Scott Webb (Host): There are lots of options when it comes to birth control and it's good that we have experts like my guest today to help us to understand the various options, the effectiveness of each of the options, and more. And I'm joined today by Dr. Erika Beatriz Garcia. She's an obstetrician and family medicine physician at Salinas Valley Health Taylor Farms Family Health and Wellness Center, located in the city of Gonzales.

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's so nice to have you here today. We're going to talk about birth control. And, you know, my head starts spinning just a little bit because there's just so many options for birth control. So, that's what we're going to talk about today. And we'll just start maybe with the, I don't know, it's the gold standard, but the most obvious one, you know, we'll talk about birth control pills. How do they work and how effective are they?

Dr. Erika Beatriz Garcia: Birth control pills come in what I say are many flavors, right? There are birth control pills that contain only one hormone. Those are called progestin-only pills. And then, there are birth control pills that we called combined oral contraceptives, and those have estrogen and progesterone. These, as well as many other birth control options that contain hormones, work by preventing ovaulation. Ovulation is basically what has to happen in order for somebody to become pregnant. So by preventing that, then it really reduces the chance of getting pregnant.

Birth control pills are very effective. They work about 93% of the time if taken like the way most people usually take them. But it's important to remember that neither birth control pills or any other kind of birth control works 100% of the time.

Host: Right. So, very effective in most aspects of life, Doctor. Ninety-three percent sounds pretty good, but when we're trying to prevent pregnancy, obviously nothing is 100% as you're saying. What about the old Plan B, Doctor? The emergency contraception pills. When should they be taken? Where do you get them? Do you need a prescription? Give us the 411 on that.

Dr. Erika Beatriz Garcia: Yeah. So, plan B is something that people should take when they don't intend to become pregnant, but they've had unprotected intercourse. And in many cases, this is something like a condom broke, or there's some sort of failure if they were trying to use a withdrawal method. These should be taken within 72 hours of unprotected intercourse. They should be taken as soon as possible. You do not need a prescription to get Plan B.

Now, there is another brand of emergency contraception pills called Ella. That tends to work a little bit better. It's a little more effective, and that gives you up to five days of a window to take it, and it's been shown to be a little bit more effective in people who have overweight or obesity.

Host: Well, it's good to have you on because I was only familiar, you know, with the original, sort of the OG Plan B. So, good to have you on, good to have your expertise. And, Doctor, I've seen commercials for IUDs and certainly known about IUDs, you know, for a very long time, but I don't have any idea really how they work. So, I want to have you tell us, like, what are IUDs, how do they work, and are they effective?

Dr. Erika Beatriz Garcia: IUDs are some of the most effective pregnancy prevention options there are. In fact, IUDs and implants in the arm, which we'll talk about later, are more effective than female sterilization. So if you really don't want to be pregnant, you probably want to get an IUD or a Nexplanon. IUDs are placed by your provider inside the uterus. So if you were pregnant, that baby would be growing inside the uterus. An IUD is going to be sitting there. IUDs come in two different flavors, hormones or non-hormonal. As far as the ones with hormones, they can last for a different amount of time for pregnancy prevention. So, there are some that last three years, others that last eight years. I believe there's also one that's a five-year one. And then, the ones that are copper are good for up to ten years. They work slightly differently as far as their effects on people's periods, so it's really important to talk to your doctor about whether heavy periods are okay with you or stopping periods is okay with you, but they are 99% effective. They are typically removed in a doctor's office. And the removal is a very simple procedure in most cases. And there's a few people who are going to have questions because historically there were a lot of cases where these would migrate and end up outside of the uterus and sometimes require surgery to get removed. That's not as common today, but it's still a risk. So, it's important that you just talk to your doctor about your concerns or anything that you've heard about that makes you think you need to know more.

Host: Yeah. So, we're getting closer to 100%, right? It was 93% with the pill, 99% with the IUD, and again, great to have you on, because I had no idea these things could stay in so long. Five years, eight years, that's crazy. Let's talk about the patch. What is the patch, and how does the patch work?

Dr. Erika Beatriz Garcia: The patch is amazing, because it's incredibly convenient. It is peel and stick, like a child's sticker from a sticker book. You'reing tonna put it in a couple of different places on your body as an option. Like, you know, your lower back, upper buttocks, or maybe the back of your arm. It is about one inch squared and it's a kind of neutral tone color, so many people won't even notice that you're wearing it. And it actually secretes hormones through your skin. It works about as well as the pill. But unlike the pill which has to be taken daily, the patch needs to be discarded and replaced once a week, much more convenient.

Host: Yeah, definitely. I hate to make this sound like sort of like a laundry list or a grocery list, but that's kind of what I have for you here today. So, what about the ring? How does that work?

Dr. Erika Beatriz Garcia: The ring is a vaginal ring. So, imagine a hair tie that people use to put up their hair, and then make it a little bit stiffer. So, what you do with this, as a user, is you place it inside the vagina, and it kind of retains its shape in there, and it slowly secretes hormones through the vaginal wall. The ring only has to be changed out about every three weeks. So, it's a four-week cycle with that fourth week being when most people are going to have menstruation occur. It's also very effective. Most people haven't heard of it, and it's going to have some side effects where it may not be the best for people who are lactating and still trying to breastfeed or establish their milk supply, and then people who don't like the changes in their vaginal secretions whenever they have something in the vagina like the ring or some other medications that we'll talk about shortly. I might say that this isn't the right one for them.

Host: Yeah. So, you know, much like almost anything really, doctor, it may not work for everybody. But it's, again, great to speak with your provider, find out all the pros and cons. I was talking about sort of like the OG earlier, but I think condoms is something that most people are familiar with. How effective are condoms versus birth control pills?

Dr. Erika Beatriz Garcia: So, condoms work well to prevent pregnancy about 79% of the time is what's quoted. It really depends on how they're being used. There's different kinds of condoms. So, the one I just quoted you is actually for one that most people may not have heard of called a female condom. And this is a condom that actually goes inside the vagina, unlike external condoms that go over a penis. External condoms work about 87% of the time.

What's really important about condoms is that they're the only ones that are going to help reduce the risk of sexually transmitted infections. So even if you're on something else for pregnancy prevention, or maybe you're on one of these other methods because you want to change how heavy your periods are, condoms are still something that we need to be considering if we're trying to avoid sexually transmitted infections.

Host: Yeah. Diaphragms have been around a long time, Doctor, at least I think they have. Are there any downsides to the diaphragm?

Dr. Erika Beatriz Garcia: Similar to the vaginal ring, the downsides would be dependent on the user. So if they feel like there's a factor where they don't want to be reaching inside the vagina to place and remove something. If they feel like the changes in their vaginal secretions are onerous or burdensome because of this, those would certainly be downsides. Diaphragms are supposed to be used with a spermicide, and spermicides themselves can cause some amount of vaginal irritation in users. Not everybody's gonna have that. They also aren't as effective as some of these other methods that we've talked about today.

Host: Right. And when you start talking about things like IUD being at 99% to being that effective, the further you get away from 99%, maybe that's not the right fit, of course. So, let's talk about the shot. You mentioned that earlier. How do these injections work? How often do you need to get them and so forth?

Dr. Erika Beatriz Garcia: Yeah. So, the shot is really neat, because you only have to give a couple shots every year in order to have really good pregnancy prevention. The shot is typically presented as an every three-month injection, and we recently got approval in the United States for people to administer their own shot to themselves subcutaneously. So, the subcutaneous shot is something that many users will have become familiar with, because they know somebody maybe who's injecting insulin subcutaneous or maybe some of these new weight loss drugs that are injected subcutaneously. It's that simple. So, a user can get a prescription for it. And right now, the FDA approval is for them to come into the office and self-inject in a healthcare provider setting. But the older way that most people are familiar with is that they are getting the injection from a healthcare provider providing it intramuscularly.

Host: All right. So yeah, we're getting to the point where folks are giving themselves, as you say, they may have had some history or experience with other types of shots for diabetes, whatever it might be. You touched on earlier, vaginal spermicide. What is that? How effective is it? And are there any downsides?

Dr. Erika Beatriz Garcia: Sure. So, vaginal spermicide, -cide means kill, so it literally kills sperm. It is not very effective. I think it ranges somewhere down about 70% as far as effectiveness. But I tell people it's a great thing to use if you want maybe to use some dual agent. If you feel like the prescription you're on or the birth control that you've decided to use, you want to pair it with something else, that's fantastic. Spermicides are safe to use with condoms. They can cause some irritation in the vagina. Spermicides and other agents that go inside the vagina will have a label that says that they can increase the risk of HIV, and it's important for people to know it's not because the spermicides or these other agents have any have HIV on them. It's that they cause such tiny amounts of irritation that it's more easy to get something acquired through blood. So if your partner has an unknown status, maybe this is a great time to say, we should go get tested before we start relying on this method.

Host: Sure, which again, just seems like good advice. Doctor, is permanent birth control a thing? And if so, is it reversible?

Dr. Erika Beatriz Garcia: Right. So, this is kind of strange to be asking about something that's permanent and also reversible. But this is something where if somebody wants to get a tubal ligation in females or a vasectomy in males. This procedure is presented as permanent. So, the idea is once that surgery is done, you're done. You don't ever have to go back and get it redone. Technically, you can have a surgery to reconnect a tube that has been cut. Now, some surgeons are removing the entire fallopian tube all the way out to the very end so there's nothing to reconnect. So many cases, if a female wants to have a pregnancy afterwards and the kinds of surgery that she underwent was not conducive to getting reversed, they might need to be looking at something like in vitro fertilization or surrogacy or some other alternative set up. And in males, you can get a surgery to get that undone. It really depends on what your insurance benefits are and what state you're in, if that's something that's potentially covered or not. Otherwise it's very expensive. And so, I just want to remind people that when you're making decisions about your future fertility, you're making it for someone that you don't know yet. We don't know who we're going to be in 10 years, but make sure that you're giving yourself the time you need to think through as much as you can what your futures might look like, and if all of those possibilities are ones where you think you would not want to become pregnant or father children before you commit to that kind of surgery. If you want to have it done, we will definitely get you to somebody who can get it done. There is no longer on the market an Essure, which used to be something that could be done in office. So, permanent birth control methods for women have to be done in a hospital setting now.

Host: Gotcha. Yeah. As you say, you know, sort of put reversible in quotes, right? It is reversible, but you know, it may not be practical. It may not be affordable.

Dr. Erika Beatriz Garcia: It may not work.

Host: It just may not work exactly, right? It's been really educational today for me, even at my ripe old age, doctor. But I'm wondering, are there birth control options depending on someone's age, right? So, is there something you recommend for, let's say, someone in their 20s, but then maybe something different for someone in their 40s? Is there sort of a range that you recommend?

Dr. Erika Beatriz Garcia: What I recommend is making sure that your doctor is aware of your health conditions, because more than your age, you want to look at your risk factors for certain complications. So, there's a guideline called the U.S. Medical Eligibility Criteria that doctors use to say if you have certain conditions, like you recently delivered a baby, or maybe you got diagnosed with breast cancer and you just found out you're in remission. Those are the kinds of historical bits of information about your life that we want to know to make sure that we're offering you something that's safe and effective for you.

Host: Right. So, there's no, let's say, one-size-fits-all, right? It's really about the patient, working with their provider, guidelines, what feels right, what works right, all that good stuff.

Dr. Erika Beatriz Garcia: Right. So, there was this old idea that, you know, teenagers shouldn't have certain kinds of birth controls, or if you're too young, we're not going to tie your tubes. And you, know, we are experts in medicine, but we are not experts in people's preferences. We're not experts in their home situations. So, make sure that you're talking to your doctor and you're telling them, "This is what I'm most concerned about. These are my goals. This is what I most want to avoid." And that's going to let you come to a decision together. That's going to be a good fit for you.

Host: Yeah. And that's why it's great to have a provider, one that you trust that you can speak, you know, openly and honestly. And it kind of led to my next question about teens and that sort of dicey area, especially I am a parent myself and I have a 16-year-old daughter who's almost 17. What's the best form of birth control for teens?

Dr. Erika Beatriz Garcia: The one that they are willing to use.

Host: Yeah, that pretty much sums it up, right? Yep.

Dr. Erika Beatriz Garcia: Well, if your goal is to just look at pregnancy prevention, you know, there were studies in Colorado where they said we made long-acting reversible contraception like IUDs and implants in the arm available to teens. And lo and behold, they work very well and there's not a whole lot of teen pregnancy there. But some teens aren't going to want to choose those methods, right? Some teens may say that's not for me, because I don't want to have an exam where somebody has to put something inside my uterus or I'm worried that people are going to be able to feel the rod in my arm and I'm going to have maybe some stigma or bullying because of that. I need something that's private to me as a user.

Host: Yeah. It's really interesting, and certainly not something I really want to think about just so we're clear, Doctor. You know, I'm asking because I have an expert on and I feel compelled to ask, but I don't even want that in my head. Good stuff today, Doctor. Lots of information, breaking all this stuff down for us. I'll just give you a chance here, final thoughts, takeaways. When we think about contraception and effectiveness and your recommendations, I'll leave it to you.

Dr. Erika Beatriz Garcia: Sure. So, we've talked a lot today about pregnancy prevention as our marker of effectiveness, but remember that people have different goals. So if your goal was really to Just try to regulate your cycles, this talk is not ranking these medications based on how well they do that. So, talk to your doctor about your specific goals.

And I want people to go to their doctors. I want to build that relationship, but not everybody has that option. So, it's important to know that there are some over-the-counter options. Birth control pills, the O Pill, just got approved for over-the-counter sales. Emergency contraception is available without a prescription, if you get Plan B. If you want the other one that works better, you need a prescription. Condoms, of course, are available without a prescription. And then, there's other methods that we didn't talk about, like natural family planning, that you wouldn't necessarily need a physician for, although we can give you some really good points and help you make sure it's effective for you.

Host: Yeah. You used that word a couple of times in our conversation here, the word goals. And I think that that sounds right to me. It sounds right to my ears. Like, what are your goals? What are your goals for your family? As you say, you don't know the person you're going to become. Not only does your provider not know, but you definitely don't know who you're going to be in 10 years, 15 years, 20 years. So, you know, these are not easy decisions. And as you say, some things may be reversible, but are they? Should they be? And just a lot to take in, but a lot of great information. So, thank you so much.

Dr. Erika Beatriz Garcia: Happy to be here. Thank you so much. And if there's any questions that you guys have, please feel free to ask your provider. We're here to give you the information that you need.

Host: Dr. Garcia is an obstetrician and family medicine physician. She's accepting new patients at Salinas Valley Health Taylor Farms Family Health and Wellness Center in the city of Gonzales. To schedule an appointment with Dr. Garcia, please call 831-675-3601. and to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.