“How to choose the right birth control” – with Dr. Stephanie Melka

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 OB/GYN 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. Melka, welcome back to the podcast. Good to see you. How’s life?

Dr. Melka: Been way too long. Life is great. How are you?

Dr. Fox: I’m terrific. Thank you so much. Thanks for asking. Yeah, so this is great. We’re going to cover contraception today, aka birth control.

Dr. Melka: Birth control.

Dr. Fox: Yeah, good stuff. And obviously this is very common amongst people who are seeing gynecologists, right, in terms of annual visits or whatever. So, I think what I wanted to do to make it sort of useful for our listeners is I want you to sort of walk us through what a visit is like for someone who wants to talk to you about options for contraception. So, someone comes to you and first time, not first time, had a baby, didn’t have a baby, whatever it is, sort of what are the questions you’re going to ask? What are the things that they should bring to the table just so everyone out there who might be thinking about what do they want to do or this, they can either help decide for themselves or know what they can bring to their conversation with their doctor, midwife, whether it’s us or whether it’s somebody else to have a very productive conversation and come up with the contraception that works best for them. So, how do you start this with somebody?

Dr. Melka: Sure. So, I started the same as any visit, you know, basically reviewing their full history in terms of medical history. Do they take other medications? Do they smoke? Do they have family history of certain medical things like blood clots where that might change what’s recommended or the risks of certain contraceptives?

Dr. Fox: In terms of what? Like, so why would that be relevant? Because I’m not sure everyone is aware of that.

Dr. Melka: Yeah, yeah. So, the biggest one is oral contraceptive pills, which are a combination of estrogen and progesterone. Very, very common method of birth control. But estrogen has a higher risk of blood clotting, of DVT, deep vein thrombosis, which is a blood clot in the legs, which could potentially go to the lungs. It’s very rare, but slightly more common in women that are on estrogen. And it’s also more common in women who smoke, women who had a family history of blood clots. So, those are women where that typically is not the right option.

Dr. Fox: Got it. Okay, so meaning when you get a medical history from them, it’s not just because you’re doing a gynecology visit, but it’s actually relevant towards the decision of what birth control they might be able to take or choose to take or be recommended to take or whatever it is.

Dr. Melka: Yes, yes.

Dr. Fox: Okay, so you get a [crosstalk 00:02:53.821] of it.

Dr. Melka: And that’s why when I talk to my friends…like, if my friends ask me in theory about things, I can talk about things in theory, but I can’t tell them what’s right for you or what’s going to be too risky without knowing their medical history.

Dr. Fox: Right. Okay, so I guess that’s a really good lesson. And I guess on a side note, that’s probably one of the reasons there’s debate about whether this stuff should just be over-the-counter and not at a pharmacy. Like, on the one hand, you want it to be available to everybody. You want to be able to have options, this or this. But on the other hand, there are potential risks for taking these things based on what you take. And so, again, we’re not going to answer that debate today, but that is why… No, because you can see both sides of it.

Dr. Melka: Of course.

Dr. Fox: But that’s the counterargument to making it just available on Amazon, you know?

Dr. Melka: There’s another thing I’m seeing more often is the GLP-1 medication like Ozempic. Because they slow down the stomach emptying, there’s a concern that they slow the absorption of certain medications like birth control pills. I don’t know if there’s any great studies out yet just because for so long all of these meds were used in women that were not reproductive age. So, some of this I think… Again, I don’t know if there’s any study yet, but there’s more anecdotal of women who are on birth control, who are on Ozempic, who might then go on to have an unplanned, unintended pregnancy.

Dr. Fox: Yeah, I mean, I guess it would make sense without the birth control, because sometimes if you’re carrying extra weight, you don’t ovulate. You don’t get periods. And this is true whether you’re on Ozempic or not Ozempic. If you lose weight, sometimes that triggers ovulation, fertility, and frequently it’s a story, “Hey, I wasn’t getting pregnant, and then I lost X amount of pounds, and now I’m getting my periods back, and I got pregnant.” But I didn’t realize that that might be the case even for someone taking a contraceptive pill. All right, we’ll see. That’s TBD is what I can say. All right. Okay, so you get a full medical history to see if there are options. Let’s assume all the options are available to them medically.

Dr. Melka: I usually start by asking patients what they’re considering, because 99% of the time a patient comes in and she has some sense of what she wants or some sense of what she doesn’t want. So, some women will come in and very clearly be like, “I want an IUD,” or, “I want birth control pills,” “I want the birth control implant.” And then, based on what their thoughts are, you know, sort of go in a little more in depth on those, and then also use that to debunk some of the myths that are out there. You know, there’s a lot of this on TikTok, on Instagram now of…

Dr. Fox: Myths debunked? Things that need to be debunked from TikTok and Instagram? Who knew? Wow. I thought it was all 100% accurate. This is big news, everyone.

Dr. Melka: You know, I get this a lot with IUDs where people have a very bad experience with an IUD. And they tell the story. And women then come in and they say, “I don’t want an IUD because I don’t want that level of pain.” It’s like nobody wants that level of pain. But I’ll tell women, if you want an IUD, you’re not going to be screaming in pain for 10 minutes. You know, there’s things we can do to decrease the pain. So, sometimes as you delve more into it, you get women to consider more of these options.

Dr. Fox: Right. So, if someone comes in with sort of a preconceived notion, like, what would be the reasons someone might come in saying, “I want a pill”? Like, what is typically the reason someone says, “I want a pill”?

Dr. Melka: My friends are on it.

Dr. Fox: Okay.

Dr. Melka: My sister was just given it.

Dr. Fox: That’s always a good reason.

Dr. Melka: Yeah, yeah. Again, reading about it online. Some women might see their dermatologist and go on medication for acne and be told, “You need to get birth control. Go see a GYN.”

Dr. Fox: I see.

Dr. Melka: Yeah.

Dr. Fox: Okay. And then it’s interesting that people come in saying, “I want IUDs, I want implants.” I guess there’s good press about them also, which is fair. I mean, these are all good options. Okay, so you take into account what she wants and…

Dr. Melka: Yeah, one of the…

Dr. Fox: How much you go over the other options? Someone says, “I want birth control pills.” Do you say, “All right, have you considered A, B and C?” or is it really…?

Dr. Melka: I try to, because, again, sometimes you get someone who they don’t know the other options, or as you go through the risks or the downsides of what they want, you bring up things they haven’t considered. You know, for example, with birth control pills, they’re most effective when they’re taken at the same time every day. So, sometimes I’ll get a patient that’s like, “Well, I’m bad at remembering pills.” So, you talk about ways to become better, like leave it in your bathroom next to your toothbrush. Every morning you brush your teeth, take your pill.

Dr. Fox: Hopefully.

Dr. Melka: Hopefully, you brush your teeth at night. That’s less…

Dr. Fox: Right, right.

Dr. Melka: That’s easier to forget but almost everyone brushes their teeth in the morning. Take your pill in the morning. Set an alarm on your phone. Some people use apps, and they’ll get an app pop-up that tells them, “Take your pill.” But then sometimes they’ll realize, “Wait, I work weird hours. I’m not always in the same place every day or at the same time of day. So, maybe this isn’t going to be as easy as I thought it was.”

Dr. Fox: Mm-hmm. Okay, so let’s do this.

Dr. Melka: Yes.

Dr. Fox: Let’s go through what the options are. And I want you to give me… I’m going to ask you three questions about each one. The pros.

Dr. Melka: Sure.

Dr. Fox: The cons.

Dr. Melka: Yes.

Dr. Fox: And what people typically would… Like, which people would typically choose that option? I mean, someone who is like this or someone who has this kind of life or someone who a medical, whatever it is, sort of like who is the typical group that… And obviously, there’s such wide variation with that. So, the third one is quite a generalization, but let’s start with the… I guess we’ll do the from the least aggressive to the most aggressive. So, let’s start with the first one, which is the pulling out, as they say. So, what are the pros? What are the cons?

Dr. Melka: So, natural family planning.

Dr. Fox: That’s what we call it.

Dr. Melka: We can group all of this together, which is timing your menstrual cycle, not having sex on certain days, withdrawal method, pull and pray, some people call it. That’s typically patients that don’t want to be using any kind of medication. So, they don’t want the side effects of the pill or the IUD. They might not like the feeling of condoms. They might be allergic to condoms. They might not have found one that works. But the downside is it has the highest failure rate. So, that really needs to be people that are okay with it not working and having a pregnancy that’s unplanned.

Dr. Fox: Right. So, the pro is that it’s the least anything because you don’t really have to do much other than, you know, understand your menstrual cycle and, you know, sort of okay.

Dr. Melka: Right. And you have to be able to trust your male partner to withdraw. Not all of them do. And there are plenty of women that have over the years come in and said, “We were doing this, but he’s not withdrawing in time.”

Dr. Fox: Right, right. And so it’s not really for someone who getting pregnant is not an option.

Dr. Melka: Correct.

Dr. Fox: Right? Like, if you cannot be pregnant, this is not a great option for you. Okay, and just to sort of put a bow on that, the reason it doesn’t work always is not just because someone doesn’t pull out in time. Like, this is not considered an effective form of contraception anyway, right?

Dr. Melka: It’s more effective than doing nothing.

Dr. Fox: True.

Dr. Melka: But failure rates I’ve seen are… It’s not much more effective. Now, there are people that are… They do everything perfectly, they do it all by the books, and they never get pregnant. So, it does work, but it can be hard to do correctly. Even with timing menstrual cycles, you really have to stop having sex full seven days before ovulation. If you have irregular cycles, you may ovulate sooner than expected.

Dr. Fox: Right. Okay. So, let’s go, I guess, next to barriers—condoms, diaphragms when they were used. Are they still using diaphragms?

Dr. Melka: They are. There’s one out there now. It’s one-size-fits-all. It used to be that you had to get fitted specifically for a certain size and shape of diaphragm. That’s no longer the case. There is one that’s out there. It’s basically a plastic cup that you put spermicide in and then place it in the vagina. It’s supposed to be placed several hours before having sex, left afterwards, and then taken out. I think it’s six hours afterwards or some amount of time after.

Dr. Fox: Right. And what about spermicides without a diaphragm?

Dr. Melka: It’s medication that basically destroys sperm. There’s different varieties. There’s a film. There’s a gel. Basically it’s placed in the vagina before having sex.

Dr. Fox: Right. How effective are these things?

Dr. Melka: Not the best. I think maybe these have, I want to say, like, a 15% failure rate because, again, they’re not always used correctly. And just the way they work is not always the most effective.

Dr. Fox: Right. Whereas condom, which is a barrier, is quite effective. So, I guess let’s flip to condoms then. What’s the pros and what are the cons?

Dr. Melka: I should have brought this up at the start when going over someone’s history. Condoms are the only contraception that’s going to reduce risk of sexually transmitted infections. So, patients that have multiple partners, if their partner has multiple partners where they’re at a higher risk of exposure to certain infections, condoms are always recommended for STI risk reduction. They’re useful because, again, it’s no medication. It’s just you use it when you have sex. So, women don’t have to deal with taking a pill every day if they’re not having sex that frequently. Downsides, they’re physically uncomfortable. Some women don’t like the way it feels. Some men don’t like the way it feels. There is a failure rate in terms of breaking or of not being used correctly.

Dr. Fox: Mm-hmm. It’s a low rate but it’s not zero.

Dr. Melka: Correct, correct.

Dr. Fox: Okay. And so I guess that would be the con. So, what people would typically choose condoms other than those who are looking to prevent infections?

Dr. Melka: Those are the main ones. Now, those women may also choose another method. I have a good number of patients that come in at their postpartum visit where they’ve got a new baby. They don’t want to start medication. They’re not ready for something longer term like an IUD. And they’ll just say, “I don’t think I’m going to be having sex very much where I want to be taking a pill every day. I’ll just use condoms for the next few months and then figure something out.”

Dr. Fox: Got it. Okay. So, let’s move on to pills, which is probably, I guess, the most common form that people use other than condoms.

Dr. Melka: Between pills and IUDs.

Dr. Fox: Oh, really?

Dr. Melka: Yeah.

Dr. Fox: Interesting.

Dr. Melka: Yeah.

Dr. Fox: All right, that’s news to me. All right. So, I guess we’ll talk about pills. So, what is the pro of using a pill?

Dr. Melka: The biggest pro that I see… So, obviously, they’re very effective at preventing pregnancy and they provide a lot of regulation of the menstrual cycle as well. So, they decrease the amount of bleeding a woman has with her period. They decrease pain and they can decrease the duration of the period as well. Very effective. One pill taken ideally at the same time every day. They often can have improvement in acne. Some women notice improvement in their mood as well. So, some women that have, like, premenstrual symptoms, premenstrual mood dysphoria often have an improvement in that when they’re on these pills.

Dr. Fox: Wow. Okay, so those are the pros. What are the cons?

Dr. Melka: Slightly increased risk of blood clotting.

Dr. Fox: Right.

Dr. Melka: That’s what I mentioned before.

Dr. Fox: Yeah.

Dr. Melka: And again, it’s not common. This is 1 in 10,000. But, again, it’s very much in the media. There’s a lot of it. Like, people that read magazines, watch TV, they’ll see things of, “Did you take this pill and get a blood clot? Call these lawyers,” like case action lawsuits. You know, and again, these are very real complications that happen but not as common as some people think.

Dr. Fox: Yeah. And I think, you know, like you said before, it is something that is sort of triage. You’re not going to give them to someone with a baseline high risk of blood clots. And so that sort of gets taken out. And also, I think people don’t always consider the alternative because since they’re so effective, right, so a pill has a certain amount of estrogen that could increase risk of blood clot. But a pregnancy is way more estrogen. And so if the alternative is doing a method where you are more likely to get pregnant, that might be the riskier option, actually. So, it has to be taken into full context of the whole situation, not just the pill itself.

Dr. Melka: Sure, and I do tell patients that, that your risk of blood clotting in pregnancy is higher than the risk of being on the pill. Now, obviously, there are different things like you’re pregnant because you want a baby. So, that’s a different reason to take the risk as opposed to someone saying, “Well, I don’t want to take the risk. I’ll just use something else.”

Dr. Fox: Right, exactly. And then I think also one of the things that you mentioned with cycle improvement or whatever it is, there’s also the ability for people to manipulate their cycle, which is for some people that don’t care for others, it’s like a godsend, you know, that they could maybe do the pill in a way that they don’t get their period every month.

Dr. Melka: Oh, absolutely.

Dr. Fox: They can take it straight through and, you know, never get their period again, twice a year, four times a year, whatever it is or for certain Jewish religious women, they have to push off their cycle, make it earlier, make it later. For whatever it is, there’s options to do that.

Dr. Melka: Sometimes it’s just, “I’m traveling and I’m going to have my period and I don’t want to, so I’ll push it off.” You mentioned the religious reasons. I see a lot of that as well. I see birth control pills used a lot in adolescents, in teenage girls, because they often really struggle with periods. But I’m getting a lot 17, 18, 19-year-olds, that they’re dealing with bad pain, bleeding. It can affect their social life. It can affect their athletics. You know, some of them are like, “I dance. I can’t dance because I’m bleeding so much.” And the pill can really help with a lot of these symptoms. And I try to parse that out as well, that just because it’s a birth control pill doesn’t mean that’s all that it’s used for.

Dr. Fox: Right, I mean, you can take it…

Dr. Melka: That it can be…

Dr. Fox: Yeah, even if you’re not sexually active…

Dr. Melka: Exactly.

Dr. Fox: …you may benefit a lot from a birth control pill. And I guess, again, really, unless it’s medically a problem to take, really the only downside is you have to remember to take it every day, which for most people, it’s fine and some people, it’s a challenge.

Dr. Melka: Yeah. Some people do get side effects like weight, mood. Sometimes the skin changes are worse, especially in the first few months. But usually once you’ve been on it for two or three months, things settle out. There can be irregular bleeding. And based on all of these symptoms, you can adjust the dose of… Like, what’s the level of estrogen? What’s the level of progesterone? What’s the type of progesterone? Right now, I should count. I want to say there’s, like, 40 formulations of birth control pills on the market.

Dr. Fox: Yeah, that was going to be my next… Yeah.

Dr. Melka: There’s so many different ones.

Dr. Fox: Yeah, that was going to be my next question is, how do you decide which one to do? And then how do you sort of…? Again, in general and also for each person, that there’s so many options. For condoms, they’re condoms, right? Whatever, you know? Size, what texture, you know, all that whatever. But for birth controls, they’re dosed differently. How do you go about doing it? Is there a baseline for everybody and then you tinker or do you sort of decide based on certain factors?

Dr. Melka: A little of both. So, the estrogen tends to be what has more of the symptoms. When you go higher estrogen, you get better bleeding control but more of the other symptoms like nausea and bloating. And then when you lower the estrogen, it’s the opposite. More likely to have breakthrough bleeding, less likely to have those symptoms. Okay, so what I usually do is start with a middle-of-the-road one, like a 25 or like a 30-microgram estrogen, and then adjust from there. Some women will say, “I want the lowest dose. Start me on the lowest dose.” And then we see how they do. Some of them do fine. Some of them we start on the 30, and they are calling in. They’re having spotting in between. And then we’ll increase them to one that’s a little bit higher. I don’t have one specific brand. I usually send in for a generic one because then it can be filled with what brand their insurance covers and what the pharmacy has available…

Dr. Fox: Yeah, the same… Yeah.

Dr. Melka: Because again, there’s so many. Like, I haven’t found a need to tell patients you need to spend $60 a month on one versus another.

Dr. Fox: Right, right. And then also, I think sometimes the exact same pill will have 12 different brand names, right? And so sometimes people say, “I take this one, I take this one.” Like, those are the same pill. Just one of them is from a manufacturer that your pharmacy works with and the other one is from a different manufacturer. So, the way we look at it is not the brand. It’s sort of the dose of the estrogen, right, and then you said the type of progesterone and the dose.

Dr. Melka: Yeah, yeah.

Dr. Fox: The progesterone will vary by type of progesterone and dose. And the estrogen is the same type for all of them. It’s just the dose. Okay.

Dr. Melka: I think it was… Yes, when it came out, the drospirenone, the part of their approval when they studied it, they looked at acne. So, they were able to advertise like we…

Dr. Fox: The acne one, yeah.

Dr. Melka: We improve acne where they all should, you know, especially once you get over that first month or two. Yeah, that was just something I always found interesting.

Dr. Fox: And the last variation between pill packs is, is it 21 days a pill and seven days a placebo? Is it 24 days a pill and 4 days a placebo? Does a placebo have iron? Does a placebo have this? Is it the same dose each day? Is it different?

Dr. Melka: Right, is it monophasic? Is it triphasic? Is it the same each month or each week? Does it increase each week?

Dr. Fox: There’s an infinite number of permutations you can do with this, and that’s why there’s so many types of pills on the market in terms of tinkering with… Again, the dose of the estrogen, the type of progesterone, the dose of progesterone, how many pills are active versus inactive with the active pills? Is it the same dose every week or different doses each week? Is there other stuff in the placebo pills like iron and folic acid? And so this can be marketed in many different ways.

But on the plus side, there’s a lot of options for people. And I usually encourage people to like, “Oh, I didn’t like this pill.” I’m like, “If the pill is the right option for you, almost always someone can find the right pill for them. It just takes some time to sort of figure out exactly what that’s going to be.”

Dr. Melka: Along with the pill, there’s the NuvaRing, which is the vaginal ring. And then there’s a patch that’s out. And it’s the same thing. It’s estrogen and progesterone. And they’re placed… The patch, I believe, is weekly and then the ring is for three weeks. So, it’s the same medication, but a little bit lower maintenance because you’re not doing a pill every day. The downside of those is they don’t have different formulations. So, if you try the NuvaRing and it doesn’t work…

Dr. Fox: That’s it.

Dr. Melka: Right, you can’t adjust the dose. You can’t adjust the formulation.

Dr. Fox: Right. What about the pills…? Some people call it the minipill, the one that only has progesterone in it. What’s the deal with that, Dr. Melka?

Dr. Melka: So, again, no estrogen. So, you’re taking out those risks on those side effects, but it does get you a little bit less effectiveness. If it’s used correctly, which is at the same time every day…

Dr. Fox: Right, this is what really needs to be the same time every day.

Dr. Melka: And I believe… Like, I think the actual packaging is like, “Don’t have sex two hours before or two hours afterwards.” Like, if you follow all of these things, then it’s as effective, but it’s so hard to do that.

Dr. Fox: Right, it’s like a gremlin. Yeah, it’s always like…

Dr. Melka: Don’t feed it after midnight.

Dr. Fox: Yeah, I don’t know how many people out there know that reference. But if you’re over, you know, 35, you might. A lot of rules, a lot of rules for gremlins.

Dr. Melka: Yeah. But again, it’s certainly better than using nothing. And it very much can be the right option. But what I often have is someone comes in and they say, “I want the progesterone pill because I don’t want estrogen. It’s too risky.” And then when I go over the correct use and the failure rate, they’ll say, “Oh, I didn’t know that,” you know?

Dr. Fox: And this is one a lot of women take when they’re nursing. And why is that?

Dr. Melka: Estrogen can impact milk supply. So, estrogen can decrease the amount of breast milk a woman is producing. And that becomes less likely the further you get out from delivery, but often it’s six weeks. A woman’s supply is still regulating. So, taking estrogen might decrease that. Some women come in and they’re oversuppliers. They’re producing too much milk and they’re like, “Great, give me the estrogen.” Some women are going to be like, “I’m only going to breastfeed another two weeks and then I’m going to go back to work. I don’t want to pump. I want to go on this, so it’ll help me to wean.” But usually with the breastfeeding and the pill, the minipill still ends up being very effective.

Dr. Fox: All right, and then…

Dr. Melka: The other thing with breastfeeding is it does suppress ovulation. So, it is a form of birth control. It’s just unpredictable when somebody is going to ovulate. You know, and I tell patients that, “It’s not like which came first, the chicken or the egg. You don’t know. Like, you ovulate first and then you get your period.” So, you can’t wait for your period to say, “Oh, I’m going to be ovulating again.” Because by that point, you’ve already ovulated once.

Dr. Fox: Right, you can do that and it’ll often work unless you’re pregnant.

Dr. Melka: Right.

Dr. Fox: “I didn’t get my period.” “You’re pregnant again.” All right. So, let’s…

Dr. Melka: Oh, wait. I have one more fun fact on the birth control pills.

Dr. Fox: Hit me. Fun fact.

Dr. Melka: The Sunday start. The packs always tell you to start on Sunday. It’s so you take your last pill on Saturday, and then you get your period during the week, and then you don’t have your period on the weekend.

Dr. Fox: Is that true?

Dr. Melka: Yes.

Dr. Fox: Really?

Dr. Melka: Yes.

Dr. Fox: Okay.

Dr. Melka: I learned that in medical school, and it makes so much sense.

Dr. Fox: Fascinating.

Dr. Melka: But, like, if you can start it at any point, it doesn’t have to start on Sunday.

Dr. Fox: Right. Some women want their period on the weekend, and they don’t want it when they’re at work. I don’t know.

Dr. Melka: Exactly.

Dr. Fox: Yeah.

Dr. Melka: It can be started at any point in the menstrual cycle. You don’t have to wait for your period to start it. If you start it in the third…the week before your period, you’ll probably have some breakthrough bleeding but it’ll get you contracepted faster.

Dr. Fox: Got it.

Dr. Melka: So, if someone’s on their third week, I’ll usually tell them if you have another method to use, start it with your period. You’ll have less bleeding. But otherwise, it can be started at any point.

Dr. Fox: All right. What about… Let’s switch to the IUD.

Dr. Melka: Yes.

Dr. Fox: So, what you said is it’s just as popular as the pill, which that’s…

Dr. Melka: That’s what I’m finding. Maybe it’s just the patients coming to me.

Dr. Fox: It’s a fun fact for me. Maybe. Maybe because you place IUDs so well with the nitrous, that there’s no pain.

Dr. Melka: Probably. I’d like to think so.

Dr. Fox: Because it’s pain-free. All right, so what are the pros of the IUD and what are the cons of the IUD?

Dr. Melka: Yes. So, the IUD, it’s a T-shaped device that gets placed in the uterus. It gets checked a few weeks later and then that’s it. Don’t need to do anything. There’s two types: there’s hormonal and non-hormonal. The non-hormonal is a copper IUD. The side effects with that are the periods get heavier and more crampy. So, women that have bad periods at baseline tend to not do very well with it. And then the hormonal IUDs have a form of progesterone. So, no estrogen acts locally in the uterus and usually leads to either no periods or very light periods but occasionally irregular staining and spotting.

Dr. Fox: What is occasionally in your experience, what percent?

Dr. Melka: With the Mirena, which is the higher dose IUD, I’d say 50% have full amenorrhea like zero bleeding, and then 40% will have very light spotting. And then about 10% just unpredictable spotting. You know, it’s not typically heavy bleeding. It’s more annoying bleeding.

Dr. Fox: Got it.

Dr. Melka: You know, you have it because you don’t want to bleed. And then every couple weeks, you’re getting spotting and you just don’t know when it’s going to happen.

Dr. Fox: Right. Okay. So, what are the cons then of IUD?

Dr. Melka: Mainly the side effects. You know, the women that have the IUDs, they might have some of that breakthrough bleeding that they don’t like. The Paragard, if they have their periods… Like I said, they’ll get heavier. They’ll get more crampy. Sometimes it just gets to a point that it becomes intolerable. The placement of it also can be tough. You know, it’s a speculum exam. It’s opening the cervix. It’s placing the IUD. And it is uncomfortable. And people tolerate it very differently, and it’s hard to predict how someone’s going to tolerate it until you try. Some women, we start and they say, “Okay, that hurts.” And then we stop. But for the most part, people usually do okay with it.

Dr. Fox: Right, another plug for nitrous.

Dr. Melka: We have nitrous in the office.

Dr. Fox: Another plug for nitrous.

Dr. Melka: Inhalational laughing gas. Sometimes people, it doesn’t work. You can’t open the cervix. People talk about things like misoprostol, which is a medication to soften the cervix. And people talk about lidocaine, which is a pain medication injected into the cervix. That, again, helps with the cervical pain, but it doesn’t help with the uterine pain. Every once in a while, someone will want this placed in the operating room where they can have IV sedation and that can get very tough with insurance coverage. You know, it’d be great to do that, but it’s not always logistically a possibility. And sometimes, insurance just doesn’t cover it.

Dr. Fox: Right. They don’t cover the OR and anesthesia stuff.

Dr. Melka: Correct.

Dr. Fox: Yeah, the placement is the same.

Dr. Melka: Correct.

Dr. Fox: Okay, and so who chooses that? Who picks IUDs typically?

Dr. Melka: So, the other con just to talk about is sometimes they can move out of place. Sometimes they can fall out. Sometimes they can shift out of place in a way somebody might need a separate procedure to have it removed. Rarely, they could poke a hole through the uterus where you have to go in from the belly button with a camera, what’s called laparoscopy. I bring that up because almost everyone that asks about IUD knows someone who knows someone who said, “Don’t get an IUD. Someone I know had it perforate.” You know, and again, it’s one of those complications that it does happen but it’s very uncommon.

People that tend to get IUDs are the ones that want very low maintenance birth control. They don’t want to remember a pill. They don’t want to deal with using condoms. They don’t want to change a ring every few weeks. A lot of people want the Mirena or the hormonal IUDs just to have the bleeding control.

Dr. Fox: Right. And we’re talking years for this.

Dr. Melka: Yes, yes.

Dr. Fox: Yeah, 3, 5, 10 based on which one you have placed. Many years. Yeah.

Dr. Melka: And they keep getting extended more and more.

Dr. Fox: Yeah, it’s cool. Okay.

Dr. Melka: Yeah, a lot of… Again, I’m also seeing a lot of… I think with adolescents, it’s sometimes tough just for them the thought of doing a pelvic exam. But a lot of women that are in their 20s like the IUDs just because they don’t… Again, they don’t have to do anything.

Dr. Fox: Yeah, but it makes a lot of sense if someone is… And again, generalizations, but younger people sometimes have a harder time with pills and every day and this or that. But it’s also important to realize that someone who’s younger, it might not be the best option unless they’re really monogamous, again, because of infections and this, so they may have to use condoms. I don’t know. They can do both, obviously, but again they’re two very related conversations, one about your cycle and contraception and one about infections. You have to have both.

Dr. Melka: Many, many years ago, there was a type of IUD that had an increased risk of pelvic infection. And from that, the recommendation changed to you can only have an IUD if you’re monogamous. People were putting IUDs in women that have never had babies before, and a lot of that’s changed over the years just based on the safety profile.

Dr. Fox: Right, so I would… Yeah.

Dr. Melka: Because the flipside is a woman with multiple sexual partners might want better contraception than using condoms. You know, so, yeah, it could be… You know, they’re pretty much… Anybody can get an IUD unless you have an underlying abnormality of the uterus.

Dr. Fox: Right. It’s interesting you mentioned, that’s even not what I was referring to, but that was so… Even when I was training, that was sort of like coming out of favor. I was saying not that, “Oh, don’t put it in someone because if they’re not monogamous, they’ll have a complication with an IUD.” I was saying, “Because they probably also need condoms so that they don’t get STIs.” That was the meaning they’re going to have to double up anyway, so they just need to know I could put that IUD in but you may still need condoms.

Dr. Melka: Oh, for sure. I’m always very clear like this does not prevent against infection, so you still need condoms with any new partners. But it’s nice that these are so widely available and I think now more accepted and more asked for over the years.

Dr. Fox: All right. Tell me about the implant.

Dr. Melka: Progesterone implant. Nexplanon.

Dr. Fox: Implanted into what?

Dr. Melka: The inner forearm. And as progesterone lasts for three years and also similar to the Mirena, decreases bleeding but higher chance of lighter periods or irregular bleeding.

Dr. Fox: So, it’s almost like taking the progesterone-only pill every day without having to take it every day at the same time, essentially.

Dr. Melka: Probably.

Dr. Fox: Yeah. So, it’s effective.

Dr. Melka: Yeah.

Dr. Fox: Yeah. Okay, who does that?

Dr. Melka: Gynecologists. I don’t interestingly, because when I was a resident, they weren’t on the market. And then when this one came onto the market, I was already here, and none of our patients wanted it because of the higher rate of breakthrough irregular bleeding, because that’s often a priority for our religious patients. They would hear that’s a possibility and say, “Nope, I don’t want it.” So, I never got trained in doing them. I would like to, but I can’t find a scheduling course… I can’t find a course that works with the schedule. And at this point, almost all of our other docs do them. I’m happy for them to do it. But basically, they use the inner forearm between the bicep and tricep. Numb the skin, poke a tiny little hole in it. And then they have this introducer that looks like a small tube. And they put that in under the skin and then push the implant through.

Dr. Fox: Right, and it just stays there like…

Dr. Melka: Stays there. Three years.

Dr. Fox: …a government tracking device. One of those? Wow. And then I guess the final is permanent, things like getting your tubes tied or removed or vasectomies. Obviously, I assume they’re quite effective. I think the pros are pretty obvious, that they’re permanent. The cons are that they’re permanent.

Dr. Melka: Yeah, yeah.

Dr. Fox: Same thing. So, who chooses that?

Dr. Melka: People that are certain that they never want to carry a pregnancy. I’m seeing more of it in younger women and in women that have not had kids.

Dr. Fox: Really?

Dr. Melka: Yes. There’s a social media site called…

Dr. Fox: I’m sure there is.

Dr. Melka: …Reddit. Are you are you aware of Reddit? Oh, I’m going to have to teach you more things.

Dr. Fox: I’m aware that there is Reddit. I’m aware that there’s something called Reddit threads or chats or something like that. Am I correct?

Dr. Melka: So, there’s a subreddit, which is the group called Childfree. And women will talk about their experiences going to doctors saying, “I don’t ever want to have children. I want to have my tubes tied or removed,” and having their doctor tell them, “No, you’re going to change your mind.”

Dr. Fox: Fascinating.

Dr. Melka: “You’re not old enough to make that decision.” And it’s a very reasonable conversation to have, but these women have lists of doctors that will do surgery on women that have never had children.

Dr. Fox: Wow.

Dr. Melka: Yeah.

Dr. Fox: I live such a sheltered life.

Dr. Melka: We’ll teach you.

Dr. Fox: I guess it doesn’t come up in my practice, high-risk pregnancies. They wouldn’t be approaching me in either direction, I would say.

Dr. Melka: So, for women, it’s surgery to either have your tubes tied or removed. Nowadays, we’re leaning more towards removal because it does improve or does decrease risk of developing ovarian cancer later in life. Some of our patients have it done at the time of C-section. They refer to it as one-stop shopping. You’re in there already. We can just take them out at that time. But otherwise, it’s done as a separate surgery, typically laparoscopically. So, it’s full general anesthesia. There is a bit of a recovery afterwards, but overall, very straightforward procedure. And then for men, vasectomy. Office procedure done under local. Few days recovery afterwards.

Dr. Fox: It’s not done in our office.

Dr. Melka: No.

Dr. Fox: Urologist.

Dr. Melka: Urologist, correct.

Dr. Fox: Okay.

Dr. Melka: We do tubals. I’ll take your tubes out. The surgery for a woman ends up being higher risk partially because of the general anesthesia. Not that it’s unsafe, but there’s always risk with it, and because it is a major abdominal surgery as compared to a vasectomy. Women often lead toward… Sometimes they’ll tell their husband, “You get a vasectomy or we’re not having sex anymore.” I’ve had all the kids. I’ve done all this. Now it’s your turn. And then there are others that are saying, “I want my tubes tied because I want the contraception. I want to know I will never get pregnant no matter what happens in the future.”

Dr. Fox: Yeah, those both make sense. Awesome. All right, Melka, we covered it.

Dr. Melka: I think so.

Dr. Fox: I think so, too.

Dr. Melka: Did we forget one? I feel like we’re forgetting something. Abstinence. The only 100% chance. That’s all.

Dr. Fox: Brought to you by the Catholic schoolgirl in Melka’s history.

Dr. Melka: No comment.

Dr. Fox: All right. Thanks, Melka. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.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.