Mary Leigh Meyer: Welcome to Sounds Like Health, I’m Mary Leigh Meyer.
Christina Sumners: And I’m Christina Sumners.
Mary Leigh Meyer: We are here with Dr. Hector Chapa, a board certified OB-GYN, Clinical Assistant Professor at Texas A&M College of Medicine, and the Assistant Clerkship Director for OB-GYN for the College of Medicine. Thank you so much for joining us today.
Hector Chapa: Hi, team. We’re here and I’m excited to talk about a very, very interesting topic, because this isn’t just for females, I don’t want everybody to think about OB-GYN, this affects males and females. So, this is broader than just women’s health, because our topic today is…
Mary Leigh Meyer: Contraceptives!
Hector Chapa: Birth control, that’s right. So everyone is interested and everyone has some form of experience with birth control, so in just a minute, we’re gonna go into some specifics.
Christina Sumners: That sounds great. So, just kind of in general, what should people know about which contraceptive to use?
Hector Chapa: Alright, so birth control’s really changed throughout the years. I’m sure you guys know, and if you don’t know, well you should, because it’s definitely not your grandmother’s birth control. So let’s go over a couple of things first.
First of all, guys, birth control is so necessary for proper family planning. Because, remember that in the U.S., still in 2018, based on who you read, you have different stats. But anywhere from 45 to 49 percent of all pregnancies in the U.S. are mistimed. Now, I didn’t say undesired, we just said not planned, not timed well. And, you know, that could change your school plans, your college plans, your work plans. This is a big deal. That’s why using an effective contraception, using it correctly, and tailored to you for your needs is so vital. So birth control as a medical concept, we’ll get into barrier types that are not medicated in a little bit, but talking about hormonal birth control, you know this is nothing that started five or ten years ago.
The first birth control pill was actually in the 60’s and that birth control pill had some issues as things do initially when they first come out. And some of those myths and some of those precautions are still lingering today, although they shouldn’t. So, lemme clear that up real quick. One of the first birth control pills that came out was called Mestranol. Can’t get it anymore, it’s obsolete. But in the 60’s, the amount of estrogen, which is one of the hormones in birth control pills taken by mouth, was literally about three or four times the amount that’s found in birth control pills today.
So what happened? Some women had strokes, heart attacks, some women had blood clots. And we’re still having to deal with that bad representation of the pill even now in 2018. So lemme talk everybody off the ledge, those risks are still possible but they’re really, really rare. Because, once again, this is not your grandmother’s birth control pill.
Mary Leigh Meyer: You mentioned a little bit about the different kinds, barrier methods versus… Can you tell us kind of a little bit more about?
Hector Chapa: So, guys, as main categories lets put this into perspective. So if you’re a young woman, if you’re a young man, if you are an older woman, an older male, this still applies. Because we have to have this conversation to pick what’s right for you. So, let’s do the general categories.
First of all, we have non-medical birth control, right? So what is that? Well those are things like barriers, of course, men know condoms. But you all know that there’s actually a female condom out there? And that’s over the counter. Well what the heck’s the female condom? Well, you gotta google that because you can’t have any visual on a podcast. But there’s a female condom and there’s advantages and disadvantages for both. But used appropriately, great for birth control and also, of course, a great protector against sexually transmitted infection. All right, so that’s barrier.
Then we have medicated types. And the medicated types are a variety. From the pill, of course has to be taken daily. For women there’s a patch that can be applied every week. There’s actually an approach that has estrogen and progesterone, the same hormones in all birth control that can be placed in the vagina. And that can actually stay in for three weeks. There’s also an injection called Depo Provera. But that only has one kind of hormone in it, called a progestin. There’s also a little rod that can go into the arm and can take care of you for three years. It’s incredible! It used to be five, but now it’s three. And then there’s devices that you can actually place inside the uterus.
Now, here’s a catch, everybody knows those as the IUDs, right? Intrauterine devices. And for a long time in medicine, if a woman had never had a child or pregnancy, or was an adolescent, IUDs were kinda off limits. Because we don’t wanna touch the uterus, right, it’s kinda sacred ground, we don’t wanna mess with the potential for fertility, and so those women were denied that choice of contraception. Well, really since the late 90’s and early 2000’s, the American College of OB-GYN, and even the Centers for Disease Control, agrees those are wonderful methods for birth control, especially in adolescents. Because they can’t mess it up. Alright, so let’s be real, right? It’s hard to to take a pill every day, it just is. But when you place something in the arm that has a residence time of three years, or something in the vagina that can stay in the vagina and be active for three weeks, or something in the uterus that can last anywhere from three years to ten, based on the different types, we can’t mess it up by human nature.
So, the American College of OB-GYN actually recommends these types of devices, these long acting, reversible contraceptive options. The one in the arm, and the ones that go into the uterus. Those are called LARCs, l-a-r-c, long acting, reversible contraception. It’s so much of a thing that the American College of OB-GYN has a whole campaign to talk to our female patients about LARCs.
Now, before we get into any more specifics, a quick word. This falls all to the female patient, right? But, you know that under development, and really has been for the last six years, international researchers are looking for the, anybody drum roll? The male only birth control. The male birth control. And there’s things in development now, some are injections, some are pills, to help reduce sperm levels from getting to a level that can impregnate a woman. But, we’re still way too far off from that.
Christina Sumners: Interesting, so you said these are reversible, so that means that if a woman changes her mind, decides she does want to have a child, it’s possible to reverse it without side effects?
Hector Chapa: Yeah, remember, these are reversible. So we’re not talking about surgical methods. The only surgical methods that are available now for both men and women, as a contraceptive theme in general, those are considered permanent. Like, getting your tubes plugged, or cut, or a vasectomy for the male. Those should be considered irreversible, and I know you’ve heard, and there’s advertised for vasectomy reversal, and tubal reversal, that’s legitimate, but there’s no guarantees for those. So once child bearing is complete, or it’s happened where your health has such restrictions, such contraindications where pregnancy may actually be life threatening, then that’s a very difficult decision, but couples do make that decision. But those should be considered not reversible.
So to be clear guys, this is a reversible concept. Once you’re done with birth control, you can switch, try to have children, or switch to another method.
Mary Leigh Meyer: Fascinating, so what would happen when these methods can fail?
Hector Chapa: So everything has its failure rate. And most of the non long-acting methods, the ones that require either daily use or more frequent use, you know, things fail. And the reason that they fail, although there’s true medication failures, again, user error is a big thing. And that’s not to blame anybody. Hey, it’s hard to remember. Now there are those patients that for whatever reason, take it every single day, without fail. I mean, it’s habitual, they’re good, full on it. But they still get pregnant. And that’s things that we can’t explain yet. There’s ultra metabolizers, and there’s all these theories of…Their bodies just have what is called escape ovulation. And it happens. But I want everybody to be confident, in that if you’re using birth control correctly, while failures occur, the risk of a birth control failure is still incredibly low.
Mary Leigh Meyer: So is there any birth control that you would recommend across the board? Or is this more of a person by person basis?
Hector Chapa: You know, we used to say that the birth control pill is just relatively safe unless there’s very, very unique contraindications, which are restrictions, but the truth is, it’s deeper than that. Every patient is unique. So the World Health Organization and the Centers for Disease Control have a whole online website to best select the type of contraception based on the patient’s medical profile.
So, in other words, let me give it to you another way. If you hate shots, why would you pick the shot as a method for birth control? That’s not a daily shot, that’s every three months, but nonetheless. If you’re terrible with pills, why would I prescribe you the birth control pill? Even though it’s low risk, it’s not the best choice for you. And in similar concepts we can walk down the line. So the idea is whenever we meet a young woman who wants contraception, we want to, number one, find out why she’s taking it. Now that seems kinda funny, right? Why is she taking it? Well of course it’s birth control. But remember that there’s a lot of non-birth control benefits to birth control. It reduces your cycle, reduces cramps, it helps prevent mood swings based on some studies. There’s a lot of reasons, even virginal women we place on birth control. And that’s okay.
One of the things that we see in women who come to our University for the first time, are very conflicted, either by societal or parental concerns, that they shouldn’t be on birth control. Cause it implies sexual activity. And some of these women are virginal. But they can’t go to class, because their cycles are just so debilitating. There are great non-contraceptive benefits, non-birth control benefits to birth control. So the short answer is, tailor the need of the patient to the medication provided.
Mary Leigh Meyer: So what are some common myths about birth control?
Hector Chapa: Alright, well we’ll do myths and misperceptions, I think they’re kinda similar. And we deal with these daily. So let’s knock these off in serial, like a top 10 list, although we may not get to 10.
So number one, on birth control pills, specifically birth control pill, is, “Dr. Chapa, I appreciate you offered me the pill, but I don’t want it because it’s gonna make me…”
Christina Sumners: Fat.
Hector Chapa: Gain weight. Well, that’s not true. So what makes people gain weight is excess calories and less burning it off. So here’s where this came from. There is some historical truth to that, because the first birth control pill that we mentioned earlier, Mestranol, was such the high dose that it had some anabolic properties. What is anabolic? Kind of building up, like anabolic steroids. So it made women hungry, and therefore they may have increased their calorie intake. So here’s the benefit, here guys, here’s the good news, is that for the last 20 years, none of the oral contraceptive pills, none of the birth control pills, have been linked to weight gain. So you can relax, it’s okay. There’s only one type of contraception that has the potential for weight gain, and that’s over one to two years. And again, so let me be very clear, it has the potential, doesn’t mean that it will. And that’s Depo Provera, which is the shot taken every three months. In women, over 12 to 24 months noted a slight increase in weight. But again, who doesn’t gain weight over one to two years? So even that’s a little controversial. Short of it is, birth control pills do not make you gain weight.
Number two, can’t use birth control because it’s gonna give me breast cancer. Well, now I’m sure you may not have heard that, we hear that all the time. And a lot of that is societal fears and concerns. Not true, even where women are considered very high-risk for breast cancer, ’cause there’s a certain gene mutation, anybody, Angelina Jolie went on People Magazine some years ago. BRCA, it’s called BRCA. The American College of OB-GYN actually states that women who have BRCA gene mutation, puts them at high risk for breast cancer, but also ovarian cancer. Those women can still use birth control pills, as long as they have appropriate follow-up because of the non-contraceptive benefit. There’s some association with reduction in ovarian cancer risk in those women. So, in general, even women that are deemed high-risk, as long as they have a physician follow-up, does not increase risk of breast cancer.
Here’s depression, how about that one? Well, I can’t use the pill because that thing is gonna make me depressed. We hear that all the time. Well, the last study that came out looked at a variety of studies, that was just in February of this year. And if this ever gets played back at another time, February 2018. The large analysis showed, hey, birth control pills don’t make you depressed. Depression has to do with different neurochemicals called serotonin, and norepinephrine, and dopamine. But not progesterone, that is ovarian, not central brain area. So we feel very confident that birth control pills should not make you depressed.
And the last one, I think, is I can’t take contraception because when I get off of it, you know, I’m just not gonna be able to get pregnant. Not true. Oddly, one of the treatments for infertility, the inability to get pregnant, is a short burst of oral birth control pills. We gotta go back, to help you spring forward. Why, because birth control pills can help normalize disorganized hormones. Especially for a condition called polycystic ovarian syndrome, where we give birth control pills first, and then try to trigger ovulation. So, no, taking birth control pills appropriately, the right way, will not make you sterile, or infertile in the future.
Christina Sumners: Fascinating, what are some myths and misperceptions about some of these other types of contraception? The intrauterine, for example.
Hector Chapa: Well, one of the myths actually again, as always, right? Some myth is always based in some truth. And the idea of the IUD and becoming sterile if it’s used, especially in a young girl, really does stem back to some truth. So in the 70’s there was a very famous kind of IUD, no longer available, it’s dead, buried, no longer to be found, called Lippes Loop. Well, Lippes Loop was an IUD that had two little strings, just like IUDs have today, that come out of the cervix. But the string materials were different. Those original strings functioned like a wick. What that meant was that it took all the vaginal bacteria that was naturally present, absorbed it up the strings, and deposited it into the uterus. Called a wicking effect, dangerous. What will result is that women had an abnormally high level of pelvic inflammatory disease. Very dangerous and can lead to infertility. That’s gone, the strings are now different. The CDC states that the risk of PID is very negligible, excluding the first month after insertion where it could be, by placement, a physician induced kind of infection, if you will. We take steps to prevent that. But the biggest myth around things in the uterus really have to do with that history of, you’ll get an infection, you won’t be able to have children. Guys, everything’s possible. But it’s just not very probable in today’s age.
Mary Leigh Meyer: And what about some of the horror stories we hear?
Hector Chapa: Now stuff is out there, guys. So we gotta remember that, listen, there’s stories for everything. That’s life, and that’s medicine. Would you believe that there’s people who take Tylenol for routine use end up with liver failure? That’s devastating, it’s terrible. But it’s possible. Everything is possible, but just because it’s possible, doesn’t mean it’s very probable. So, I’m sure you’ve heard, the woman who took a birth control pill, and some months later developed a blood clot. May have dislodged and went from the leg or what other part of the body, to the lung, called a pulmonary embolism. That’s real, guys, it happens. So I don’t wanna minimize this, like, hey, they’re great, they’re user free, it’s rainbows, it’s not true. There’s risks to everything. But that’s why we have to tailor what? The patient to the medication. So horror stories, a lot of those are taken out of context. Or if they’re real, happen at such a statistically small amount, that our College, and I don’t mean that as a University, I mean the American College of OB-GYN, and even the CDC says, way, way worth any small theoretical risk.
Christina Sumners: And what are some things women can do to prevent some of these risks? Just keep in contact with their health care provider, or?
Hector Chapa: Sure, absolutely, appropriate selection. So, the CDC once again, has that website called a medical eligibility. So, if women who have very severe migraines, especially ones where they have visual changes, seeing little spots before their eyes, called an aura, they may not be the best to use certain types of birth control. That’s where physician counseling has come in. Now, for a long time, there’s been a push to make oral birth control pills, think about this, over the counter. Why do we need that obstacle? Now, that’s not my argument, I’m just saying that’s argument in medicine, right, in the community. Let’s make that over the counter. I completely see that benefit. I also see the potential risk. Because this is still hormonal manipulation. And I think it’s valid for a 15 minute consult, that’s all it takes, to sit with a patient, go through her medical history, give her any contraindications, and then tailor the medication appropriately. So I’m kind of in the middle. I think there’s a time for it, I also think it needs to be done judicially, and with some education.
Mary Leigh Meyer: There are quite a few options out there. How do we know what works for us?
Hector Chapa: You know, really, it depends, again, on what you’re interested in. So, from the American College of OB-GYN standpoint, LARCs is the way to go. Again, we can’t mess it up! That’s a little rod in the arm, or the ones that go intrauterine. But, listen, there’s some women who are just terrified of getting a gynecological exam. And I understand that. And if that’s the case for you, we definitely don’t want to cause more psychological trauma for you. We want to help you. Maybe choose another option. But remember, does anybody have an idea of what the most common, most typical birth control pill used worldwide is? Ah, I messed it up! The most typical type of birth control used, and that’s the birth control pill. Without doubt, hands down, the birth control pill’s the most common method. Why? ‘Cause it’s easy. And if you don’t like it, you can switch it very easily.
Mary Leigh Meyer: Okay, so what happens when your original contraception plan fails? Is there anything that you can do?
Hector Chapa: So, we’re talking about two different concepts here. We’re talking about traditional birth control, that’s regular use birth control or contraception. Then, there’s the issues of life. When things happen, you’re off the pill, or you forgot to take the pill on time. And those events require what’s called emergency birth control. So we wanna be very clear, we’re talking about contraception here that’s still contraception. This has nothing to do with an established pregnancy. I just wanted to be very clear with that. And, again, life happens. But this is usually an issue, emergency contraception, is much more of a valid concept for those who are not on any kind of birth control. Or, who are trying to protect themselves, and it happens, the condom breaks. It slips, it falls, or whatever your scenario can evolve to include. Because, again, life happens. Emergency birth control is valid at this time, but they’re all different. So, in general, three main types, okay?
One is the copper T IUD. That can actually be placed in the uterus, as regular birth control can, and is effective up to five days, 120 hours, after the event. That’s incredible! So, the American College of OB-GYN actually says, that’s your most effective birth control. But, it requires a physician’s visit, a little procedure to place it, and then once you place it, the commitment is that you’re going to keep that for the length of the device, right? So some women don’t want to make that big commitment. So the IUD, just to knock that out there, is still considered the most effective type of emergency birth control.
Now that we’ve talked about that, now we’re left with the two types that most people know. The two oral types of medication. Now these are both types of hormonal manipulation, alright? So I hate to say one, which is not an endorsement of any kind of brand, but everybody knows the term Plan B. Because plan A failed. So Plan B is the branded name of the generics called levonorgestrel. And taken within 72 hours, is about 89 to 90% effective. Now, that sounds scary, right? Wait a minute, that’s not a hundred? There’s nothing a hundred percent. But 89 to 90% is a dramatic reduction in your chance of getting pregnant. So, first of all, let’s stop there for a minute. What’s the chance of becoming pregnant per-cycle anyway? It’s actually pretty low. Actually, in a young, reproductive aged woman, up to the age of about 30, the chance of getting pregnant per month is 20%. 20%, it’s amazing any of us are here, right? It’s 20%, because it’s just all the factors that have to come into play, are actually mind blowing. So, the A Cog states that the monthly chance of getting pregnant, the medical term for that is fecundability, you can look that up, fecundability is only 20%. So if you take a 20% baseline, and then you bring it down 89, 90%? That should give you some relief. Now here’s the catch, birth control pills should be taken as, emergency birth control should be taken as soon after the act as possible. Because if it’s taken within the first 24 hours, it’s 95% reduction. Everybody get that? So, take it up to three days later for Plan B, but within 24 is your goal.
There’s another type of emergency birth control that is not Plan B. It’s actually called ulipristal, that’s the medication name, the brand name is Ella. And it’s one pill that can be taken up to 120 hours. Is everybody sitting in their car doing math? That’s five days. So Plan B is three days, Ella, five days. It just works differently. That’s why one is by prescription, which is Ella, and the other one is over the counter. Because if you use Ella, it actually works against progesterone. So, think about that. Plan B is a progesterone high dose, Plan B, Ella, pardon me, is an anti-progesterone, works totally opposite. So we don’t want those two mixing. So, quick word, don’t take those two together! If you take Plan B one day over the counter, and you go to the doctor the next day to be really sure and he gives you Ella, you’re gonna cancel one of those out. So, don’t take those two together, alright? So, yes, it’s very effective. Plan B’s within 72 hours, ideally within the first 24. And then Ella gives you a little bit more grace in terms of the calendar, because you have five days. Just like the copper IUD.
Christina Sumners: That makes sense. What will it do if you’ve been mostly taking your pill on time, but then you, you know, maybe you miss a day and then you wanna make sure and you get the emergency contraceptive?
Hector Chapa: Great.
Mary Leigh Meyer: Side effects?
Hector Chapa: Absolutely, no, no, no. No side effects as long as…What you said is absolutely correct. What would have been a switch is to say, hey, I’m on regular birth control pills, I missed two days, an event happened. We’ll call it an event, right? And then I took Ella. Remember, that’s an anti-progesterone. But birth control pill has progesterone. That’s why the counseling comes in. But if you take an extra dose of progesterone, we just took a little booster. So, no, outside of getting some menstrual irregularities, is there any health concerns? No, and if you’re off, if you did not use birth control pill correctly, or if you missed some days, it is worth taking Plan B. And then starting your regular oral birth control pills immediately the next day, without break. Not the case for Ella, for which you have to wait five days to start regular birth control. But for Plan B, take it. Outside of some menstrual irregularities, well worth that extra protection.
Mary Leigh Meyer: And what are the odds, say an event happens, and you’re interested in one of the options that require a doctor’s visit, or a doctor’s prescription, are doctors pretty understanding?
Hector Chapa: Listen, there’s a couple of things that get you in very quickly to a physician. And, without going through all that list, cause that’s cheating and I’m not doing that on a podcast. One of those is, I need an appointment for emergency birth control. You will get in, because remember, we’re not trying to hinder or make roadblocks. That is a universal standard. They’re members of the American College of OB-GYN, and they’re fellows of the board, they’re meant to get you in there. We will bump somebody to get you that medicine. That’s part of our medical ethics and beneficence. First, do no harm. Alright, guys, so again, we’ve covered a lot of information and hopefully it’s been helpful. Because contraception, again, is just one of the most common reasons why women go to the gynecologist, outside of abnormal bleeding, and everyone’s favorite, especially on a podcast, vaginal discharge. That’s a topic for another day. But it’s one of the top three reasons women go to the gynecologist, is birth control. Birth control has amazing, non-birth control benefits. So it’s okay to take even if you’re not sexually active. But if you are sexually active, use it as directed, appropriately. Appropriately selected for you. And it’s a great way to time and plan pregnancies. Remember, 45 to 49% of pregnancies in the U.S. are just mistimed. It shouldn’t be when we have the availability for all these medications. And for those times when life happens, there’s always emergency backup.
Christina Sumners: Well that’s really good to know that if plan A fails there are other options out there for contraception.
Mary Leigh Meyer: Well, awesome Dr. Chapa. Thanks for teaching us about well-timed events and how contraceptives play a role in them. And this wraps up this episode of Sounds Like Health.