Lets talk about birth control


[00:00:00] Saturday. I don't even know what Covid day this is. I've completely lost track. I'm in my call week. I'm almost done tomorrow. I came to the office to just get some charts done, so that Monday is not so crazy here when I'm back seeing patients in the office. And I thought we would talk about barf control. 

I'm kind of sick of talking about Covid. I gotta be honest. I know that sounds immature as a doctor, but you guys are sick of it too, so, I'm sorry to all you pregnant ladies, I'm not gonna talk about Covid right now. I'm gonna talk to all of my gynecology ladies about birth control. So we're not gonna talk about the pill today because that's a whole nother topic in and of itself. 

We're gonna talk about alternatives to the pill that we can do as doctors. And I say that meaning there might be people on here who advocate for natural family planning. I am. Disavowing Natural Family Planning, which has to do with checking your basal body temperature and your cervical mucus. It is just outside of the scope, really of my knowledge. 

I'm completely happy when people choose to do it, but it takes a lot of work. So without further ado, we're [00:01:00] gonna talk about I U D. Rings, patch shot and implant. And again, this is not comprehensive. There are details about each that I'm not gonna be able to cover, but I wanted to show you and we'll go kind of in order of what I have in front of me. 

We're gonna talk about rings first. The original ring was called Nuva ring. . You see this blue? It's really actually white clearish, but this is our model. So the ring has the same hormones as the birth control pill in the ring. So instead of swallowing the pill and it gets absorbed through your stomach and it suppresses ovulation, which stops pregnancy, as well as it can improve mood changes in acne and all kinds of other things, this goes into your vagina. 

I'm gonna show you my model of a vagina. So you put it in your vagina and then it kind of sits like this. The beauty of the ring, this is not an actual scale model, is that it can't go in the wrong place. Patients will say, what if it gets lost, just like a tampon? It can't get lost. What if it goes in the wrong place? 

It's not a diaphragm, so it's not [00:02:00] covering the cervix. It's just meant to sit in your vagina, and it will basically, if you push it all the way in, You see how it's collapsible. You push it in, you let it plop open, it'll sit where it feels comfortable, and then your vagina will absorb the hormones from this. 

So instead of swallowing the pill, your vagina absorbs, it suppresses ovulation, all the same side effects as the pill. The good side effects. It decreases ovulation, which stops not only pregnancy, but mood changes. Acne, it can stop ovarian cyst. It can decrease endometriosis pain. It can decrease colon and ovarian cancer and uterine cancer, as can the pill. 

On the downside, it can increase breast cancer a little bit because it's hormone and all those things that it shouldn't improve. Mood, AC. Irregular bleeding. It can cause all those things as well. Sometimes short-lived for a couple months, sometimes it continues. And then you have to switch to a different form of birth control. 

There's definitely a lot of, um, I don't use like the word chatter, but I'm gonna use the word chatter cause I have no other word to use. Chatter on the internet among [00:03:00] more holistic providers about the ills of suppressing our hormones. And here's my. do I think there can be ills to suppressing our hormones? 

And can it interact with hormones in a way that we don't actually know about? Or that maybe integrative doctors do know about and they feel differently about? And I, I acknowledge that. I think it's like anything else. We have to weigh the pros and cons. So in a perfect world, would we all not have sex until we're ready to get pregnant or use condoms every single time? 

I guess yes, but all in, that's likely not gonna happen. And so I want everyone to know that I am. pro contraception a hundred percent. It has zero side effects that are concerning, but I'm also not anti contraception because in aggregate I think that for the most part, these side effects can be managed in the right patient. 

Some patients just don't feel well on them at all, and they report all kinds of side effects and they shouldn't be on them, and that's okay. Just like anything else, I'd rather be a little bit open-minded. Okay, so that's maneuver. You can either skip your period or [00:04:00] you can have your period. This can stay in for three straight weeks. 

Then you take it out for a week, put it in the garbage, put a new one In. That week of placebos is where your brain says, oh, I'm done with my hormones. Give me a period. Or you leave it in for four straight weeks at a time, four straight weeks at a time, and skip your period. The newer version of the Nuva ring, or I should just say another ring, is called Anno vera Anno in the Latin. 

Yearly. Um, I forgot what Vera means. Someone tell me that I should know. This is actually softer. Squishier a little bit thicker. Also has the hormones in it. Slightly different progesterone, but same estrogen, same side effects. I'm not gonna keep repeating them. So because I'm already at four minutes here, the beauty of an novera is in unlike having to get a new ring every month, this is one ring for the whole year, which I know sounds gross, but it can be taken out, rinsed quickly, put back in. 

So you can either do three weeks in, one week out, three weeks in, one week out, put it in your little compact. [00:05:00] one straight year in which is off label, but okay to do. You don't need a period if you are on contraception, and that that is the reason why you're skipping your period. Now, what I didn't mention is things, the questions commonly asked besides, will it get lost or can it go too far? 

No. And no. What if I feel it during sex? Or what if he feels it during sex? So the answer is you might, but unlikely he might. And studies have. , he might like it, so if he feels it and he doesn't like it, a, I'm sorry. B, if you're using a condom, he won't feel it. And C, if you care that he doesn't like that, then you could always take it out just during intercourse and then put it back in. 

Don't forget, I don't really love people to do that, cuz I feel like they'll forget. Okay. Those are the rings. We're trying to move quickly here. People. I don't have a com, a picture of a patch, but there's also a patch. Ortho Ebra was the brand. Zula is the. The patch goes either on your arm, on your stomach, on the top of your buttocks, on the back of your shoulder, um, that also has the same hormones as the. 

Secreted from the patch through your skin. The benefit, just like the ring, is it [00:06:00] bypasses metabolism through your liver. So some people might feel less nauseated than things like that. Other patients just like it cuz they don't have to remember a pill every day. So that is a weekly patch, so you put it on for three straight weeks. 

One week off where you get your period again, you can safely skip your period if you wanna use a patch. Weekly, weekly, weekly, weekly, weekly. That's really all I have to say about the patch. There is some data that maybe at slightly high risk of blood clots, um, with the patch and maybe even the ring than the pill, but it seems unclear. 

So for the most part we use it because believe it or not, pregnancy itself is a risk factor for blood clots in your cabs. Okay, that's all we're gonna say about that cause there's a lot more to discuss about blood clots and out of the scope of this discussion. Okay. IUDs? There are generally two forms of IUDs. 

Um, I'm saying generally there's a couple more, but there are two forms. One is just made of copper. This is a little uterus with a little copper. I u d in. The inside of your uterus is actually about that big. You see the I U D I'm pulling on it cuz there's strings that come out of the I U D that come out of your vagina. 

This is actually just an example of the [00:07:00] outside of your uterus. I'm gonna switch now to this model, but I wanted you to see the I U D. . This is a pin in the form that's copper, that is no hormone. It is meant to perform contraception in a couple of ways. So imagine if this was in here. So basically the strings coming out. 

Create a type of change in the cervical mucus so that the sperm are unlikely to get into that cervix. That's one. Two, if this sperm gets past the i u D gets out of the tube and meets the egg and then comes back in as an. This can block the embryo. That's the secondary mechanism. Okay. So it's very mechanical, how it works. 

It goes in pretty easily through your cervix, easier if you've had a baby, but it can still be done even if you haven't had a baby. The downside to this i u d, while upside is its. Non-hormonal. So it's kind of the most natural thing you can do besides doing nothing or condoms. Um, and it can last for 10 years, which is great. 

The downside is that the localized inflammation in your uterine lining can make your period heavier and [00:08:00] crampier hopefully just for a couple months, but sometimes forever. The one risk is that you have to be compulsive. If you have an i u D that you do not get exposed to gonorrhea and chlamydia, how would I do that? 

Well, you would use condoms or you would some. Absolutely, um, confirm a thousand percent over it that your partner is not carrying chlamydia or gonorrhea because if chlamydia, gonorrhea sticks to that IUD you can get a bad pelvic infection. Okay. All right. The other form of IUD has hormone in it, the original brand name was Marina. 

Now it is, there's a generic one called Liletta, which is less expensive. So many of us use it. And then there's two others, Skyla and Lina, but we're not gonna talk about those. Those are a little bit smaller. Who's calling in my office? It's on a Saturday. Um, okay. So if we were to put it in, it would go in like this. 

It's funny doing this with a model and then we would pull back. 

It's hard to do it with two hands, but anyway, we [00:09:00] pull back and then the strings would come out. The benefit of this i u D over copper is that because it's got hormone in it, just progesterone hormone, the hormone keeps the lining of the uter thin so that you have bar and barely any period or no period at all. 

So imagine your brain and your ovaries are still stimulating the lining of the uterus with estrogen, but the progesterone is constantly antagonizing. So that no lining is built up. So barely any period. No period at all. Very safe. People like it because they don't want their period. Some people don't like it because they want their period or they want no hormones. 

This one can last six years. They used to say five. They changed indication to six, not 10. Okay. Um, what was the other one? Oh, injections with progesterone. So there's a shot called Depo-Provera with progesterone only. It's every three. The benefit is, ah, every three months you go to the doctor, you get a shot, it hurts a little bit. 

It's in your muscle, but done. You don't have to think about it. That [00:10:00] sounds great, but there does seem to be a lot of irregular bleeding in that first three to six months. That often goes away after that and patients miss their period. The biggest downside I would tell you is that because it's a high dose of progesterone, people get hungry. 

We, we actually prescribe progesterone for patients, for example, during chemo who need to eat more. So we know that progesterone is a potent stimulus of your. . So I have very few patients who really love it because many of them like the convenience but don't like the weight gain that is definitely associated with it. 

On the pill, in the ring, we say that a third of the patients gain weight, a third of the patients lose weight, and a third of the patients stay the same weight, which is kind of what the rest of the population does outside. But with the I, with the injectable, it does seem like it's a higher rate. Similar to the injectable shot is the implant. 

So there's an implant called Nexplanon. , it looks like a skinny little rod of, um, that has hormone, again, impregnated in it. And it gets injected. I dunno what is going [00:11:00] on here. It's Saturday and nobody's in my office but me, so I don't know who's calling. It's like the call is coming from in the building. 

Doo do doo anyway, so it gets injected underneath your arm. Um, it doesn't really hurt. I mean, it hurts like you're getting an injection and it can stay there for actually three years. Very convenient, less irregular bleeding, less weight. , but still some. Okay. Um, that's basically it for the alternatives that I can think of off the top of my head outside of withdrawal, which is not a great choice outside of condoms, which are a great choice outside of a diaphragm, which is not a great taker. 

Um, okay. So that's it. I hope that helps. Bye.