Amanda Wilde (Host): There are many options for birth control these days, and we're going to talk about all of them and ultimately how to find the best birth control option for you. I'm Amanda Wilde, and my guest is Dr. Rachel Allan, OBGYN at PRISMA Health. This is Flourish, a podcast brought to you by PRISMA Health. Dr. Allan, welcome.

Rachel Allan, MD: Thank you for having me.

Host: Well, let's straighten some things out. There are oral contraceptives, implants, patches, shots. Let's sort out those birth control options, and I'd like to start with a classic, the pill. How safe are birth control pills, and what are their side effects?

Rachel Allan, MD: So birth control pills are considered safe for most women, but there are some where they are not recommended because of their medical history or inability to remember to take them very often. And there are some common side effects that women experience, especially when they first start taking them.

So these can include things like nausea, headaches, and some irregularity to their bleeding at first and these tend to improve the longer that a patient is taking them and also do not happen for all patients, but we do like to bring them up in visits just so patients are aware.

Host: Are there side effects if you take the pill on the long term?

Rachel Allan, MD: So, one of the common questions we get is, oh, does being on birth control impair my future fertility? And that is not the case. So that's one of the long term questions we sometimes get asked. It is true, people sometimes bring up risk of blood clots. So we know that birth control specifically, let's start here, the hormones that are in the birth control pill are estrogen and progesterone.

So these hormones are known to affect the metabolism of some clotting factors, which can slightly increase the risk of blood clots. However, this risk, even when increased, is still much less than 1%. So, you can kind of consider this not to be a huge risk, but there are some patients who are more at risk for blood clots who should avoid taking birth control pills for that reason.

Say, if they have a history of a blood clot, they have high blood pressure that's uncontrolled, they're over the age of 35, and smoke cigarettes. These are all things that can predispose women to getting blood clots and therefore they would benefit from likely picking a different option of all the birth controls that are available.

Host: Yeah, totally makes sense because you have higher risk in those cases. Can oral contraceptives also, I've heard they can help with pain from your period and just making you regular and PMS. Is there truth to that?

Rachel Allan, MD: Yes, so taking birth control in multiple different forms with hormones can not only help decrease the amount of bleeding you have with periods, they can make them more regular and predictable, they can make periods less crampy as well. So it's kind of a improvement across the board for a lot of patients.

Host: How do oral contraceptives control your menstrual cycle?

Rachel Allan, MD: So the effects of the hormones, the estrogen and progesterone, what they do is they provide a steady state of hormones to the body. Now the body, naturally, off of birth control, has a lot of fluctuations in those hormones, and those fluctuations are what trigger things like ovulation, aka the release of an egg, which provides an opportunity for pregnancy. So what birth control at a steady state does, is it tells the body to kind of calm the cycle down and basically evens out where those fluctuations don't occur, therefore inhibiting ovulation. The birth control pill also somewhat thickens the cervical mucus as a part of its effect, which also decreases chances of sperm penetrating to meet the egg.

Host: So, that part of the pill can really be a plus for some women.

Rachel Allan, MD: Yes, especially women, say, with like endometriosis, which we know is a pain syndrome with periods that is triggered by those flares in hormones, it also causes a flare in their symptoms. So having a steady state, also same with PMS can kind of help even out some of those less desirable effects.

Host: Effects Now of course you take a pill internally, but let's talk about another kind of birth control that is also internal, but I don't really understand it. Can you talk about implant birth control?

Rachel Allan, MD: Yes, so the implant are by brand name is known the NEXPLANON. That is a progesterone only method, where it is a thin flexible rod that is actually inserted beneath the skin near the elbow. The implant is superficial enough that a patient can feel it. However, it's not noticeable to the naked eye. What that birth control does is it releases a constant amount of that progesterone hormone over a long period of time. So now that's been FDA extended to work for four years for effective birth control and is actually the most effective. They are all 99 percent effective, but the implant even more so.

Host: What are the pros and cons of implants?

Rachel Allan, MD: So one is it is not the best if you're looking for a birth control that will really help to regulate your periods. The implant is less predictable on how it will affect periods. So about a third of women will have typical once a month periods. The other third can have less or no periods. And then the final third may have irregular bleeding.

So we do not know which of the three a patient will end up being because every patient is different and every NEXPLANON is different, but the most common reason we have patients ask for it to be removed early other than wanting to become pregnant is if they fall within that one third that do have irregular bleeding with it, but two out of three chance, most women do not have issues with the bleeding and are very happy with it.

Host: And does it regulate periods the way the pill does?

Rachel Allan, MD: The progesterone effect, it doesn't necessarily regulate the periods, but it does inhibit ovulation through those effects of the progesterone.

Host: Another thing you can insert is an IUD. How do those work?

Rachel Allan, MD: So IUDs, aka intrauterine devices, they are also technically implants. However, they as the name suggests are placed within the uterus. So those devices both the NEXPLANON and the IUD, those are placed at doctor's visits. For the IUDs, we get the patient set up very much like for a pap smear in stirrups, where we visualize the cervix. And then the IUD is actually loaded into a very skinny instrument that we pass through the cervix to the top of the uterus and let the IUD out. It is shaped similar to a T, so it nestles perfectly with the size and shape of the uterus. And it constantly releases an amount of progesterone also over a long period of time.

There are two hormonal IUDs that are commonly inserted these days and a few others as well, depending on locations and the stock of that office. But the ones that patients have most often heard of for hormonal these days are the Mirena and the Kyleena. The Mirena is slightly larger and at a slightly higher dose of the progesterone, therefore, it lasts longer.

So it lasts up to 8 years for effective birth control. And is a nice investment piece, therefore. And the Kyleena is slightly smaller with a slightly lower dose of hormones and lasts for 5 years. Both of which can also help with periods and tend to decrease bleeding and up to 80 percent of patients with a Mirena do not have a period.

So some women are looking for that when choosing a birth control because some say, hey, if I don't have to have a period, why have one?

Host: Exactly. There's a shot called Depro-Provera. How does that one work? Now we're getting sort of further away from inserting something to a shot. So, is that also hormonal based?

Rachel Allan, MD: Yes, so the Depo shot, Depo-Provera, Depo infers that it is a long acting medication. So, it is also a progesterone, a different type, that has a prolonged release through the body. It is given every three months. Typically, we have a pharmacy or a nurse office visit scheduled where the patients can come and receive their injections every three months. The thing with Depo-Provera is it tends to suppress periods as well like the IUDs typically do. It can take a few injections to get to that point, so it's a little bit of trial and error at first and there may be some irregular bleeding at the beginning, but it can often lead to menstrual suppression.

Host: And is there a reason one might pick a Depro-Provera over an IUD?

Rachel Allan, MD: Some patients are against the idea of having a foreign body within them. So, for those who do not want a device, sometimes the Depo-Provera is something that they find more manageable. But really it's the patient's choice and what they're most comfortable with.

Amanda Wilde (Host): There's a birth control patch. How does that work?

Rachel Allan, MD: So the patch has the same hormones as the pills. There is one form of pill that's effective for birth control that is progesterone only, but when we think of the typical birth control pill, it is that estrogen and progesterone combination. The patch also contains estrogen and progesterone and works in the same way as the pill. The benefit of the patch, though, is that you only have to remember it once a week instead of every day. So sometimes if someone has a hard time thinking, Oh, you know, I've got my busy schedule. It's hard for me to remember something every day. The patch is another good option. The patch is about the size of a Band Aid, same in coloration as well.

And you apply it to the skin much like a Band Aid. The hormones absorb through the skin to have their effects. The patch can be placed anywhere on the body except for the breast. We don't like to overstimulate the breasts with hormones. And each week, say Sunday is your patch day, you would put a patch on, say, on your arm. The following Sunday, you would take that patch off and put a new one on somewhere else, say on the small of your back, rotating where you put it to decrease local irritation, and then also help with absorption. You would wear a patch once a week for three weeks, then that final week of the month you would not wear a patch and have your expected period. So it follows the same schedule as the pill packs, which if many have seen them before, it is three weeks of active pills and that last week of the birth control pack is actually placebo pills that help the patient keep on schedule, but allow that decline in the hormones that trigger a more predictable, less heavy, less crampy period.

Host: So some of these birth control methods, you will get a period, others you won't. Why would you prefer one over the other?

Rachel Allan, MD: Some patients will want to skip their period, say if they have endometriosis and they say, no matter what I do, when I have my period, it is terrible. So, you know, if they would like to skip periods, there are ways where you can actually use some of these combination, you know, the estrogen progesterone medications like the pill and the patch by skipping that placebo or off week and just continuing to suppress periods. But some patients would rather not have periods for a multitude of different reasons, while some say, I don't like how it is. I like getting my period. It makes me feel regular and I would prefer to have one.

Host: Yeah. Totally understand that. There is something I hadn't heard of before called vaginal rings. Sounds very exotic, like the rings of Saturn. How do the, how do the vaginal rings work?

Rachel Allan, MD: So the vaginal ring, like the patch and the pill, has both estrogen and progesterone. It's a flexible silicone ring that patients place themselves high within the vagina, kind of like placing a tampon. You want to get it high up, so that it does not slip or fall. The vaginal ring slowly releases hormones over, actually the course of all three of those weeks that we previously discussed.

So some say, you know, even once a week might be hard for me to remember, or I just don't want to remember that often to have to change my birth control. The vaginal ring, they can place, leave in place for all three weeks. And then for that final week of the month, they throw it away and leave it out to have their period.

And those hormones are just absorbed through the mucosa or basically the skin of the vagina, to have the similar effects.

Host: Now, all the options we've been talking about are hormonally based. Are there non hormonal birth control options?

Rachel Allan, MD: There are non hormonal birth control options. So some patients aren't candidates for hormone therapy and therefore, or they just would rather do something without hormones by preference. So we do have one IUD that is copper. So it does not contain any hormones and it works in a little bit of a different way.

The hormonal IUDs, they basically thicken the cervical mucus, create a lining that is not favorable for implantation, and then also decrease the migration of the egg to meet the sperm in the fallopian tubes. The copper IUD just creates an environment that it would be toxic for a pregnancy to start to develop.

And then toxic sounds like a bad word, but it's really on a cellular level. And actually, the copper IUD lasts for up to 10 years, so it is our longest acting, but reversible contraception option available. It's inserted the same way as the other IUDs at an office visit. And some people like kind of that length of time saying, I don't want to have kids anytime soon. And I want to try something non hormonal, so that would be a great option for them. I will say with the copper IUD, sometimes that can cause patients to have somewhat heavier periods, so I will often caution patients who say, well, I have heavy periods already, I don't need a heavier period, that might not be the best option for them, but say a patient has a typical or even a light period, I think it would be a great option for them if that's what they choose.

Host: That is really fascinating. With all these options, it seems to me that we're talking about birth control that you will get with help of your doctor. Can you get birth control without a doctor? Or is a doctor required?

Rachel Allan, MD: There are some states that allow pharmacists to dispense birth control, and South Carolina is one of them. Also, there's been a lot of buzz lately about getting your birth control online. But typically those websites still require you to have somewhat of a consultation with a doctor, whether it be a checklist of your medical history, to make sure that those options are safe for you.

I typically recommend that it's a great opportunity to go to see the doctor to discuss birth control and that way you can also make sure things like your pap smear are updated. You have the opportunity to ask all the questions that you have and you can really talk through with your doctor your history, what your interests are and then they as a discussion can help you, the patient, make the best decision for you and what you would like to try.

Host: So going to the doctor can be good for your overall sexual health, not just birth control. And then what about some permanent birth control methods? I have talked to some young women who know they're ready for that, but how do patients know if they're ready and what are some of those permanent methods?

Rachel Allan, MD: So in terms of permanent methods, there is the option to have the tubes tied and or removed. It really just depends on whether patients are ready to make that decision or am I done with potential future fertility? Do I not want kids at all? Some people don't want kids at all through their whole lifetime and that's completely fine.

 Some say, you know, I've had this many so far. I'm done here on out. And I don't want to say I have to worry about complying with any sort of birth control. It's a great option for those patients, but that decision is definitely very personal and depends on the individual because that decision occurs at different points in people's lifetime.

 They've done studies that suggest that patients who have permanent sterilization, have higher risk of potentially regretting that decision if performed before the age of 30. But it doesn't mean that it is a hard stop because some people know that they do not wish to have children. And that is an option to talk with the physician.

Surgeries can only be performed by doctors, so that would require a doctor's visit to discuss. But really it's based on when someone is ready to make that decision. We also recommend that when patients decide to have those procedures, that they are sure and not consider them reversible. So, as long as they are sure, we are happy to perform those procedures.

Because there is no going back. Some have heard of the tubal reversal procedures, those require very specific requirements, including having enough tube remaining to bring back together. So if a patient decides to go ahead with a sterilization procedure, we just want them to be sure that that's what they want.

And if so, we are happy to get them set up. The other thing I want to bring up as an option is vasectomy. So if a patient has a male partner, and they have made a decision together that they do not want to have children, the vasectomy is an even lower risk procedure, that is effective for permanent contraception and always something to consider as well.

Host: So, with all of that said, and you've given us a lot to consider in terms of pluses and minuses of each of these methods, is there anything else you'd like to add that we should consider when deciding which birth control method is right for us?

Rachel Allan, MD: I would say I did want to mention there are a couple of other non hormonal methods for birth control as well. One of those includes a new product called Phexxi . Some have probably seen commercials for it, but it is a vaginal gel that's applied just as needed within an hour before intercourse. It is prescription only, but that is another option available as well as, some people call the rhythm method, some called natural family planning, or patients can just track their cycle. Sometimes, say, with the help of an app or a physical calendar to determine based on their cycle length when they're most likely ovulating and avoiding having intercourse during those time frames. So there are lots of options because I do encounter a lot of patients that say, I just don't like the way hormones make me feel.

What are all those options out there? But in terms of finding the right birth control for you, considering all the things that we've discussed, there are lots of things to consider; your medical history, are you at risk for, having, an increased risk of, say, things like the blood clots, albeit rare, and should you avoid certain birth control methods?

How often do you want to take the birth control or use the birth control? Are you interested in something that's more long term, like years, as opposed to just month by month? These are all factors that definitely deeply individualize a person's decision, which birth control method is right for them, and if they would like to try any of them.

But I always encourage the conversation because sometimes, the doctors provide information of things you might not have considered. And also making sure that you know all the options that are available to you, some that could be recommended based on what is most important to you that you've voiced during the appointments and just finding the perfect fit, which can sometimes take a little trial and error, but that's why we have all the options to find the best one for you.

Host: So the right option for you is the one that fits best with your body, your lifestyle, and this information that you've given along with going to a medical provider will help each one of us make the best decision for ourselves. Thank you so much for this education on birth control, Dr. Allan.

Rachel Allan, MD: It was my pleasure. It's always fun to talk about birth control.

Host: That was Dr. Rachel Allan, OBGYN with PRISMA Health. For more information and to listen to additional episodes of Flourish, please visit prismahealth.org/Flourish. This is Flourish, a podcast brought to you by PRISMA Health.