Birth Control: Facts vs Myths

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're talking about birth control, a topic filled with options, opinions, and sometimes confusion from pills and patches to copper and hormonal IUDs, from concerns about weight gain to questions about fertility. I'm joined by Dr. Erica Bishop to help you separate fact from fiction and make informed decisions about your reproductive health. Thank you so much for joining me on the podcast, Dr. Bishop.

Erica Bishop, MD:

Thanks for having me.

Erica Newlin, MD:

Before we start, can you tell our listeners a little bit about your role at Cleveland Clinic and your background?

Erica Bishop, MD:

Absolutely. So I am a fellowship trained subspecialty complex family planning provider, which means that I take care of patients who have early pregnancy complications or have complex medical backgrounds where they might require additional help choosing a contraceptive method as well as patients who are experiencing complications later in pregnancy in the second trimester.

Erica Newlin, MD:

Let's begin with the basics. And by basics, I mean a big question of what kind of birth control options are there as far as what are the most common types and how do they work differently?

Erica Bishop, MD:

Yeah, so there are a multitude of different birth control options and that ranges from ones that people are more familiar with like traditional birth control pills. And then we also have birth control patch and vaginal ring as well as a birth control shot. And then there are also IUDs, intrauterine devices, as well as the birth control implant that goes under the skin of the arm. And it really depends on the method in terms of how they work. Many types of birth control like the pill, patch, ring and the shot and the implant work by stopping people from ovulating, releasing an egg every month during their normal menstrual cycle. But then there are other methods that don't necessarily do that. For example, IUDs and some lower dose birth control pills might prevent pregnancy by stopping sperm from getting into the uterus by basically making the mucus inside the cervix thicker and preventing sperm from getting inside.

Erica Bishop, MD:

Some IUDs also make the lining of the uterus thinner. And then also there's a copper IUD, which releases copper, which is toxic to sperm and it prevents pregnancy in that way.

Erica Newlin, MD:

When someone comes for just a general birth control consult, how do you help them understand their options and choose between those options?

Erica Bishop, MD:

So what I would say here is that it's really highly individualized. And what I usually do is I start by learning more about patients, what their goals are, first of all, for using birth control, whether they're just trying to prevent pregnancy or whether there are other things that they're looking for, other benefits that they're looking for in birth control options, other things like what their plans are for reproduction and future fertility. Do they have any children? Do they want more children? Do they ever want to have children in the future? And then also more about their medical backgrounds. Do they have any medical conditions? What medications do they take? Because that can also have an impact on what options might work better or worse for them.

Erica Newlin, MD:

When it comes to options, I think one thing patients ask about a lot is what options there are for non-hormonal birth control. And it's often we're thinking about the copper IUD, correct?

Erica Bishop, MD:

Yeah, absolutely. So the copper IUD is certainly one non-hormonal option and it's a very effective one. It's more than 99% effective and it is long-lasting. There are other options as well. Spermicides, which can be either prescription or over-the-counter. Traditionally they were just available over the counter, but there is a newer prescription form that's available. And then of course you have other types of barrier methods like condoms and diaphragms.

Erica Newlin, MD:

Can you still get diaphragms?

Erica Bishop, MD:

Yes, you can. There is at least one that's still on the market and that is available for patients. It doesn't require a fitting the way diaphragms used to in the past. And that is something that is available for patients. Those in general barrier methods like the diaphragm and condoms and spermicide are not as effective as some of the other birth control options that we've mentioned, but depending on patient's circumstances and their medical conditions and what their goals are for using birth control could potentially be a very appropriate method.

Erica Newlin, MD:

And there are also some newer options on the market like the birth control gel. What should people know about that option?

Erica Bishop, MD:

Yeah, so that is essentially the prescription spermicide that I just referred to. So similar to the over-the-counter spermicides that don't require prescription and other barrier methods, they are methods that need kind of some advanced planning in the sense that they need to be used in the moment when someone is planning to have intercourse. And most people are eligible to use the prescription gel method. The one consideration is it's not necessarily the best option for people who have issues with frequent or recurrent UTIs.

Erica Newlin, MD:

Birth control isn't one size fits all and many people have questions about what's normal and what's not when starting or switching methods. Let's discuss those concerns. Can you get pregnant while on birth control?

Erica Bishop, MD:

So absolutely. There is a possibility really with any type of birth control for someone to get pregnant. I'd say really the only exception to that is having sterilization surgery where your fallopian tubes are completely removed. But setting that aside, thinking about all the other methods of birth control that we discussed, they all have a failure rate. It kind of varies depending on how the method works with a kind of general concept that if there's something that you're having to remember to do, it's going to be less effective. So thinking about pills, if you maybe forget to take a pill or forget to change your patch or your vaginal ring or you're late for your appointment to get your birth control shot, then those are all things that could make that method less effective and make you at higher risk to get pregnant. Thinking about other methods like the birth control implant that stays in your arm or the IUD that stays in your uterus, those methods tend to be a lot more effective just because they're not relying on you remembering to do something every day or every week or month or a few months.

Erica Bishop, MD:

And that being said, they're also not perfect. They're more than 99% effective, but they're not perfect. So if you have concerns that you might be pregnant while using any method, it's always a good idea to take a pregnancy test. And if it's positive, that's a real result that you should see a healthcare provider about.

Erica Newlin, MD:

One of the things that people worry about the most are side effects. And one thing people ask about a lot is weight gain. How much can one expect to gain weight-wise when starting a birth control method?

Erica Bishop, MD:

So that's a great question. And we actually have really good data on this that shows that the only method of birth control that really has any associated weight gain is the birth control shot. All of the other methods as far as the pill, the patch, the ring, IUDs, implant, none of them have been shown to actually cause weight gain. Of course, people sometimes gain weight during the natural course of their life as diet and lifestyle and other factors might fluctuate, but the birth control shot is the only one that has really been shown to cause weight gain. For people who are on the birth control shot, not everyone gains weight even. When people do, it's typically on average about five pounds per year. And the people who gain weight tend to be people who might already be overweight and adolescents in particular.

Erica Newlin, MD:

What effect does birth control have on mood?

Erica Bishop, MD:

In fact, there's some people who may actually use birth control to help with mood. For example, people who have premenstrual dysphoric disorder, which is essentially a very severe type of premenstrual syndrome or PMS where people have worsening mood symptoms around the time of their period. There are actually a couple of brands of the birth control pill that have actually been shown to be helpful with people who struggle with PMDD.

Erica Newlin, MD:

Can birth control affect your fertility or your hormone levels long-term after you stop taking the pill?

Erica Bishop, MD:

So for birth control pills, no. In general, almost all types of birth control after you stop taking them or using them are very quickly reversible and people will go back to baseline fertility quite rapidly. And that also includes the IUD and the implant. For really any of those methods, the patch, the pill, the ring, the IUD, the implant, once you stop using that method or you have that method removed, hormone levels generally are out of your body within about 48 hours. The big exception to that is the birth control shot. That is a method that you get every three months. So as you can imagine, it's much longer lasting than those other options. And that being said, while we can't guarantee that someone won't get pregnant if they don't get their shot every three months, we do know that some people take longer to go back to baseline fertility after getting the birth control shot, sometimes as long as up to 12 to 18 months.

Erica Bishop, MD:

So when I'm talking to patients about their reproductive plans and their family building goals, I will sometimes potentially see someone who tells me that they want to prevent pregnancy right now, but they are hoping to start trying for a pregnancy maybe in six months or 12 months after they pass some milestone in their life. And for those people, I would really recommend avoiding the birth control shot since they may have a more challenging time getting pregnant in the short term.

Erica Newlin, MD:

Should people be concerned about the effect of particularly the birth control shot on bone health long term?

Erica Bishop, MD:

So we know that the birth control shot does decrease bone mineral density. That impact is reversible after people stop using the birth control shot. And the important thing to know here too is that we don't really have any data that shows that that decrease actually leads to important clinical outcomes. So what we're talking about here is fracture risk because whether or not your bone mineral density decreases, what we really care about is are you going to have a fracture? And we don't really have strong data to support that. So for people who are using the shot and it is working well for them and meeting their goals, we don't have a recommendation that there's a cutoff or a restriction on the length of use. In fact, the American College of Obstetricians and Gynecologists has committee opinion, essentially a guideline that says that healthcare providers should not restrict patients' length of use for the birth control shot.

Erica Newlin, MD:

There are also a lot of myths and misunderstandings when it comes to birth control. Let's tackle some of the biggest ones. What are some of the most persistent birth control myths that you would like to debunk?

Erica Bishop, MD:

So I think one myth is that you have to take the birth control pill at the exact same time every day. And I think that can lead to unnecessary stress for patients. When we're thinking about the most common type of birth control, a combined pill that has an estrogen type hormone and a progesterone type hormone as long as you take the pill every day at some point, it's going to be effective. Ideally, you're going to take it on approximately the same time on a regular schedule, but as long as you take it every day, you should be covered. Even for the other types of birth control that have only progesterone and a lower dose, the one that's available over the counter and the one that's been available for a very long time and is sometimes referred to as the mini pill. Those ones do have to be taken on a more strict schedule, but even then there's a three-hour window in which you can take it so you're not having to take it on the dot at the same time every day.

Erica Newlin, MD:

What medications or supplements should people watch out for that can interfere with birth control?

Erica Bishop, MD:

So one of the most common and biggest class of medications that can interact with birth control is anti-seizure medications. So not all of those medications, but many of them will decrease the levels of estrogen and progesterone in people's bodies and can potentially make birth control pills less effective and other methods like the patch and the ring. So people who are on some of those medications might need to think about other options like the birth control shot, which is a much higher dose of hormone and isn't as impacted by those medications or other methods like the implant or IUD, which are also not impacted. And so that's really the most common type of medication. Other than that, they're not super common, but thinking about things like antibiotics used for people with tuberculosis, some antiretrovirals for people who have HIV. Some people might take St. John's Word as a supplement to help with symptoms of depression.

Erica Bishop, MD:

And those are also medications and supplements that we know can decrease the levels of birth control in people's systems and make them less effective. So it's really important obviously whenever you're meeting with a healthcare provider to let them know what medications you're taking and what supplements you're taking so that you can come up with the best birth control option that fits with your health history.

Erica Newlin, MD:

Many of those anti-seizure medications are sometimes being used for migraines or mood now. So I feel like I've seen them more and more as far as being an interaction in the office. How might birth control affect someone's periods or what should someone expect as far as their periods in birth control?

Erica Bishop, MD:

So what I would say is that it depends a bit on the method. So for the birth control pills and the patch and the ring, basically any type of birth control that has estrogen and progesterone in it, people should expect to have regular periods where they're getting bleeding every month predictably. And that is in general the case for any type of birth control that has both the estrogen type hormone and the progesterone type hormone in them. When we think about other methods that don't have estrogen in them, so progesterone only pills, the birth control shot, which only has progesterone, the hormonal IUD, and also the birth control implant that only have progesterone, that can sometimes lead to some more irregular bleeding. Essentially the estrogen component in combined birth control is what is regulating people's periods. So that's always important for people to know when they're starting a method that if they're having irregular bleeding, if it's bothersome to them, they can certainly talk to their provider about that and we would encourage them to, but also to understand that that's a function of the method that they're using.

Erica Newlin, MD:

One question I get a lot is whether when someone is on continuous birth control or when they have a hormonal IUD, whether it is safe to not have a period.

Erica Bishop, MD:

Yeah. So when someone has a hormonal IUD and also when people are using the shot or if people are using birth control pills and skipping the inactive pills, basically anytime you're getting continuous exposure to hormones, that is one way that people could potentially skip their period. And while that can be concerning to patients, especially if they're not prepared for it in terms of thinking about the reason why it's happening, we know that it's due to that continuous exposure to hormone and it's not necessarily a medical cause for concern because we know why someone is not getting a period.

Erica Newlin, MD:

Birth control should empower you, not overwhelm you. Let's talk about how to make choices that truly support your health and lifestyle. What should someone consider when choosing the birth control method that's right for them?

Erica Bishop, MD:

So I think the things that are most important to consider really are your goals and then also your medical background like I mentioned earlier. So thinking about whether you want to have children at all in the future or not at all, what kind of medical conditions you might have or medications you might be taking that you should consider, whether they could interact with birth control options. And then also whether you have any other goals for using birth control, any kind of non-contraceptive benefits that you're interested in. Some people will want to choose a type of birth control that might help with their acne or help make periods lighter or less painful, for example.

Erica Newlin, MD:

And you did touch on this in mentioning that birth control can be used for PMDD and might be used to treat other conditions, especially people who have conditions like endometriosis or abnormal bleeding. But how can birth control be used for skin or acne?

Erica Bishop, MD:

Yeah. So we see that for combination birth control, including birth control pills, that it can be helpful for people who have acne. In particular, each of the types of birth control pills typically has the same estrogen component, but then they have different forms of progesterone. And some of those may be more helpful for acne than others in particular ones that contain the progesterone type drospirenone. I would just caution though that as OB/GYNs, we're not dermatologists. So while we can take someone's concerns about acne, for example, into consideration when we're choosing a birth control option, if someone does have a serious problem with acne, that is something that they should be seeing a dermatologist for and have a more comprehensive plan to address.

Erica Newlin, MD:

What signs suggest it might be time to switch birth control methods?

Erica Bishop, MD:

So anytime someone is having side effects that are bothering them with a birth control method, I absolutely recommend and encourage them to see their healthcare provider to discuss that. There is almost always a way that we can either troubleshoot while someone stays on that method or talk about other methods that might be better in that respect. So for example, if someone is having irregular bleeding with the birth control implant, we can talk about medications to potentially help with that irregular bleeding, or someone might decide that they would rather be on birth control pills to try to have more regular periods if that's a safe option for them.

Erica Newlin, MD:

We've covered a lot today. Before we wrap up, what's one key message you want our listeners to remember about choosing birth control?

Erica Bishop, MD:

I'd say the most important thing is that this is not a one size fits all kind of scenario. Everyone is an individual and should be able to work with their gynecologist or healthcare provider to find a birth control method that fits their goals and their lifestyle and their health history.

Erica Newlin, MD:

Dr. Bishop, thank you so much for joining me on the podcast today. For more information and helpful resources on birth control, visit clevelandclinic.org/birthcontrol. That's clevelandclinic.org/birthcontrol. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your birth control options is an important step toward making informed, confident decisions about your health.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.