S10 EP3_SEXUAL HEALTH_Birth Control Misinformation, Debunked: Audio automatically transcribed by Sonix

S10 EP3_SEXUAL HEALTH_Birth Control Misinformation, Debunked: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Intro/Outro:
Hi, I'm Kristyn Hodgdon, an IVF mom, proud women's health advocate, and co-founder of Rescripted. Welcome to From First Period to Last Period, a science-backed health and wellness podcast dedicated to shining a light on all of the women's health topics that have long been considered taboo. From UTIs to endometriosis, we're amplifying women's needs and voices because we know there's so much more to the female experience than what happens at the doctor's office. With From First Period to Last Period, we're doing the legwork on your whole body so you can be the expert in you. Now, let's dive in.

Kristyn Hodgdon:
Hi everyone, and welcome back to From First Period to Last Period. I'm your host, Kristyn, and I'm here today with Dr. Michael Guarnaccia. Hi, Dr. Guarnaccia.

Michael Guarnaccia:
Oh, how are you?

Kristyn Hodgdon:
I'm doing well. How are you?

Michael Guarnaccia:
Good.

Kristyn Hodgdon:
But yeah, we're both in New York. It was really sunny earlier. Now, it's a little gloomy, but I'm looking forward to better days ahead. So, for those of you who don't know Dr. Guarnaccia, he is a double board-certified OB/GYN and REI, as well as the medical director at Pinnacle Fertility in New York City. Welcome! I'm thrilled to talk about today's topic, which is birth control misinformation.

Michael Guarnaccia:
Sure.

Kristyn Hodgdon:
There's so much of it out there, and there was a recent Washington Post article about how a lot of women are coming off of birth control due to the misinformation on social media. So, at Rescripted, we always like to say that, ultimately, the choice is up to you, but we want everyone to know the science-backed information that they need to make their own educated decisions. So yeah, let's dive in. First, we want to hear from you on your take on all of the information that's currently out there about birth control and why you think it's actually a helpful form of contraception, but it also has many other uses.

Michael Guarnaccia:
Sure. I think the information and misinformation out there about birth control has stemmed from a shift in people's perspective about naturally occurring substances versus, quote, artificial hormones, and things like that. So I think definitely in the world there has been a shift away from, quote, artificial hormones and artificial substances and more towards natural taking control of your contraception or your fertility naturally versus with a hormonal intervention type of perspective. Now, that being said, I don't think I think each camp has its opinions, and I think there's not a right way or a wrong way. But I think, like everything else, one size does not fit all, and nor does one size fit all at various stages of a woman's life. So I think the type of contraceptive options available to somebody in their teens versus somebody in their 20s, 30s, or 40s versus somebody in their late 40s or early 50s up until menopause can vary. Like everything else in our lives, we go through definite stages of our lives depending on where we're at. So that being said, I mean, we know the birth control pill has been around since the late 60s and early 70s in common usage since then. And I think, once again, it's definitely a hormonal substance. Birth control pills that are composed of estrogen and progesterone or progesterone only, and these are artificially created estrogens and progesterone. So, let's set the stage right away in terms of that regard. Birth control pills over 50 years have really changed the metrics both health-wise and societally speaking, so to speak. ..., I still think there is a place for them in 2024. Now, I think that being said, birth control pills are not the only method of contraception available to women or hormonal contraception. There are IUDs, which there are both hormonal and non-hormonal IUDs, which in and of themselves have gone to a frame-shift 30 years ago. The IUD was looked at one way, then, perhaps negatively, because of bad outcomes with early IUDs in terms of increasing a woman's risk for pelvic infection, and then it morphed into copper IUDs, and now we have hormonal IUDs, and each one has benefits both in terms of contraceptive effect. But also, in terms of non-contraceptive effects, something that was more common in the past, where diaphragms, which were very common in the 80s and the 90s, somewhat have become less common, but there's still a place for diaphragms, which once again represent a non-hormonal method of contraception.

Kristyn Hodgdon:
How is that different from an IUD?

Michael Guarnaccia:
A diaphragm is, actually the old-style diaphragm actually sits on the cervix. It covers the cervix, and spermicide will be placed into the diaphragm itself; that's the way they work. And then it's inserted within the vagina, it covers the cervix. It is a little less efficacious or effective than, let's say, birth control pills or IUDs, obviously, but still very common, or it used to be a more common form. So, it's once again a non-hormonal form of contraception. And I think obviously condoms were and still are a very important adjunct with both contraceptive health and sexual health in terms of preventing STDs and STIs and things like that. So condoms, I think, are the baseline that will always be there. And then for other reasons, women will, in addition, utilize birth control pills or IND or IUDs.

Kristyn Hodgdon:
Have you found that more women are leaning towards non-hormonal IUDs, given just the fact that a lot of women don't want to be on hormonal?

Michael Guarnaccia:
So, there are two types of IUDs. One is a copper IUD, which is non-hormonal, and then the other is a progesterone IUD. Now, in terms of more women, and this is just anecdotal on my part. I don't have any data to show this, but more women, as the safety of IUDs has been once again re-established. More younger women have gone on IUDs because the IUD is inserted, as opposed to taking a birth control pill every day. It's not something you have to think about. Interestingly enough, the progesterone-containing IUD will also have other contraceptive benefits in terms of its small dose of progesterone that's leached out of the IUD over 5 to 8 years. And what that also does is it will minimize or even eliminate menstrual periods. So, for some women who, let's say, suffer from heavy, irregular periods, having the progesterone-containing IUD will limit, minimize, or even eliminate their menstrual cycles. There's some data to show that it can also be efficacious or effective in women with endometriosis or adenomyosis, which can be which can lead to painful, heavy periods that in and of itself can be beneficial as well. The, on the flip side, the copper IUD does not contain hormones, and I think more women are leaning towards progesterone-only IUDs. But for those women who can't take hormones for whatever reason, for health reasons, they may offer the copper IUD as contra distinct to the progesterone-containing IUD, even though that has come back in common use. When I was a resident in obstetrics and gynecology, now 30 years ago, the rules were given the bad rap that the copper IUDs had. The rules were that if a woman wanted an IUD, she would have to be at a stage in her life where she was done with childbearing. Usually, these were women in their late 30s, early 40s, and things like that. But then, as the safety of these IUDs was reestablished, now more younger women are opting to take control of their contraception by having an IUD inserted in for various reasons, and the amount of progesterone in the IUD is much smaller than, let's say, the birth control pill. For those women who will say, when I take the pill, I feel all sorts of side effects from the estrogen and the progesterone, the progesterone containing IUD, since the minuscule amount, they tend not to have those same side effects.

Kristyn Hodgdon:
And, okay, so I wanted to go into a little bit about the benefits of hormonal birth control pills, and like when you would recommend those, obviously, PCOS and endometriosis. I have PCOS, and I've personally used them throughout the years, especially in my teenage years and early 20s, and then, even when going through IVF, I've had to use them like in between transfers, in between cycles before an egg retrieval. So it's definitely had, and for me, who literally cannot predict my periods for the life of me, it really does it.

Michael Guarnaccia:
Yeah. It's an effective adjunct to IVF treatment, the birth control pill.

Kristyn Hodgdon:
Exactly, yeah. So, I wanted to go into a little bit about like why it can be effective for women with PCOS and endometriosis. I guess I'm like interested in: sometimes people talk about the side effects related to hormonal birth control pills. Are there specific combinations that are better for some people and not others, like progesterone only versus combination, etc.?

Michael Guarnaccia:
So I would start off by saying ... sort of 64,000-foot view combined hormonal contraceptive estrogen and progesterone really definitely has benefits and will start off with women with PCOS or just irregular menstrual cycles. It will allow them to get regular withdrawal monthly periods. So, one of the concerns that one would have in a woman with PCOS is, let's say, going without periods for months and months. So, in essence, that puts if a woman doesn't have a withdrawal bleed, at least every metric is you want to have a withdrawal bleed, if not every month, at least every 2 to 3 months. The problem is, is that in women with PCOS, where there's a chronic level of estrogen circulating in their system, there can be a build-up of endometrial tissue and menstrual tissue, which over the years can increase the risk of that menstrual tissue. It doesn't sluff out becoming irregular and, let's say, precancerous things like that. So what the birth control pill does is it prevents it. It basically gives the body enough estrogen and progesterone in the pills that are at the end of your pill packet. So, most combined contraceptive birth control pills have estrogen and progesterone for the first three weeks, and then that last week is what we call placebo. Now, during that last week where, the pill is devoid of any estrogen and progesterone. The woman will go through that withdrawal period. So you're basically shedding out the artificial lining every month. So, number one, it allows women to have regular monthly withdrawal periods as opposed to, let's say, in PCOS, never having a period and having dysfunctional bleeding. And it's all of a sudden you start bleeding or spotting and it's not at a prescribed time, or also be minimizing the risk that tissue has the chance to go through any abnormal changes over the course of many years. So that's the first benefit, and in addition to obviously the contraceptive benefit. Now, in terms of other benefits for women with PCOS, one of the other side effects is that they can have hair growth. In a male pattern, it's called hirsutism. So let's say excess facial hair or hair in other locations on their body, hair around their nipples, or even chest hair, things like that. Now, what the birth control pill does by taking it and by taking a chronic level of estrogen and progesterone and shutting the ovaries down is it also prevents the production of what we call androgens. So it suppresses that so that what women find is that if they're on the pill, they find that the hirsutism or the hair growth will become less over time, and the hair that does develop is not quite as thick and dark. It can be less obvious. Now, that, it can take up to 6 to 12 months to see any effect with that, but once again, a lot of women notice the benefit of minimizing the hirsutism or hair growth that they have.

Kristyn Hodgdon:
Acne, too, right?

Michael Guarnaccia:
Acne, too. Absolutely, anything that lowers the testosterone or the androgens or any androgen situation, acne, hair growth, hair loss in a male pattern, and things like that will ideally be ameliorated or lessened. Maybe not completely eliminated, but the pills in when they're shutting down the ovaries, for lack of a better expression, are minimizing androgen or male hormone production. And for some women, that's really all it takes. There are other women with PCOS where the pill might not be quite strong enough. Still, even in that situation, the pill can be an adjunct to other medications, such as spironolactone, which is an anti-androgen that can help with hirsutism and things like that. So, I think that in and of itself is the beneficial function of the estrogen-progesterone pill. Now, the progesterone-only pill is used as well. Now, a lot of women may use, or the women who tend to use the progesterone-only pill may not be able to tolerate estrogen. If they have a situation where they should not be on excess estrogen, for maybe they've had a blood clot in the past, which can be worsened with estrogen or an estrogen, or there might be women who were on the pill and then had either a thrombosis or blood clot or a pulmonary embolism, something really bad such as that, but they still need contraception, they can go on the progesterone-only pill. The one downside of the progesterone-only pill is that it works great, but you've got to take it every day at the same time. It's not quite as strong as the estrogen-progesterone pill in terms of preventing ovulation, so its contraceptive efficacy can be limited. So, number one, women need to take this pill, and if you miss a pill or if you miss two pills, then the effectiveness of the progesterone-only contraception is marginalized, and you would need to use another form of contraception for the remainder of the month. So that's number one. Number two, women who use the progesterone-only pill tend to maybe have some dysfunctional spotting or bleeding because of the fact that when the uterine lining is exposed to chronic progesterone only, it tends to become brittle and sluff away. So physiologically, the uterine lining is seen as a woman's developing an egg. A little bit of high school biology, a woman's developing an egg, the estrogen level goes up, and then, around days 12 to 14, she ovulates that egg, and then that's when the progesterone level starts to go up. So you've got estrogen and progesterone, and then if pregnancy doesn't occur, that corpus luteum on the ovary that was producing the progesterone degenerates away, estrogen-progesterone levels fall, and then that's when she gets a withdrawal period. So the uterine lining is used to a combination of both estrogen and progesterone. So that being said, one of the drawbacks for some women on the progesterone-only pill will be that they'll have this dysfunctional spotting or bleeding because the lining is brittle and breaking down. The progesterone-only pill provides contraceptive efficacy for those women who can't take estrogen for whatever reason. Also, if a woman can't take estrogen because of a medical condition or an issue, putting in the progesterone-only IUD as well will help them to be able to have contraceptive benefits. Yeah, but the progesterone-only pill also doesn't have the same maximal effect in terms of ameliorating the hirsutism and things like that.

Kristyn Hodgdon:
So, for women with PCOS, you'd recommend the combination pill.

Michael Guarnaccia:
If they can tolerate it, then once again, there may be somebody who can't tolerate it. I would say we can use the progesterone-only pill that will help keep your uterine lining thin. That'll provide you with those pills, but it may not do anything for the hirsutism and the acne and things like that.

Kristyn Hodgdon:
What about endometriosis? I know that it can be fueled by estrogen. So, do you typically not recommend the combination pill?

Michael Guarnaccia:
In terms of my experience with endometriosis, in the estrogen and the birth control pill, the estrogen-progesterone combination can actually cause quieting or regression of those endometriotic implants, and nobody is quite sure why. There may be some newer research on doctors who have a little more updated experience with endometriosis. Still, in the past, it was felt that some women would benefit from both the estrogen and progesterone combination. And perhaps it was because this is a synthetic estrogen versus a naturally occurring one, yeah.

Kristyn Hodgdon:
Got it, that makes sense. So, how do you address concerns about birth control? So, in some cases, it might be the best option for someone, and maybe they're just dead set against it because of misinformation or other concerns.

Michael Guarnaccia:
So I would tell you, for what I do for a living primarily, I'm a fertility specialist. So the concerns I have from women are I've heard that the pill diminishes your fertility. It can decrease your egg count or its effects on your ovaries, which is diametrically not belied by the facts. So what I tell women when they come to see me is if your periods were irregular before you started the pill, you're going to go on the pill. You're going to get periods regularly. You stop the pill. Your periods are just going to go back to the way it was before you started the pill because the pill periods are artificial periods. So, the pill itself does not impact a woman's physiology or ovarian physiology. Also, unfortunately, the ovaries have a programmed lifespan, meaning, you know, a woman, a child, a female child is born with, let's say, a million eggs. By the time she reaches puberty, she has about 350,000 to 400,000 eggs. And then, over the course of her reproductive life, from puberty to menopause, she will go through those eggs. Being on the pill does not change that. What do I mean? That every month, and a lot of fertility patients will hear this every month, a certain number of antral follicles develop, right? This is just the way the ovary is. So a bunch of follicles that are tiny and contain immature eggs will come to the starting line, right? One follicle will develop faster than all the other ones, and that's the follicle that ovulates the egg out. The remaining follicles started the marathon. They drop away, and they degenerate. And then with the next period or not, even with the next period, even if a woman gets pregnant or is on the birth control pill, a group of follicles come to the starting line again. The difference with being on the birth control pill is that the dominant follicle is not going to develop and ovulate out of an egg, so you get follicles that come up to generate away. There are waves of follicular development. Once again, within each follicle is an immature egg. So that being said, being on the birth control pill does not change that being pregnant does not change that. So even when a woman is pregnant, she'll have follicles developing and degenerating away.

Kristyn Hodgdon:
Yeah.

Michael Guarnaccia:
So, the ovarian lifespan, unfortunately, is set. Obviously, every woman has a different sort of ovarian reserve. But this does not change when a woman says to me, I was on the pill for 20 years now; I'm like really concerned that I may have done some damage to my ovaries, so to speak. No, you didn't, but while you were on the pill, your ovaries went through their normal lifespan. Once again, being on the pill doesn't change that in any way. And that's why when a patient comes to somebody like me, the first thing we do is check their ovarian reserve and do a blood test. Test the number of eggs they have, and also an ultrasound to see those little tiny immature follicles that are developing or coming to the starting line this month. So that's the biggest sort of misnomer because you have a lot of women who basically are like, listen, I've been on the pill. Obviously, I wasn't ready to conceive a child. And for various reasons, I'm worried that now that I'm ready to conceive a child, I've done something to affect my ability to conceive a child. Absolutely not, absolutely not. But bearing in mind that if that is their ovarian function, their inherent fertility won't be affected positively or negatively by being on the pill; it just is what it is.

Kristyn Hodgdon:
No, that makes sense. What about long-term risk? I often think about if I were to go when I'm done having kids. I have PCOS, and I just get my period maybe three or four times a year. Should I go back on the pill after I'm done in perpetuity till menopause?

Michael Guarnaccia:
You know what? So that's changed as well. Now, with the proviso, I don't do much of General GYN anymore. It used to be thought that the birth control pill shouldn't be prescribed, any hormonal contraception shouldn't be prescribed, for women, let's say, over 35 years old, because of the risk of being ... I would defer to some of the general gynecologists, but now that the understanding is as long as you're healthy and a nonsmoker, you can stay on the pill, quote-unquote, up until menopause. Smokers have a little bit of an increased risk of blood clots on the pill and things like that. But theoretically speaking, being on the birth control pill is not seen as negative. Now, also bearing in mind when the pill first came out, you know, back in the 70s, these high-dose estrogen pills, so there were higher risks. Nowadays, the birth control pills on the market, you're getting a much lower estrogen concentration, 20 micrograms versus in the old days, it was like 50 microgram pills, and things like that. Theoretically speaking, a healthy woman can stay on the pill for most of her reproductive life until menopause, with the proviso being making sure of a mammogram once you get to a certain age: normal mammogram, not a smoker, no history of blood clots, and things like that.

Kristyn Hodgdon:
I have seen online some sort of natural medicine. Doctors say that birth control can deplete your body of certain essential vitamins and minerals. Is that completely false?

Michael Guarnaccia:
I will be the first one to admit, I never looked into that. I don't know of any data that shows that, but certainly, I would love to engage the naturopaths and see what their data is because, obviously, as a Western medicine physician, I'm always more engaged in seeing what the data is. So, I'll be the first one to say I'm not familiar with that literature. Would always be good to see what they're basing that on. Is it anecdotal, or is it scientifically based? Remember, the birth control pill has been used universally for what now, 50 years? There's data, there's such a wealth of data here. And what's great about a lot of the European countries, is everything a National Health Service, all their data is tracked rigidly from cradle to grave. I've never seen any of that data, but I will tell you, I could just be unfamiliar with whatever studies they're looking at. But I think what's great about the pill, with its estrogen, let's say, is that estrogen also does. If a woman, let's say, goes through premature menopause, for the sake of argument, let's say she, for whatever biological reason, goes through menopause earlier than most women in the United States, anywhere between 48 and 52 is the average age of menopause in the Western world. Let's say she goes through menopause very early, in her 40s, in her early 40s, in her late 30s; having some estrogen supplementation will help to protect your bones, will also make her feel better. There's not just the contraceptive benefit, let's say, for a woman who's gone through premature menopause, but there's also the benefit of feeling better, sexual health, and all of those things. So, really, once again, the pill does have a benefit as well.

Kristyn Hodgdon:
Awesome. What are the most common uses that you have for it in your practice with IVF? To clarify, I know we mentioned it earlier, but so people understand a little bit better how it's used.

Michael Guarnaccia:
For IVF, there's data to show that having a woman on the pill prior to an IVF cycle, number one, becomes also in women, let's say without regular periods, if we wait, IVF starts at a proscribed time. We like to start IVF when the hormones are low, and that typically coincides with when a woman is on her period. Now, if we have a woman who, for whatever reason, does not get regular periods, having her on the pill will allow us to synchronize her treatment cycles. So number one, for synchronization, there are some studies to show that the pill also may benefit those women with diminished ovarian reserve or very low egg number in terms of certain protocols that we use, the progesterone, and the pill will actually lower the LH levels and might facilitate a good cycle outcome. But I would say the number one reason to use the pill that we do is more of allowing us to start a woman's IVF treatment at an optimal time, and not just wait for her to get her period with all that because there are a lot of patients who, even if they're getting periods, if their ovarian egg count is low, if their ovarian reserve is diminished, their ovaries may not be functioning up to snuff, so their hormone levels may be a little bit out of whack, even though they're like, it's my period, doc. Yeah, your estrogen level, your progesterone level is not good for us to start by having them on the pill. We can control that, so to speak. For my practice, it's mostly about using it for control. Now granted, I don't really do a lot of endometriosis care anymore, but definitely, for endometriosis specialists, it's an important aspect of their treatment as well.

Kristyn Hodgdon:
Yeah, yeah, like in between, children even suppress everything a little bit.

Michael Guarnaccia:
And for a lot of patients. Now, the only proviso would be if you're breastfeeding it would be better to be on, let's say a progesterone-only pill. And although now that started to change, maybe I'm showing I'm dating myself a little bit, but with the very, very low estrogen-containing pills, your OB/GYN may not be as averse to doing that. But classic conventional wisdom has been if one when you're breastfeeding, probably either non-hormonal contraception or progesterone only, but your OB with a lot more experience with that would know that better. And then also for patients who want to space out their pregnancies and are like, listen, I have a baby, I would rather use something a contraceptive that's a little bit more efficacious, and I want to space out. I want to be able to be pregnant when I want to be pregnant and not be controlled by that, definitely. And the misnomer that when you're breastfeeding, you can't get pregnant. That's not true.

Kristyn Hodgdon:
So lastly, I always like to ask: what you would rescript about the way people think about hormonal birth control or just birth control in general?

Michael Guarnaccia:
How I would rescript is hormonal birth control has won 60 to 50 years of safety data. Even with that safety data, the birth control pills that we use now have less hormones in them than the birth control pills that came out in the 60s and 70s, 1960s, and 1970s. Also, I think a lot of us have gone through a frameshift, the progesterone-only IUD, and the Marina, there are various types that are really effective and safe. So, for women who have not had children yet, as I said, in the old days, your OB/GYN would only feel comfortable giving a woman an IUD who had already completed childbearing or had children. The safety around using an IUD, either a copper, progesterone-containing, or young woman who's not yet had children, there's no data to show that it affects her ability to have children when that IUD is removed in the future. And I think what I like about it, the IUD, is that I can even for women, let's say, who want to do egg freeze, right? A lot of women will come to my office who are interested in doing this. I can still put her through an egg-freezing cycle with the IUD in place. She does not have to remove it. It has no negative impact on how many eggs she's going to produce or the safety of doing that. So that's also beneficial because if you want to freeze your eggs and I have to go to my OB/GYN and get it pulled out, then I have to go through a cycle.

Kristyn Hodgdon:
One less thing to worry about.

Michael Guarnaccia:
I need a contraceptive once the cycle is over. Most young women are lucky enough to only have to do 1 or 2 cycles of egg freezing. So that's a very limited couple of months in their life, and to go in, get it taken out, have it put back. So the point is, I would say, from a societal standpoint, the IUD has really come back and is a good part of a young woman's armamentarium for controlling when she wants to have a baby. And once the IUD is in it, it's in her hands, and she's not having to worry about taking pills all the time and whatever other consequences of using birth control pills. But birth control pills are still excellent.

Kristyn Hodgdon:
But that's so cool that you can freeze your eggs with an IUD in.

Michael Guarnaccia:
Absolutely. And I think, once again, for those of us older doctors, we've gone through a frameshift with that as well as the data has come out and said, no, this is perfectly effective, in terms of simplifying the process and not having any negative impact on the process. Because if I said to somebody, listen, if you leave your IUD, it could diminish your chances of getting eggs by 10%, 15%, or 20%, most people would like to wait a minute. Okay, you know what? I want to make sure this is successful. It doesn't help, it doesn't hinder, it's just there.

Kristyn Hodgdon:
Awesome, I love it. Choices, we love choices. Thank you so much for your time. This was so helpful, and I think we busted a lot of birth control myths.

Michael Guarnaccia:
Hopefully, we've gotten good information out there for everyone, but I appreciate you listening to me gab away.

Kristyn Hodgdon:
No, I appreciate your time. It's so nice to meet you.

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