Finding the Right Birth Control Option with Dr. Ashley Brant

Podcast Transcript

Deanna:  Hi, welcome to Health Essentials Podcast by Cleveland Clinic. I'm your host, Deanna Pogorelc here on our main campus in Cleveland, Ohio. Joining us today is Dr. Ashley Brant. Dr. Brant is an obstetrician gynecologist and family planning specialist here at the Cleveland Clinic, OB GYN and Women's Health Institute. Today, we are going to be talking about the many different contraceptive options that are available to women today and what to consider when choosing the best option. So please remember, this is for informational purposes only and is not intended to replace your own physician's advice. Thanks for being here, Dr. Brant.

Dr. Brant:  Thank you for having me.

Deanna:  Can we start by just kind of doing a basic refresher about what's happening in the female reproductive system when we have our periods and then eventually, when we get pregnant?

Dr. Brant:  Yeah. Your hormones naturally go through a cycle about every four weeks. At different phases of the month, there's different hormones that are higher and then they change later in the month and they go lower. Your body, right around the mid part of the cycle, your body releases an egg and if you're sexually active and not using contraception, that's when you have the potential to get pregnant. If you get pregnant within a few days, that egg implants in the uterus and begins to grow and it shifts your hormones a little bit so that your body can tell that you're pregnant. When you're not getting pregnant, the hormones then shift again towards the end of the cycle and that signals your next period to come.

Deanna:  Okay. When a woman comes into your office and says she wants to start talking about birth control options, how does that conversation start or what are some of the first things that you talk about?

Dr. Brant:  So I'm always so excited when women come to talk with me about birth control. I really think that contraception is an essential part of healthcare and there's no one size fits all approach for all women. I'll often start off by asking her which methods she's used before, what did she like about them? What didn't she like about them? What side effects has she experienced? What are her future plans? Is she trying not to get pregnant ever again? Is she trying not to get pregnant for just a few months or a year? Those things help guide me.

Deanna:  Yeah. Does age matter at all? What about younger patients versus older patients?

Dr. Brant:  So age itself doesn't matter all that much. Sometimes if people have other medical problems, like for example if they're a smoker, that can play into effect with age.

Deanna:  Okay. One of the most popular methods for a while, or at least one of the most well known forms of birth control would be the pill. But I know the pill isn't necessarily just one thing. Are there different kinds of pills now that women can take?

Dr. Brant:  Yeah, so you're right. There are lots of different pills on the market. Almost a hundred different brands of pills are available. Generally, the pills are kind of divided into two classes. There are the combined birth control pills, which have estrogen and progestin in them. That's the common birth control pill that most people are on. There's also a progestin only birth control pill, which is sometimes called the mini pill.

Deanna:  Okay. So I've heard of some women, they skip that last week of the sugar pills in their pack and then go immediately to the next pack in order to skip their period. Is that safe? Is that an okay thing for people to do?

Dr. Brant:  Yes, it's totally safe. In fact, for some women that have medical problems like very heavy periods or severe PMS symptoms, that might even be a preferred way to take the birth control pills. The one downside is that the longer you go without a period, the higher the risk of getting a little bit of unpredictable spotting.

Deanna:  Oh, okay. Interesting. I'm guessing a lot of women ask you about which method is most effective. So is that the pill or is that something else?

Dr. Brant:  Just based on effectiveness alone, the long acting reversible methods, the IUDs and the implants are the most effective.

Deanna:  I've been hearing a lot about the implant. Can you talk a little bit about what that is and how it works and some of the pros and cons?

Dr. Brant:  Yeah, absolutely. The contraceptive implant that we have available in the United States is called Nexplanon. The prior version was called Implanon, So you may talk with women who've had that before. It is a small plastic rod about the size of a matchstick that's inserted on the inner side of the upper arm.

Deanna:  Okay.

Dr. Brant:  It's FDA approved for three years, although there is some evidence that it's probably good for up to four years. It's put in in the office during an office visit. We basically give some numbing medicine into the skin of the arm and then insert the device under the skin.

Deanna:  Okay. Does that hurt at all?

Dr. Brant:  It's actually really well tolerated. I would say nine times out of 10, my patients tell me that it was much easier than they were expecting and much less painful than they were expecting.

Deanna:  Interesting. Okay. So how does it work once it's in the arm?

Dr. Brant:  It releases a small amount of hormone, progestin every single day. It's a very steady amount of hormone that's released and that prevents ovulation, prevents you from releasing an egg.

Deanna:  Okay. Then how is it removed eventually, or you said it lasts for like three to four years?

Dr. Brant:  Yeah. During an office visit, we take it out. We do the same numbing medicine in the arm and make a small cut just three to five millimeters usually and then we remove it through that.

Deanna:  Okay. Do women still get their period when they have the implant?

Dr. Brant:  It's a little bit unpredictable. Some women end up having periods that are lighter and shorter than what they were used to. Others, their periods are unchanged and others have what we would describe as more problematic bleeding where they bleed for a lot of days out of the month or have periods that are heavier or longer than they used to.

Deanna:  Okay. So there's not necessarily a normal, it can be really dependent on the woman.

Dr. Brant:  Yeah, and it is a little bit difficult to predict what people are going to experience when they choose the implant. When I'm counseling somebody, I usually ask them how bothered they would be by unpredictable bleeding.

Deanna:  Okay, interesting. Then what about the IUD? There are two different forms, right?

Dr. Brant:  Yeah. The IUDs fall into two major classes: the hormonal IUDs and the non hormonal IUDs. The non hormonal IUD that we have available in the United States is called Paragard. It's also sometimes called the copper IUD. Then there are a number of different hormonal IUDs. All the IUDs and implants are more than 99% effective.

Deanna:  Wow. Okay. So how do those work? I know it's different probably for the hormonal and the non-hormonal.

Dr. Brant:  Yeah. The non-hormonal, the Paragard, like I said, it has copper on it and that copper creates an environment that's really unfriendly to the sperm. Primarily, it creates an environment that the sperm can't survive in, so the sperm never make it to meet the egg. It also changes the lining of the uterus a little bit so that fertilized egg couldn't implant.

Deanna:  Okay. What's the procedure like for getting that put in? Is that an in office thing as well?

Dr. Brant:  Yeah. We put the IUDs in the office. Generally, people just make a regular office appointment for an IUD insertion. I usually counsel them to take some ibuprofen beforehand and it involves a speculum exam and then inserting the IUD through the cervix.

Deanna:  Can we talk a little bit more about the hormonal IUD and why maybe a woman would think this was a good option for her, some of the pros and cons?

Dr. Brant:  Yeah, absolutely. The hormonal IUDs are growing in popularity recently. There's a number of different brands or types that are available. The thing that they all have in common is that they are progestin only IUDs. Some of the different brand names of the IUDs that are available are the Mirena, the Liletta, the Skyla, and the Kyleena. Each of these is slightly different from the others, except Mirena and Liletta are pretty much exactly the same just different manufacturers. So they vary a little bit in terms of like how long they're good for, how many years they're approved for and what the side effects are like. But in general, the hormonal IUDs tend to cause periods that are lighter and shorter and less painful.

Deanna:  What about the difference between estrogen and progesterone and maybe some of the side effects that either or both of those would cause?

Dr. Brant:  Yeah, so estrogen, as we mentioned before, is one of the components in the birth control pill. Estrogen we know is thing in the pill that slightly increases the risk for getting a blood clot or causing a stroke or a blood clot in the legs or the lungs.

Deanna:  I know one of the side effects that women are worried about sometimes with birth control is weight gain. Do all forms cause weight gain potentially or just certain forms?

Dr. Brant:  So one of the common things that people ask about is weight gain. A lot of people start birth control at a time in their lives when they're already sort of at risk for gaining weight, women are going off to college or they're moving out of their parents' home or doing other things that cause weight gain. So it can be really difficult to untangle someone's weight gain from whether or not it's related to their birth control. We do know that the only method of birth control in the studies that's associated with weight gain is the depo injection. That's because it's a large dose of progestin that you get all at once and it has to last for three months. On average, women in these studies, women who were on the Depo-Provera injection only gained a few pounds, like up to five pounds in that first year. But we know that some women gained no weight and other women gained more than five pounds. So it's a little tricky to predict who's going to gain weight.

Deanna:  Okay. What about someone who maybe doesn't want something quite as longterm? What are some of the more short term options aside from the pill?

Dr. Brant:  The contraceptive ring and the patch are very similar to the pill. So it's just different ways of getting the hormones into your body. The ring is just a small, flexible ring that the woman herself puts in her vagina, leaves it there for about three weeks and it releases the same hormones that are in the combined contraceptive pill. The patch is also similar, but it's a sticker that you put on your skin and use a new patch each week. Same hormones as the pill,

Deanna:  Put it anywhere?

Dr. Brant:  You can put it anywhere except for your breasts.

Deanna:  Okay.

Dr. Brant:  Mm-hmm (affirmative).

Deanna:  Interesting. Then what about the shot? I've heard about an injection.

Dr. Brant:  Yeah. So the shot, also called Depo-Provera, or the depo injection sometimes is an injection that you get every three months to prevent pregnancy. The plus side of that is that for people who don't want to have to remember to do something every day or every week, it's a nice method that will cover them for three months at a time. Downsides are that it does require a visit to your healthcare provider usually to get the shot. Occasionally, it does take longer than three months to wear off, even up to nine months to wear off.

Deanna:  Oh, that's interesting. Okay. So that was going to be one of my other questions is I know some women think about getting pregnant after going on a birth control and they wonder how long is it going to take? Is it going to be a problem? What do you counsel patients about that?

Dr. Brant:  Yeah, so really for all methods except for the shot, women can get pregnant immediately after stopping the method. We probably all have talked to people who missed one or two birth control pills and accidentally got pregnant. So it really wears off pretty. The shot is the one thing that can linger on.

Deanna:  Okay. With all these different methods of hormones, are there going to be different side effects for each one or are they generally similar when we're taking these hormones?

Dr. Brant:  Yeah. So depending on the method that you choose, there may be a difference in side effects. For example, the birth control pills, the side effects can be both positive or negative. Mostly, they're positive though. It generally results in periods that are a little bit shorter, a little bit lighter, less painful, more predictable. In the first few months, sometimes people have some breast tenderness, maybe a little bit of nausea when they first start taking it, sometimes some unpredictable bleeding. That usually goes away after they've been on it for a couple of months.

Deanna:  Okay. What about  long term? What do we know about how safe it is to be on hormones for many years?

Dr. Brant:  Yeah. This is a question that I get frequently, especially as women are getting into their forties and they say to me, "I've been on the pill for over 10 years, is that okay?" It is absolutely safe. We actually have some really good data that says that being on birth control methods for a long time likely reduces your risk of certain types of cancer. So specifically, endometrial cancer and ovarian cancer.

Deanna:  Okay. What about risk of stroke? I've heard that might be a thing with the birth control pill.

Dr. Brant:  Yeah, you're right. Any of the methods that have estrogen in them, so that's the birth control pill. The patch or the ring do slightly increase the risk for having blood clots, so that can present like as a blood clot in the leg or in the lungs or even a stroke. That's obviously a very serious health problem if that occurs, but it is rare. There are certain medical conditions where if you have these, we wouldn't offer you those methods that have estrogen in them.

Deanna:  Okay. Yeah, that makes sense. What about if a woman doesn't want to take one of these hormonal forms. Are there any natural ways? I've seen some women use an app to track their period or things like that. What about options for those women?

Dr. Brant:  Yeah, I think that's a great thing to bring up because all women are different and everyone has different values and preferences and some women are not willing to tolerate certain side effects and they'd rather do something more natural. What you're describing is a whole class of methods known as fertility awareness method, or natural family planning, and there's a number of different methods that can be used in that class. These methods are a little less effective, closer to 75% to 85% effective because it requires a lot of consistency and discipline to use those methods, usually involves tracking your cycles on a calendar and then paying attention to your symptoms like your temperature or even the consistency of your cervical mucus to determine when you're fertile and then abstaining during those days.

Deanna:  Okay. What about a woman who doesn't want children or maybe knows that she's done having children? I've heard about it called having your tubes tied. What does that actually entail and what is that procedure?

Dr. Brant:  Yeah. So for women that are definitely done having children, the long acting reversible methods are still totally appropriate and there's actually some evidence that they are probably even more effective than having sterilization done or tubal ligation done. But for women who decide that they don't want to use a contraceptive method anymore, they just kind of want to choose to move forward with sterilization, there are a couple of different options. For the woman herself, she could have a tubal ligation. That's something that we can do at the time of childbirth. If she's planning to have her last child, we can do that during a C-section or in the postpartum period. We also can do laparoscopic tubal ligation, which is surgery where we go into the abdomen through small incisions and it involves cutting, burning, tying, banding the fallopian tubes.

Deanna:  Okay, and those are non-reversible?

Dr. Brant:  Correct. Let's not forget vasectomy. Men definitely have a role here too. Vasectomy is very safe and very effective too.

Deanna:  Yeah. So I was going to ask, even though there are so many options, are there still any unmet needs or are there any kind of forms of birth control that are being developed? I've heard about some kind of male contraceptive that's being developed. Do you know anything about any of those?

Dr. Brant:  Yeah, absolutely. Like I said before, all women are different and there are still women who have not been able to find a contraceptive method that fits their needs and their preferences. So researchers are continuing to work on developing new methods. In the last year even, we've seen the release of a contraceptive vaginal ring that's good for a full year. We've also seen a new progestin only pill recently being released. The current methods that are available are being studied to see if they can be approved for longer. One of the hormonal IUDs was just approved to increase in time from five years to six years, so that's really exciting. These changes are being driven by women, by our patients that are saying, "We need more methods. We need more options."

Deanna:  Great. Well, that was the end of my questions. Is there anything else that we didn't talk about that you think is really important to mention on the topic of birth control for women?

Dr. Brant:  Yeah. So as I mentioned, I think that contraception is an essential part of women's healthcare. As a doctor who takes care of women in all phases of their lives, I really see how the ability to decide when and if to have children can influence their ability to lead the lives that they want to lead. I would encourage my patients and I encourage our viewers to meet with their doctors or their healthcare providers to talk about what options might be best for them.

Deanna:  Great. Well, thank you so much for being with us, Dr. Brant. If you'd like to schedule an appointment at Cleveland Clinic's OB GYN and Women's Health Institute, please visit our website at clevelandclinic.org/OBGYN or call (216) 444-6601. To listen to more Health Essentials Podcasts from our Cleveland Clinic experts, visit clevelandclinic.org/hepodcast or subscribe wherever you get your podcasts. For more health tips, news, and information, follow us @ClevelandClinic on Facebook, Twitter, and Instagram. Thanks for joining us.