Melanie Cole, MS (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. This is Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And joining me today is Dr. Julia Cron. She's the Site Chief of Obstetrics and Gynecology at Lower Manhattan Hospital New York Presbyterian Hospital and Vice Chair and Assistant Professor in the Department of Obstetrics and Gynecology at Weill Cornell Medical College. And today, she's here to tell us about contraceptive options.

Melanie Cole, MS: Dr. Cron, you are just such a great guest and I welcome you back. Thank you so much for joining us again. I'd like to jump right into this because this could be very long, but we're not going to do that. So, let's go over some of the different types of birth control out there, some of the contraceptive options, and what are some of the tried and true options that have been around a long time. And then, we'll get into some of the newer ones that are pretty exciting out there.

Dr Julia Cron: Yeah. Hi, Melanie. I'm happy to be here today to talk about this really important topic. So yeah, we can start by talking about the tried and true, right? So, I would say the most tried and true is the birth control pill. And it's been around for more than 50 years. It revolutionized women's lives and their ability to control their own reproductive choices, and it's still around. The doses of the birth control pills that we use today are much lower than the ones when it was first developed. And that translates into less side effects and less risk. There's some different delivery methods of the medication that is in the birth control pills. So when I talk about the pills, I add the corollary of the patch. So, the contraceptive patch has also been around for a while. And it is the same medication. It is just the way it is delivered. So, it is a patch that is applied to the skin for a week at a time. So, you put a patch on, a week later you take it off, put on another one. And then, you do that for three weeks. And we can get into the alternative dosing. But typically, patients have a week off of the patch, which is equivalent to what we call the sugar pills or the placebo pills of the birth control pills, so that's when young people or patients in general have their period.

The other delivery method is a ring. So, it is a synthetic ring, which is inserted into the vagina and that stays there for three weeks at a time. And then, it is typically removed for a week. And again, that's the off week when patients have their period. Also, putting under the traditional methods we still have the depot medroxyprogesterone also known as Depo-Provera. This is an injection that patients can receive every three months. There is a newer formulation of that where it is injected under the skin, and this can be self-administered. So similar to how patients self-administer insulin, you can do what we call subcutaneous depo. And this was actually really great during the pandemic when patients couldn't come in every three months for their injections. So, you can do the self-administered depo.

And then, I would put the IUD under the tried and true method. So, many, many years ago, there were IUDs that had complications and were taken off the market. But for the past 20 plus years, we have had newer IUDs, which are a really fantastic option particularly for adolescents. So, we put two things under the category of what we call LARC or long-acting reversible contraception. So, what could be better for a teen, right? Something that is long-acting, right? Because many teens want to avoid pregnancy for many years. Reversible, in other words, as soon as it is removed, pregnancy is possible. So when patients feel they are ready and desire a pregnancy, they have almost immediate return to fertility. And then, these methods have the highest effectiveness. So again, what could be better for a teen? Something that is long-lasting, something they do not need to think about on a daily basis, something that is fully reversible when they do want to become pregnant, and something that is the most effective method. So, I feel like teens today are lucky that they have these options.

When you think about the LARC category, there are two subcategories to that. One is the IUD or the IUS, we call it the intrauterine device or the intrauterine system. And there are two categories of that. There is the non-hormonal IUD, which is a copper IUD. The brand name is called ParaGard. That lasts for 12 years, which is pretty great. The downside of the copper IUD is it works by irritating the lining to the uterus, so it generally makes people have heavier, more painful periods. But for some people that really don't want any hormones or can't have any hormones, the copper IUD is an option, just recognizing some of the downsides of it.

Flipping to the other type of IUD, which is a progesterone-secreting IUD, so that's a hormonal-secreting IUD, and that generally works by thinning the lining to the uterus. So, it makes people have very, very light periods. And the majority of patients that have a progesterone-secreting IUD don't have a period at all. So again, back to that, what could be better for a teen, if you add very light or no periods, that's pretty great for a lot of people. I would say the downside of the IUDs is the placement. So, some people, the idea of a very minor procedure to insert something into the uterus is unfavorable to them. But I would say the majority of teens really love this option. And for those that are motivated to do it, the procedure really usually goes very, very smoothly.

So, the other category of LARC or long-acting reversible contraception is the contraceptive implant. So, the brand name for this is Nexplanon. This is a rod that is inserted under the skin. Most people do it in the upper arm. It is inserted. It's a very simple procedure to insert it. We put some numbing medicine like lidocaine medicine, similar to what you get when you go to the dentist. That's really all they feel. And then, we insert the device and that releases a low level of progesterone, which works as the contraception. I would say the biggest difference between the contraceptive implant and the IUD is the bleeding profile. So, most people that have the contraceptive implant have irregular bleeding that doesn't go away. So, they generally won't have a true period. But they have irregular spotting, which can be bothersome. But again, going back to what we call anticipatory guidance in patients that understand that this is going to happen and accept that and maybe don't want an IUD, it's a really good option for them. Because again, going back to the "procedure", a lot of people view the arm insertion as a little bit more favorable than the uterine insertion. The Nexplanon is currently approved for three years of use. However, there is evidence that it is protective for up to five years. So, we generally talk about evidence-based use. And the Nexplanon fits under the category of five years for evidence-based use.

Melanie Cole, MS: Wow.

Dr Julia Cron: That's a lot.

Melanie Cole, MS: That was awesome. That was so awesome. You just laid out so many of those options, explained them so clearly with the risks and benefits, and that was incredible. Listeners, you could just rewind this podcast and listen to that a bunch of times because that was really comprehensive, Dr. Cron. Now, what about some of the newer ones that people may not have heard of? There always seems to be new ones on the market. Is there anything you're really excited about?

Dr Julia Cron: Yeah. And I think the first comment on new things is everyone's always trying to improve on what we have, which is great and it's great for patients, with the caveat that new doesn't always mean better and sometimes newer things have coverage challenges. So, the new things generally aren't available as a generic. Therefore, sometimes, there is a higher out-of-pocket cost. So, you know, that's just a comment that patients should be aware of. However, I am always in favor of developing new things that will give patients more options particularly giving teens more options for contraception.

So yeah, let's talk about what the new things are. We talked a little bit about the under the skin medroxyprogesterone, the subQ depo, that's relatively new. Going back to the birth control pills, so there is always new tweaks on the birth control pills, different doses of hormones, different ratios of hormones. But when you think about birth control pills, generally, the "traditional birth control pills" have the two female hormones, estrogen and progesterone. There is also progesterone-only birth control pills for those patients that cannot take estrogen for whatever reason. And there is a new progesterone-only birth control pill that's out there. It is drospirenone, which is a type of progesterone. It is generally an antiandrogen or what we think of as the male hormone. So for patients that have certain conditions where they might have androgen excess, we'll use polycystic ovary syndrome as an example, using the antiandrogen birth control pill may be beneficial. So, that is a new thing that's out for the birth control pills. There is a new patch out there. It contains a different progesterone. It contains levonorgestrel. The brand name for this is Twirla. And again, is new better? We're not entirely sure. But the more options out there, the better. Also, I spoke before about the vaginal ring. There is a new vaginal ring out there. The brand name for this is called Annovera. And this is a ring that can stay in for the entire year. And patients can take it out as desired, but it is a one-year ring. And then, there is something called Phexxi, which is a vaginal gel. Again, it is a non-hormonal vaginal gel that can be used as a contraceptive option.

Melanie Cole, MS: So many really exciting advancements. But as you say, new doesn't necessarily mean better. And some of those tried and true might be the best option for any given person that's looking up to these. So, are you seeing young ladies also using birth control for other benefits like acne, controlling PMS, endometriosis? My daughter absolutely used it starting at like I think 16 just to really get control of some of those hormonal changes.

Dr Julia Cron: Yeah, excellent point. So when I talk about contraception and birth control, I like to tell patients and their caregivers that, in some ways, I wish that it wasn't called birth control. I wish that it was called the period regulator or the hormone modifier because many, many people use this hormonal modification known as birth control pills and its varieties for things other than contraception. And I think it's really, really important not to underestimate that. And some caregivers are reluctant to have their daughter take birth control pills simply because of the name. But remember, that this hormonal modification can be life-changing for people.

You know, I always say, in today's world, in our country, young people should not be missing school because of their periods. We have lots of options. And if young people are missing school because of their periods, then we should do something about it. And so, a lot of patients use the pill, the patch, all of the things that we were talking about for menstrual regulation and menstrual regulation for a huge variety of reasons, whether it's heavy bleeding, painful periods. Some people choose to have menstrual suppression, simply because they are an elite athlete or because they are going to camp for two months. And I think those are all really reasonable options or really reasonable reasons to have menstrual suppression.

Melanie Cole, MS: Dr. Cron, how do you counsel your patients on the fact that what you've mentioned here, and I think you didn't mention the condom. So, about the fact that all of these hormonal modulators do not really protect against STIs. And while you're answering that, speak about that discussion about these options and even where caregivers fit into that discussion, how you might meet with this young lady by herself or with her caregiver, one of her parents, whoever it is, and how you discuss that, but also where condoms fit into this to protect against sexually transmitted infections.

Dr Julia Cron: Yeah, excellent point. So, with every conversation about contraception must come a conversation about sexually transmitted infection prevention. So, every single thing that I mentioned when I talk to patients about it, I say, "And this does not protect you against STIs. The only way we have now to protect against STIs is condoms." So if patients want to protect themselves from STIs, it is imperative that they use condoms in addition to contraception." And we look a lot at what we call dual use. And actually, dual use seems to be declining. And it could be that now we have lots of contraceptive options that are actually very, very, very effective at preventing from pregnancy. But we should not underestimate the importance of STI prevention.

Your second question about engaging caregivers. So, I learned a long time ago when I first started doing this, that in most circumstances, it is really, really important to engage caregivers because the caregivers are the gatekeepers to your office, right? And so if you don't have the engagement of caregivers, for the most part, patients don't have access to you. And there are certainly some instances where engaging a caregiver can be harmful. But I think that is very much the exception instead of the rule.

And so, I start my visits usually with the patient and her caregiver, and we talk about how we are going to have a group conversation, and then we are going to have a private conversation where the caregiver exits the room. And then, I have the ability to have a private conversation with the patients. And if we bring the caregiver back in the room, I always tell the patient that we're going to figure out how we're going to have the conversation between all of us. Of course, recognizing safety as an issue, there are certain instances where the caregiver must be engaged, and that's mostly surrounding patient safety. But I think the more we can engage with caregivers, the better. I think it is also important to recognize that there are legal protections for adolescents surrounding reproductive healthcare. So, it is not required to have a conversation with a parent or caregiver about contraception and STI screening. The adolescent is protected under federal and state law where I practice. But the federal law, it offers privacy for contraception and STI testing. Now again, the legal landscape is changing every single day as we know. So, it is important to know what the legal landscape is in your particular state. But hopefully, it will stand that the privacy is protected.

But I generally feel when I talk to parents and caregivers about the importance of patients having a place where they can go and have private conversations and ask questions to a trusted health professional, it really does benefit the patients. I always say, "Wouldn't you have me in addition to their friends and the internet, so that maybe I can dispel some myths and provide factual information, so that your child can make an informed decision?" And generally, I have not had any parent or caregiver that has said no to that. And I think everybody agrees that the more trusted adults an adolescent has, the better off they are.

Melanie Cole, MS: Well, we certainly could talk about this a very long time, but I would be remiss if before we wrap up this episode that we didn't mention emergency contraception.

Dr Julia Cron: Yes. I was hoping you would ask about that.

Melanie Cole, MS: Yeah, because it really is something that we are hearing so much about in the media. It's been very politicized. Can you speak to emergency contraception and then end your brief discussion about that with your best advice about choosing the right type of contraception for that individual person?

Dr Julia Cron: Yes. Emergency contraception is a vital part of full reproductive care. So, we need to have it available to all patients who choose to be sexually active. So in terms of what is out there now, first, we'll talk about the IUDs. So, IUDs can be used for emergency contraception. The copper IUD that we talked about has been available for quite a while for emergency contraception. Recently in the past several years, there was a study looking at the copper IUD versus the progesterone-secreting IUD for emergency contraception, and it was shown to be comparable. So now, you know, remember we talked about how many patients choose the progesterone-secreting IUD because of the benefits for the period, we can now offer that as emergency contraception and then, remember again, it lasts for many years. So, you can put it in for emergency contraception and leave it in for long-term effective contraception. So when you think about EC, think about the IUD; however, recognizing there are barriers to that, right? It is sometimes hard to get in, to find a provider that can place an IUD, particularly in an emergency situation.

So fortunately now, there are other oral emergency contraception that is available to all patients without a prescription. And that is a change from the past where it was different depending on your age. And what we know is it is better to have access. And so now, the progesterone pill is available for emergency contraception over-the-counter without a prescription for all patients. There's several options actually available online that can be ordered online. So again, speaking about privacy and having patients have many options so they can go to a pharmacy, but we do know that there are some places where it is not accessible and there are barriers. But you can get progesterone emergency contraception online through the mail, which is, in my opinion, really great. There is another oral emergency contraception, ulipristal, which requires a prescription that is more effective than the progesterone pill. But again, it does require a prescription. So, again, speaking of options and there are lots of options out there. And the more options, the better.

Melanie Cole, MS: Absolutely. Great episode. That was so comprehensive, Dr. Cron. What an amazing guest you are and such a great educator. Thank you so much for joining us today and laying that all out for us because, boy, that was a good one. And listeners, share this show with your friends and your family, because we are learning from the experts at Weill Cornell Medicine together, and that was just outstanding. Thank you again.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate and review Kids Health Cast on Apple Podcasts, Spotify and Google Podcasts. For more health tips, please visit weillcornell.org and search podcasts. We have so many great ones in our library. And don't forget to check out Back to Health, another good set of episodes that give so much information from the experts at Weill Cornell Medicine. I'm Melanie Cole. Thanks so much for joining us today.

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