to state it…
Dr. Fox: Pull and pray.
Steph: For lots of different people is not a very effective form of birth control and is probably way less than 75% effective as a form of birth control for patients. But for patients who think that they have no interest in hormones and no interest in birth control, it’s out there. People do it.
Dr. Fox: Yeah, I mean, listen, it is certainly…you’re less likely to get pregnant using that method than not using it. It’s just not reliable enough in the sense it really matters.
Steph: Correct. Because there’s pre-ejaculate, there’s ejaculate, there may be some inside the vagina, depending upon if you’re at the very fertile time of the month, it may only take a little bit, and it is definitely not 100%.
Dr. Fox: Right. And the same is true what you were referring to, before this idea of, you know, either timed or rhythm method. I think the rhythm method is you have to like have like Barry White playing in the background.
Steph: You want good music at the time that you do it.
Dr. Fox: Yeah, so but that’s ideal where you try to calculate when is she gonna ovulate and just not have sex during that time period. Again, it is more likely to be effective than not doing that but since you don’t know for sure when someone’s gonna ovulate, it doesn’t tend to work. And so these are things that, for example, are not recommended for like teenagers, for example. This is signed, like, are you people who are like, all right. Yeah.
Steph: As far as the rhythm method goes, if you have somebody who is open to getting pregnant hypothetically because it’s not that effective, if you have a very predictable cycle, if you happen to know that you are a 28-day cycle and that you know that you are ovulating at a certain time of the month get within certain days, that would be a fairly decent. If you are an immature younger patient or someone who has cycles that are all over the place, it’s a setup for disaster. It may not be very effective.
Dr. Fox: Right. Okay, so let’s move on to sort of the next level, things that work a little bit better. So talk about spermicides.
Steph: There’s the next category which would probably be a third-tier as far as efficacy, the over-the-counter preparations that you can go to your local pharmacy. Spermicides have been on the market forever and ever and ever. They can be used alone, or they can be used with other forms of birth control, such as a diaphragm or a condom. They require you to place it around the time of intercourse, a generous amount of spermicide to some degree. You’re looking at a failure rate probably of somewhere at least 18 people out of 100, it may not necessarily work well for.
Dr. Fox: Meaning they’ll get pregnant.
Steph: Correct. It’s not very effective. It’s decent and it’s definitely an option for patients who are looking for an over the counter preparation. And it increases efficacy when you join it with a different form of birth control, such as condoms, or a diaphragm. But alone, it’s not the best form of birth control.
For some patients, for women, they may have a sensitivity to the spermicide. It may increase irritation, yeast infections, bacterial infections, so they may notice some irritation with the spermicide itself. But it’s definitely out there and it’s been around for years and years.
Dr. Fox: Right. And how are they marketed? They’re gels, they’re films, they’re tabs, like what is it they they…as everything?
Steph: They come in all different forms. The most popular probably would be the gel, and it comes in a tube. There’s a VCF film that has like a spermicide component to it that’s an over the counter preparation as well. Once again, I think for some of our patients who are looking for short term forms of birth control, they don’t do well…they say that they “don’t do well” with hormonal forms of birth control. It’s definitely an option that’s out there.
Dr. Fox: Right. And then tell us about the diaphragm. What is that?
Steph: So the diaphragm used to be quite popular years ago, and then it fell out of favor. It kind of made a little bit of a resurgence I think now. It’s a barrier form of birth control. So literally, it has a ring on the outside that’s collapsible and it has a film on the inside that has no holes literally. And you fill that diaphragm with some spermicide prior to placing it inside. Ideally, it’s placed approximately 30 minutes before intercourse. It is not hard to place. Nowadays, it’s one size fits all, practically. It’s easily prescribed by your gynecologist.
Dr. Fox: Because you used to have to get fit for a diaphragm, what size are you.
Steph: Correct. They were all different sizes. And they ran from, you know, certain sizes in millimeters to a little bit larger and we would have the patients come in and fit them. And now there’s just kind of this one size diaphragm that pretty much has taken over the market. You have to leave it in for a period of time after intercourse in order for the semen to kind of stay with the spermicide so that you don’t pull it out and get pregnant.
I think for patients, once again, it’s in the third tier of efficacy to some degree. Patients don’t necessarily…aren’t uncomfortable, it doesn’t bother them. It may bother patients partners, they may feel it like they’re hitting something and that may not be so pleasurable. But it’s not one of the most effective forms of birth control out there. It also may, depending upon if you’re prone towards urinary tract infections and yeast infections and such, you may have a higher risk of developing those if you’re using the diaphragm.
Dr. Fox: Right. Why did it fall out of favor? I mean, it was definitely used… I mean, 20 years ago it was much much more common. Is it just because it was inconvenient, or because it wasn’t as efficacious?
Steph: I mean, it’s definitely not as efficacious, number one. Two, it’s not as user friendly. You have to be comfortable, I think, a little bit with your body that you’re willing to put it in beforehand. It requires some knowledge of intercourse, the spontaneity of it is a little bit less, you know, let’s do this. And you also have to remember to take it out a period of time afterwards.
But I do think it has come back because patients in general…I don’t know about nowadays, but are leaning less towards hormones. There are a lot of patients that come in specifically and say I don’t want a hormonal form of birth control, I just want my body to be my body. This is a perfect form of birth control for them.
Dr. Fox: Right. And there are also some women who, for medical reasons, really can’t take hormonal birth control. It’s the minority, but there are some, and for them, they’re like, listen, what am I supposed to do?
Steph: Right. These are my options. And it fits into a very good form of birth control that’s accessible to lots of people. You can get it through your local pharmacy, we write a prescription with some refills. The cleaning afterwards is really easy. Some soap and water, you let it air dry. You, as a female, are taking control of this form of birth control as opposed to a male condom, which to some degree, then you’re waiting for the male to be responsible for the form of birth control. So this puts the power in the woman’s hands a little bit more.
Dr. Fox: And just to be clear, the diaphragm, even though it is a barrier, it’s really just a barrier to semen and sperm not to infections.
Steph: Correct.
Dr. Fox: It does not protect against infections.
Steph: It does not. The only one that we say is effective to decrease the risk of transmission for HIV and sexually transmitted diseases are the male condom.
Dr. Fox: Right. So let’s talk about that next. So condoms are obviously barrier contraceptive. They’re quite effective in regards to pregnancy.
Steph: Yep, they are easily accessible. Any person can go into a pharmacy and pick up a condom. They are different sizes for the condoms so we hope that when the male partner is picking up a condom, that they are being accurate as far as the size because a poorly fit condom will not be a very effective form of birth control. It is the number one form of birth control that will decrease the risk of transmission for sexually transmitted diseases, and is the gold standard for that.
So if I have a patient who comes in is interested in birth control and they have a new partner, the condom always goes hand in hand with another form of birth control. It is fairly effective. In perfect use, I think they say can go anywhere from, you know, maybe 10 to 15 out of 100 to all the way, in perfect use, to as few as 5 out of 100 getting pregnant. So if it’s well fit, if it’s perfectly used, if you add spermicide on top of it, it is a very good form of birth control.
Dr. Fox: Right. Excellent. And again, it’s the only one that’s really gonna reduce the rate of infections. So someone is either going to rely on that alone, or that plus something else, if they want to lower their chance of getting pregnant on top of that.
Okay. And then from there, the most, I guess, common I would say other than condoms would be the hormonal like pills. How do contraceptive pills work? Like what happens?
Steph: So there’s different types of pills that we break down to either monophasic, which is the same dose every single day that you take a pill or you could have a triphasic pill, which is a different dose every week hypothetically. And so the ingredients in the pill vary from brand to brand. You have pills that can be progesterone, only one single hormone or you can have a combination, which is estrogen and progesterone. But the whole goal is that it prevents ovulation. So essentially, your hormones that we’re taking in a pill will supersede the hormones that are being produced in your body. They will prevent ovulation and allow you not to get pregnant.
Dr. Fox: There are so many different pills out there on the market.
Steph: There are.
Dr. Fox: And there are so many options. But basically, you know, they all have progesterone, some form of progesterone. It’s actually not technically progesterone, it’s something that’s made to look like progesterone, but whatever, it’s a detail. And most of them will have an estrogen component.
And the only thing that differentiates the pills, one from another, is number one, the dose of the estrogen. Meaning everybody uses the same estrogen it’s just how much is in there, ranging from zero to a certain number, and the second one is, which type of progesterone. So that’s where it really gets varied. And so you can imagine you have, you know, six different doses of estrogen, times six different types of progesterone and each of those have doses, and that’s why there’s so many on the market.
Steph: I could give you the same pill to 10 different women, and I will say…two will say they love it three will say that they’re fine with it, two will say that they hate it and it could be the same pill [inaudible 00:20:49].
So how you choose the pill, it’s kind of like anything in medicine, you develop your favorites. You find the ones that patients don’t complain about the most, that they seem to have less bleeding profile with, that they don’t feel… Because the biggest complaints that we will hear from patients, I’m getting breakthrough bleeding or spotting, I feel super moody or emotional. They will complain that they feel like they’re gaining weight, or they feel puffy or bloated. And the last thing that you want to do is prescribe a pill that they’re gonna call you back and complain on.
So when I look at the patient, I kind of look at the age of the patient, I look at how heavy she is. Is she very thin, is she a little bit heavier? Has she taken the pill in the past? And I always start out with well, have you ever been on the pill and what was what did you take and if you liked it. I usually will write them for what they have taken before. If it was a winner before, why would I switch it? And if they haven’t liked something in the past, once again, is it a different dose every day or week or maybe the progesterone wasn’t ideal for them. And so, you kind of play with it a little bit and there’s no right pill for anybody.
Dr. Fox: Yeah, and I think one of the important lessons there is that if someone starts a pill, and you find that it doesn’t sit well with you, you don’t like the side effects, there are so many other options. It does not mean that you are not going to find the right pill. I mean, you can keep, I mean, trying for years. I mean, it’s possible but you can keep switching until you find that…
Steph: But I think most of us would say to the patient, you really do have to try to give it two to three months before you say you love it or you hate it. I mean, clearly, if you start it and you’re having no issues, that’s amazing and I’m the best gynecologist in the world, yeah, winner. But if it doesn’t, and you’re feeling off the first month or two, I usually say stick with it. Most of your symptoms will settle in by month two or three, and then you should be doing great. But once again, just because the first pill didn’t work, that’s the beauty of the pill. Then I can start with something and then kind of go off it…
Dr. Fox: Based on what the side effect is.
Steph: Based upon what their side effects are.
Dr. Fox: Right. Do you need more estrogen, do you need less estrogen? Do you need different progesterone? And also one of the interesting things is they were sort of…when they were made, they were sort of designed to mimic a typical cycle. So they were done…you get three, you know, in a 28 pill pack, the first 21 pills are three weeks of that hormones, and the last seven would have a placebo or nothing, or maybe some iron or whatever. And that sort of mimics what happens naturally to the hormones in a woman’s body. They go up and then after they start dropping on their period.
And so on the pill, you know, the cycle is very controlled. Everyone got their period, you know, after the, you know, when the placebo started. You have it for five days and it’s very predictable. But it doesn’t have to be that way. So there are formulations that are actually marketed so that you take active hormones for three months, and you only get a period every three months or four times a year.
Steph: There was a pill that was tried for a year. I mean, there was a pill that came out on the market and the goal was… And also how we choose to try to pick a pill. Do patients suffer with migraines? Do they have endometriosis? Do they have underlying medical conditions that if they get their period, they can’t go to work, they can’t go to school?
Well, for those patients, then I would try to think well, how can I give them less cycles in a year. And I think that’s exactly what the gynecologist does. We take a detailed history, we try to figure out what you’re coming in for, what your major complaints are. If it’s just straight-up birth control, you’re young, you’re healthy, you have no medical problems, fine. You may be fine with the three week on, one week off.
There’s new pills now that are 24-day pills. Twenty-four days of active pills, and four of them are sugar, placebo or a combination of all. And that would make your periods much lighter, you are off of hormones much less. There’s the lowest doses to what used to be a high dose. Those aren’t as popular as well. But if you’re somebody who suffers with migraines or you’re uncomfortable, we can bring your periods every three months or play it up.
Dr. Fox: And all the pills that have the same dose, what did you call them? Monophasic?
Steph: Monophasic.
Dr. Fox: All of those can be done in a way. That’s why someone could take, you know, let’s say they just for one cycle and extend by a week potentially. I mean, there’s things you can do if you know what you’re doing…
Steph: Correct. And I usually say to the patients…
Dr. Fox: Don’t try this at home.
Steph: Don’t get fancy the first month, that’s when problems happen. But if you’re on the pill and you’re hypothetically going on vacation and you need to skip a week or there’s something going on in your life and you don’t want to get your period, the pill gives you flexibility and allows you to play with it a little bit. I would hope that you would reach out to us before you try to do it on your own, but there’s some that you can play around with the pill a little bit.
Dr. Fox: Right. And I notice…when I discuss this with women, a lot of them, sort of their gut reaction’s that that can’t be healthy, that that seems like a bad idea to not get your period every month. And what I try to remind them is that, you know, in nature, women did not get their period every month, because typically…I mean, typically they were pregnant. And after they delivered, they were nursing. And so during both those times…
Steph: They could be 18 months without a period.
Dr. Fox: Yeah. And then they would, you know, stop nursing and get a period, and then they would get pregnant again. So I see like in nature, it’s actually unusual. This is probably the first, you know, 100 years where women would expect to get a period every month. And so it’s certainly not unhealthy.
Steph: And the only reason you’re getting your period is because you didn’t get pregnant.
Dr. Fox: Right. Exactly.
Steph: That really the way that I try to explain to the patients. If you got a period, it’s because you did not ovulate get pregnant, and therefore your lining basically started to withdraw and you got your period.
Dr. Fox: And reboots.
Steph: And there’s nothing unhealthy about not getting a period on a monthly basis. So for patients who we put on a three-month pill or… The one year pill probably is the least popular of all, and I haven’t prescribed it for longer periods of time, but some patients go six months. Yeah, there is no increased risk to you, from a fertility perspective or cancer perspective, by not getting a period.
Dr. Fox: Correct. And I think that’s a really important point. And I think that, again, like you said, there are other benefits for some women, either symptoms, or some women get very heavy periods and they’re anemic, or some women have pain during their periods. And so there’s other reasons that someone might choose to do a hormonal contraception and sort of, you know, [crosstalk 00:26:45]
Steph: Try to space it.
Dr. Fox: To adjust to what works for her. Now, some of these we don’t give when women are nursing, for example, but it’s not a safety issue. It’s really just an issue of whether it’s going to affect your breast milk. People again think is it not safe for the baby, it’s just about how much breast milk is she going to make.
Steph: So we typically lean towards giving patients… When we see them at the postpartum visit, we always have a contraception discussion with them, because ideally, we don’t want them getting pregnant too quickly after they just had a baby…
Dr. Fox: And they usually don’t either.
Steph: …and they usually don’t want to either. And so if they are breastfeeding, we typically do recommend a progesterone-only form of birth control or a non-hormonal form of birth control for those patients, because there have been some studies that have looked at estrogen in the pill, that it may affect the breast milk supply.
And so ideally, if a patient would like to go on birth control and they’re interested in a pill, we would put them on what we used to call the mini pill or Micronor. There’s another new brand called [inaudible 00:27:40], but a progesterone-only based pill that should not affect the breast milk supply.
We also offer patients the IUD at their postpartum visit, which is a really popular form of birth control. They don’t have to think about taking a pill. I mean, life is crazy when you’re a new mom. And so taking one thing away from them, a pill a day, that they may not be so able to multitask. The progesterone-only pill even though it’s a very effective form of pill, it really does need to be taken the same time of day, every day.
Dr. Fox: It’s a little finicky.
Steph: It’s a little finicky, and it’s got only one hormone in it. So for those patients, you really do have to tell them, same time a day, every single day for the progesterone-only pill. It is a good form of birth control and it should really hold them from a bleeding perspective. They shouldn’t have too many issues. Once they play with their breast milk supply a little bit, they may get some breakthrough bleeding and have some bleeding issues, at which point we could change them.
Dr. Fox: Now, why would women who are nursing need any form of contraception if they’re nursing exclusively?
Steph: So for patients who obviously are breastfeeding, there’s a hormone called prolactin. That prolactin goes quite high when they’re breastfeeding. And it’s a very good form of birth control, probably somewhere around 75% or 80% chance of not getting pregnant while you’re breastfeeding exclusively. It lowers estrogen levels, but it’s certainly not 100%. And the problem is, depending upon how your baby’s feeding, and if you’re spacing out your feeds, or you’re adding more bottles, the efficacy of that prolactin and breastfeeding as a form of birth control becomes less.
And so we usually tell patients not to rely just on breastfeeding as a form of birth control and to encourage them to either use condoms, at the very least, you could use the withdrawal method or that phrase that we talked about before, IUD mini pill or something over the counter, like a VCF at the very least.
Dr. Fox: Just to lower the chances.
Steph: Just to lower the chances.
Dr. Fox: And so, we had a totally separate podcast with Caroline Friedman on the IUDs and the LARCS, and so we don’t have to go into that because it’s a whole other discussion.
Steph: She did an awesome job.
Dr. Fox: She always does.
Steph: Yeah, she always does.
Dr. Fox: At what point do either you bring up or the patients bring up permanent…what we call permanent sterilization?
Steph: Sterilization.
Dr. Fox: Yeah, so like getting their tubes tied, so to speak, or vasectomy.
Steph: So, I would say the most popular form of birth control in the world is sterilization when you look at the entire globe. Here in the United States, I think the pill and hormonal forms of birth control, including the LARC, is still slightly more common than permanent sterilization. But I do always bring up permanent form of sterilization usually while a patient is pregnant, if they have a high-risk pregnancy, if it would not be encouraged for them to get pregnant in the future. If they mention to me that they think that they’re done having children, like if they know that they don’t want any more kids…
Dr. Fox: Especially if they’re having a caesarian.
Steph: Especially if they’re having caesarian section, it’s the perfect time. Deciding to do permanent sterilization, there are some caveats. You have to sign paperwork, it has to be done within a certain number of days, etc, etc. So you have to be a little bit more forward-thinking when you look at a patient that you’re thinking about that for.
But the male form sterilization really it requires just a male to go to his urologist. The procedure is so simple and men are, no offense to you, but babies and they really are not that happy about…
Dr. Fox: None taken. I speak for all men that we agree.
Steph: We agree.
Dr. Fox: We are babies, particularly in that region.
Steph: Correct. So it’s easy, it’s quick, it has really no long term risk.
Dr. Fox: We’ll go get tattoos, we’ll go and we’ll do all that but if it’s over there, forget it.
Steph: Gutters, you’ll clean out, you’ll do all these fancy things.
Dr. Fox: No problem.
Steph: But the only downside of the male sterilization is that you do have to use backup birth control for three months afterwards, because it is not fully effective. Typically, for the male sterilization, we do have them get a semen analysis before we do give them the clear.
But I think for patients who have a large family or know that they’re done, it doesn’t even have to be large. They got one child, but know that they’re done with childbearing. High risk, meaning that their pregnancies are not conducive to getting pregnant again, or they have medical conditions themselves that would really not benefit. I think it’s a great form of birth control, obviously, and it’s the most “effective” although the LARC equals that.
Dr. Fox: Yeah, I think people don’t always realize that it is obviously quite effective. Nothing’s 100%, people can get pregnant after these procedures, but it’s very, very rare. But the same with an IUD if it’s in there, it’s very, very rare to get pregnant.
Steph: They are all quoted at 99.99%. And that includes even the Nexplanon or the Implanon, which is basically a little rod that gets placed under the skin. That’s in the same tier as being equally effective.
Dr. Fox: Right. And so, you know, we went through all the options, and there are so many. And so if someone knows what they want, okay, it’s a lot easier. But let’s say someone doesn’t know what they want, and they’re starting for the first time. And you said, you’re gonna find out in five minutes, basically, like, what are the four questions you’re going to ask them to sort of get right at it? Let’s assume it’s a 22 year old single woman. I mean, what are the questions you would ask her to figure out what’s best for her?
Steph: Are you sexually active currently? Obviously, they’re coming in probably for birth control, not for bleeding issues. But for protection, for birth control, obviously, they have a male partner. So are you in a monogamous relationship? Are you interested or are you capable of taking a pill on a daily basis? Or if not, are you looking for something that’s more long term that you don’t have to think about?
And are you thinking about getting pregnant in the short term or long term, would be how I would narrow it down to start. And then, do you have any menstrual concerns or complaints that would lean more towards pushing towards a hormonal form of birth control, like terrible periods, etc, as opposed to maybe a copper IUD, which maybe would not be ideal in those patients?
Dr. Fox: Those are very straightforward questions, obviously. And then, in terms of the first one, you said about being in a monogamous relationship, is that because if they are, the risk of infections is lower, and so they might be, you know, less, “necessary” to use a condom?
Steph: The old school thought used to be that we…back in the day when the IUD was less popular, and the Dalkon Shield was there and there was lots of risks for infection in the uterus itself, those strings have been changed and those have all been debunked. The IUD is one of the best forms of birth control in the market. And I think we here put in a ton of it. I mean, I love the IUD.
But if you have a patient who is really…got multiple partners, there’s going to be really an increased risk for sexually transmitted diseases. Those patients should be using condoms regardless, don’t get me wrong. But I think if you have a T or a strings sitting there, and they’re not going to be very careful, it just can slowly increase your risk of other long term issues that I would maybe just put in the back of my brain to be careful on.
But there is no reason that if someone’s… And another issue to be debunked is if you’ve never had kids, you can’t have an IUD. That is not true. Anyone can have an IUD. So I think all forms of birth control can be used for almost all forms of patients. But if they’re young and they’re not gonna remember a pill, then you’re looking at something that takes that away from them, such as injectables, an implant or an IUD as a good form of birth control.
Dr. Fox: Okay. And then sort of the last thing I want to ask you is, how do you address women who are progressing in their 40s? Meaning because at some point, they’re not gonna be able to get pregnant, they’re gonna be menopausal, but until then, they sort of can, but it’s less likely and do you just… Is there like a certain age cutoff you say, you know, use regular birth contraception until you hit menopause or do you sort of change it?
Steph: I remember talking to [inaudible 00:34:45] once and he said, he sees a good number of what we like to call oopsies women who think that they cannot get pregnant, they didn’t use birth control, and then they walk in the office, that they think that they’re not getting their period for other reasons and they’re pregnant.
So yes, the older that we become as women our fertility levels definitely decrease but they are not zero until you completely stop getting your period almost. And the issues for women, as we get older in our 40s, are definitely heavier periods, PMS-like symptoms, perimenopause-like symptoms.
And for me, my practice has evolved a little bit. As I’ve been doing this longer and longer, I see more patients in their late 40s and early 50s. I prescribe a lot of birth control, whether it’s a pill or an IUD to help transition them through those phases and changes.
So for me, a patient may come in and say, well, I’m not that sexually active, hypothetically, or I’m less worried about getting pregnant because I’m now 47 or 48, but their periods are blistering or irregular. That’s really where the pill can help transition you or an IUD, to kind of carry you through the menopause.
Dr. Fox: Fascinating.
Steph: It is. The whole world of birth control, like you said, when we think of contraception, it’s to try not to get pregnant, but it’s used for so many amazing things. And I think you could just…it really becomes like an art, which pill you like, what you like to use? And I think Friedman’s, you know, talk on LARCS was amazing because it has become a big part of our practice. And social media has just blown up the space of the ParaGard and all the other forms of birth control, of hormonal…
Dr. Fox: In a good way.
Steph: In a good way. Right. We want people to get unwanted pregnancies, fewer and fewer. And so, I think there’s just tons of great options and all you have to do is just call to make an appointment with your gynecologist and, you know, you’ll figure it out.
Dr. Fox: Amazing. Steph Lam, thank you so much.
Steph: Nathan Fox.
Dr. Fox: See, you’re gonna have your own podcast and I’ll come on as your guest.
Steph: I will defer that to you. You can continue to hold the topic, but I’ll come back to talk about something else if you want.
Dr. Fox: We’re going to try to really reduce the silence of the Lam.
Steph: On that note…
Dr. Fox: All right, have a great one. Thanks a lot.
Steph: You too. Take care.
Dr. Fox: Thank you for listening to the “Healthful Woman” Podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H-F-U-L-W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.
The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.
