Selected Podcast
Update on Contraception
Brief overview of various contraceptive methods, including efficacy and dosing, but with focus on the beneficial "side effects" of each method, whether menstrual suppression, acne management, or relief of pelvic pain.
Featuring:
Learn more about Margaret Boozer, MD
Margaret Boozer, MD
Margaret Boozer, MD Specialties include Obstetrics and Gynecology.Learn more about Margaret Boozer, MD
Transcription:
Dr. Huh: Hello, everyone. This is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama at Birmingham. And I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh.
Today, we're going to discuss perhaps really one of the most important topics in women's health, the topic of contraception. And with me today is Dr. Margaret Boozer, who's an Associate Professor in the Division of Women's Reproductive Health. She's also the Director of the Ryan Family Planning Program here at UAB in the Department of OB-GYN. Welcome, Dr. Boozer.
Dr. Boozer: Thank you.
Dr. Huh: You know, what's interesting to me, Dr. Boozer, is that, you know, oral contraception has been around for a really long time. And I think many of us argue that it's the true inflection point in terms of women's health and has changed many things of how we look at women's health going forward. But I think for this particular audience, it might be helpful if you could just comment on the history of contraception and its overall impact on birth rates in this country, particularly teen pregnancy.
Dr. Boozer: So, as you were mentioning, the oral contraceptive pill or the pill was not available until about 1960. It did not become available to women more widely until unmarried women had access to it in the late '60s. And while the birth rate started declining in the '60s, it was really in the late '60s and early '70s that it took a more precipitous drop.
Teen pregnancies thankfully have been declining throughout, but really became more of a significant drop in the 2000's. And we have right now one of the lowest teen pregnancy rates in history, thankfully. And it's largely felt to be due to increased numbers of contraceptives available to young women.
Dr. Huh: Again, this podcast is not sponsored by The New Yorker, but I do want to say that, you know, the history behind the birth control pill and how it came to be is a really kind of a fascinating historical perspective. And there's a fantastic article in The New Yorker Magazine on this topic for the audience that are interested in how that really came to be.
But I think in general, Dr. Boozer, we categorize contraception into really two main categories, those that are medical or non-surgical, and then those are that obviously surgical. So I think for our listeners, it would be extremely helpful for them to hear what those options are.
Dr. Boozer: So the medical options largely refer to hormonal options that would include estrogen and/or progesterone-based methods. The pill is the most commonly known. There are certainly other options. But basically, the use of hormone prevents ovulation from occurring and therefore successfully prevents pregnancy.
The non-medical actually could include barrier or surgical, which would include both having your tubes tied or having the fallopian tubes blocked or vasectomy, which is of course the male form of sterilization.
Dr. Huh: Are there any non-surgical non-hormonal forms of contraception that are out there?
Dr. Boozer: There are really a handful. Most of them refer to barrier. The most common of which is the condom, which has been around thankfully for decades, even longer. And then of course, we've got spermicide as well. There is a new spermicide marketed that is nonhormonal that is actually meant to change the pH in the vagina and is about as effective as a condom. So there are barrier methods and then there are more effective spermicidal methods available now.
Dr. Huh: And I think what the listeners would probably like to know is that, you know, I think different types of contraception have different types of success rate, being the number of resulted pregnancies after contraception. Can you comment on a little bit on that for the audience?
Dr. Boozer: So certainly people think of having their tubes tied as the most effective form and it certainly is, either form of sterilization, either male or female. So, vasectomy or having your tubes tied, which is female sterilization, is by far the most effective method.
Thankfully, there are two other methods that are reversible that have become available in the last decade or so. One is a hormonal IUD. The other is a hormonal contraceptive implant. These are similarly effective to sterilization and yet can be removed with rapid resumption of fertility, which is really exciting for someone looking for a longer-acting birth control.
Dr. Huh: I want to make sure whether this is an accurate comment or not though, but if you have an individual woman who's on, let's say, a daily birth control pill, if that patient takes the pill as instructed daily, that does represent a highly effective form of contraception. Is that correct?
Dr. Boozer: Yes, absolutely. But there are two different ways to look at efficacy. One is taken with "perfect use." The other is what any of us more typically do, which is to miss a pill here or there, or to have a condom accident. And so that can often impact and decrease the efficacy of the birth control method used to what is called typical use. And typical use for the pill results in an efficacy closer to 95% as opposed to perfect use, which is 98 to 99%.
Dr. Huh: So your answer like dovetails perfectly into my next question, which is this thing called LARC. It's an acronym, L-A-R-C. Can you tell us a little bit about that?
Dr. Boozer: So I've touched on a couple of the methods that would fall under a LARC. But LARC is technically long-acting reversible contraception. There are three things largely that fall under the umbrella of LARC. The first are IUDs, which can be either a non-hormonal or the copper IUD, or the hormonal or progestin-based IUD. Both of them are reversible and have varying lengths of use, can be anywhere from five to ten years and maintain that efficacy without relying on daily dosing, et cetera, around 99 plus percent effective.
The other that I mentioned a moment ago is something that is called the contraceptive implant, marketed as Nexplanon, which is a match stick-shaped flimsy rod that is slid in under the skin of the upper arm and provides effective birth control with progestin only for up to three years, also with rapid resumption of fertility after removal.
Dr. Huh: Yeah. I mean, my understanding is that these LARC contraceptive options have really revolutionized contraception as a whole and I think has only further contributed to the decreasing pregnancy rate, particularly unintended pregnancy rate. Can you just comment on what else you think is new in the field of contraception that the listeners might be interested in learning about?
Dr. Boozer: So the main thing I want to focus on is exactly what Dr. Huh was just saying, is that they've really been a game changer because I think that they've taken out not only the frequency of dosing of the pill, the patch, the ring, those shorter-acting methods, but they've also improved women's access to ongoing birth control. So overall, they've enabled women to take the control over family planning back to their own ownership.
But as far as new things on the horizon, there are a couple of things. One is a long-acting year-long vaginal contraceptive ring that is prescribed a year at a time and the woman can wear it for as long as she wishes, remove it and replace it to have her cycle. So that again doesn't require a refill monthly, like we are so accustomed to with the pill. The other is the non-hormonal spermicide called Phexxi that I mentioned previously, that changes the pH balance in the vaginal vault and makes a lot of women comfortable that they're using a non-hormonal method. It does suffer somewhat in efficacy though. So like I said, more around 85 to 90% efficacy with typical use, more similar to a condom.
Dr. Huh: I think it's remarkable. And I think one thing that you may want to comment on, which, you know, I hear questions still about is I think it concerns women when they don't have a period every month. Can you just comment on just whether or not women should be worried about that? And I would actually think that if women didn't have a period of every month, that would be a plus. But just to kind of dispel some of the myths that having not having a period monthly is unhealthy.
Dr. Boozer: So, what I usually tell my patients is that if they are doing something to achieve not having a period, then it's perfectly healthy. What we don't want as a woman to have missed periods that could signal something abnormal. But if she's using birth control to achieve a healthy, thin uterine lining and therefore not having a period, then like you said, that's a plus.
Dr. Huh: Yeah. And similarly, you may want to comment that we have a lot of women who've have a levonorgestrel or progestin IUD put in. And some of these women actually have abnormal irregular bleeding, and it basically ceases their bleeding and it's a huge quality of life improvement. I'm not sure if you've been seeing that in your practice as well.
Dr. Boozer: Oh, my goodness. Absolutely. So of course, women benefit from the contraceptive efficacy of the levonorgestrel or progestin IUD, but also the decrease in monthly periods to often achieving no period is a benefit that many women who have heavy periods, bad cramping, really appreciate.
Dr. Huh: Yeah. And as aside, obviously as an oncologist, we've been even using some of these progestin IUDs to treat cancer and the outcomes have been really quite impressive. So, you know, it's amazing to me because as you talk about LARC options, whether it's the implant or the IUD that we have an effective form of contraception that lasts multiple years, patients don't have to worry about taking a pill, I would argue it revolutionizes their overall quality of life. I don't see us going the opposite direction. And it's really remarkable to me how far this field has come.
I don't know if you have any other closing thoughts or comments that you want to make to our listeners about the topic of contraception, Dr. Boozer.
Dr. Boozer: I just want to underscore the safety of contraception. I think, as you mentioned previously, hormonal contraception has been around decades now, and we have a large number of women who have used it at different dosages. And we really have not seen any adverse health risks associated with hormonal contraception. Yes, of course, there are certain women who should not use combined hormonal estrogen and progesterone. But overwhelmingly, progestin-based contraception is safe for all women. So I just want to, again, underscore the safety of contraception.
Dr. Huh: That's a great point. I couldn't agree more. And I think that women in general really should have great confidence in the studies that are being done and the recommendations that are being made by providers, particularly at UAB.
I guess my last question to you is, do you have any thoughts about just the expertise in contraception or complex contraception at UAB and why women should consider getting their care here?
Dr. Boozer: Well, I hope they'll all have a chance to come see me. I do specialize this and I try to do what I can to stay abreast of the new developments in contraception, and to really be mindful of what is best for the woman coming to me and what will suit her best. So I'm hopeful that we all here keep in mind the patient first and try to meet their needs.
Dr. Huh: And I think you'd probably agree with this. This is more than just prescribing a pack of pills or putting an IUD. But I think there's a lot of pre-contraception counseling that happens and a fair amount of post-contraception counseling that happens as well, which I think is part of the entire clinical care package that patients may not recognize. I don't know if you agree with that or not.
Dr. Boozer: Oh, absolutely. That's what I really am getting at when I say that I try to meet the patient where she is and provide what she needs.
Dr. Huh: Well, great, Dr. Boozer. That was fantastic. I think this is information that is relevant and helpful to many women that listen to this podcast.
So again, I'd like to thank Dr. Boozer for her time and sharing her expertise in the area of contraception. As always, please rate this podcast and we welcome any comments, particularly on topics that you're all interested in
For more information on contraception and the clinical services that UAB provides, please check out uabmedicine.org. And until next time, thank you. Have a great day and be safe. Take care. Bye-bye.
Dr. Huh: Hello, everyone. This is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama at Birmingham. And I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh.
Today, we're going to discuss perhaps really one of the most important topics in women's health, the topic of contraception. And with me today is Dr. Margaret Boozer, who's an Associate Professor in the Division of Women's Reproductive Health. She's also the Director of the Ryan Family Planning Program here at UAB in the Department of OB-GYN. Welcome, Dr. Boozer.
Dr. Boozer: Thank you.
Dr. Huh: You know, what's interesting to me, Dr. Boozer, is that, you know, oral contraception has been around for a really long time. And I think many of us argue that it's the true inflection point in terms of women's health and has changed many things of how we look at women's health going forward. But I think for this particular audience, it might be helpful if you could just comment on the history of contraception and its overall impact on birth rates in this country, particularly teen pregnancy.
Dr. Boozer: So, as you were mentioning, the oral contraceptive pill or the pill was not available until about 1960. It did not become available to women more widely until unmarried women had access to it in the late '60s. And while the birth rate started declining in the '60s, it was really in the late '60s and early '70s that it took a more precipitous drop.
Teen pregnancies thankfully have been declining throughout, but really became more of a significant drop in the 2000's. And we have right now one of the lowest teen pregnancy rates in history, thankfully. And it's largely felt to be due to increased numbers of contraceptives available to young women.
Dr. Huh: Again, this podcast is not sponsored by The New Yorker, but I do want to say that, you know, the history behind the birth control pill and how it came to be is a really kind of a fascinating historical perspective. And there's a fantastic article in The New Yorker Magazine on this topic for the audience that are interested in how that really came to be.
But I think in general, Dr. Boozer, we categorize contraception into really two main categories, those that are medical or non-surgical, and then those are that obviously surgical. So I think for our listeners, it would be extremely helpful for them to hear what those options are.
Dr. Boozer: So the medical options largely refer to hormonal options that would include estrogen and/or progesterone-based methods. The pill is the most commonly known. There are certainly other options. But basically, the use of hormone prevents ovulation from occurring and therefore successfully prevents pregnancy.
The non-medical actually could include barrier or surgical, which would include both having your tubes tied or having the fallopian tubes blocked or vasectomy, which is of course the male form of sterilization.
Dr. Huh: Are there any non-surgical non-hormonal forms of contraception that are out there?
Dr. Boozer: There are really a handful. Most of them refer to barrier. The most common of which is the condom, which has been around thankfully for decades, even longer. And then of course, we've got spermicide as well. There is a new spermicide marketed that is nonhormonal that is actually meant to change the pH in the vagina and is about as effective as a condom. So there are barrier methods and then there are more effective spermicidal methods available now.
Dr. Huh: And I think what the listeners would probably like to know is that, you know, I think different types of contraception have different types of success rate, being the number of resulted pregnancies after contraception. Can you comment on a little bit on that for the audience?
Dr. Boozer: So certainly people think of having their tubes tied as the most effective form and it certainly is, either form of sterilization, either male or female. So, vasectomy or having your tubes tied, which is female sterilization, is by far the most effective method.
Thankfully, there are two other methods that are reversible that have become available in the last decade or so. One is a hormonal IUD. The other is a hormonal contraceptive implant. These are similarly effective to sterilization and yet can be removed with rapid resumption of fertility, which is really exciting for someone looking for a longer-acting birth control.
Dr. Huh: I want to make sure whether this is an accurate comment or not though, but if you have an individual woman who's on, let's say, a daily birth control pill, if that patient takes the pill as instructed daily, that does represent a highly effective form of contraception. Is that correct?
Dr. Boozer: Yes, absolutely. But there are two different ways to look at efficacy. One is taken with "perfect use." The other is what any of us more typically do, which is to miss a pill here or there, or to have a condom accident. And so that can often impact and decrease the efficacy of the birth control method used to what is called typical use. And typical use for the pill results in an efficacy closer to 95% as opposed to perfect use, which is 98 to 99%.
Dr. Huh: So your answer like dovetails perfectly into my next question, which is this thing called LARC. It's an acronym, L-A-R-C. Can you tell us a little bit about that?
Dr. Boozer: So I've touched on a couple of the methods that would fall under a LARC. But LARC is technically long-acting reversible contraception. There are three things largely that fall under the umbrella of LARC. The first are IUDs, which can be either a non-hormonal or the copper IUD, or the hormonal or progestin-based IUD. Both of them are reversible and have varying lengths of use, can be anywhere from five to ten years and maintain that efficacy without relying on daily dosing, et cetera, around 99 plus percent effective.
The other that I mentioned a moment ago is something that is called the contraceptive implant, marketed as Nexplanon, which is a match stick-shaped flimsy rod that is slid in under the skin of the upper arm and provides effective birth control with progestin only for up to three years, also with rapid resumption of fertility after removal.
Dr. Huh: Yeah. I mean, my understanding is that these LARC contraceptive options have really revolutionized contraception as a whole and I think has only further contributed to the decreasing pregnancy rate, particularly unintended pregnancy rate. Can you just comment on what else you think is new in the field of contraception that the listeners might be interested in learning about?
Dr. Boozer: So the main thing I want to focus on is exactly what Dr. Huh was just saying, is that they've really been a game changer because I think that they've taken out not only the frequency of dosing of the pill, the patch, the ring, those shorter-acting methods, but they've also improved women's access to ongoing birth control. So overall, they've enabled women to take the control over family planning back to their own ownership.
But as far as new things on the horizon, there are a couple of things. One is a long-acting year-long vaginal contraceptive ring that is prescribed a year at a time and the woman can wear it for as long as she wishes, remove it and replace it to have her cycle. So that again doesn't require a refill monthly, like we are so accustomed to with the pill. The other is the non-hormonal spermicide called Phexxi that I mentioned previously, that changes the pH balance in the vaginal vault and makes a lot of women comfortable that they're using a non-hormonal method. It does suffer somewhat in efficacy though. So like I said, more around 85 to 90% efficacy with typical use, more similar to a condom.
Dr. Huh: I think it's remarkable. And I think one thing that you may want to comment on, which, you know, I hear questions still about is I think it concerns women when they don't have a period every month. Can you just comment on just whether or not women should be worried about that? And I would actually think that if women didn't have a period of every month, that would be a plus. But just to kind of dispel some of the myths that having not having a period monthly is unhealthy.
Dr. Boozer: So, what I usually tell my patients is that if they are doing something to achieve not having a period, then it's perfectly healthy. What we don't want as a woman to have missed periods that could signal something abnormal. But if she's using birth control to achieve a healthy, thin uterine lining and therefore not having a period, then like you said, that's a plus.
Dr. Huh: Yeah. And similarly, you may want to comment that we have a lot of women who've have a levonorgestrel or progestin IUD put in. And some of these women actually have abnormal irregular bleeding, and it basically ceases their bleeding and it's a huge quality of life improvement. I'm not sure if you've been seeing that in your practice as well.
Dr. Boozer: Oh, my goodness. Absolutely. So of course, women benefit from the contraceptive efficacy of the levonorgestrel or progestin IUD, but also the decrease in monthly periods to often achieving no period is a benefit that many women who have heavy periods, bad cramping, really appreciate.
Dr. Huh: Yeah. And as aside, obviously as an oncologist, we've been even using some of these progestin IUDs to treat cancer and the outcomes have been really quite impressive. So, you know, it's amazing to me because as you talk about LARC options, whether it's the implant or the IUD that we have an effective form of contraception that lasts multiple years, patients don't have to worry about taking a pill, I would argue it revolutionizes their overall quality of life. I don't see us going the opposite direction. And it's really remarkable to me how far this field has come.
I don't know if you have any other closing thoughts or comments that you want to make to our listeners about the topic of contraception, Dr. Boozer.
Dr. Boozer: I just want to underscore the safety of contraception. I think, as you mentioned previously, hormonal contraception has been around decades now, and we have a large number of women who have used it at different dosages. And we really have not seen any adverse health risks associated with hormonal contraception. Yes, of course, there are certain women who should not use combined hormonal estrogen and progesterone. But overwhelmingly, progestin-based contraception is safe for all women. So I just want to, again, underscore the safety of contraception.
Dr. Huh: That's a great point. I couldn't agree more. And I think that women in general really should have great confidence in the studies that are being done and the recommendations that are being made by providers, particularly at UAB.
I guess my last question to you is, do you have any thoughts about just the expertise in contraception or complex contraception at UAB and why women should consider getting their care here?
Dr. Boozer: Well, I hope they'll all have a chance to come see me. I do specialize this and I try to do what I can to stay abreast of the new developments in contraception, and to really be mindful of what is best for the woman coming to me and what will suit her best. So I'm hopeful that we all here keep in mind the patient first and try to meet their needs.
Dr. Huh: And I think you'd probably agree with this. This is more than just prescribing a pack of pills or putting an IUD. But I think there's a lot of pre-contraception counseling that happens and a fair amount of post-contraception counseling that happens as well, which I think is part of the entire clinical care package that patients may not recognize. I don't know if you agree with that or not.
Dr. Boozer: Oh, absolutely. That's what I really am getting at when I say that I try to meet the patient where she is and provide what she needs.
Dr. Huh: Well, great, Dr. Boozer. That was fantastic. I think this is information that is relevant and helpful to many women that listen to this podcast.
So again, I'd like to thank Dr. Boozer for her time and sharing her expertise in the area of contraception. As always, please rate this podcast and we welcome any comments, particularly on topics that you're all interested in
For more information on contraception and the clinical services that UAB provides, please check out uabmedicine.org. And until next time, thank you. Have a great day and be safe. Take care. Bye-bye.