Benefits & Issues with Birth Control | Dr. Sara Gottfried & Dr. Andrew Huberman

00:00:00.000 | [silence]

00:00:02.720 | What are your thoughts on sort of pure estrogen birth control?

00:00:06.300 | This is what I learned when I was in college

00:00:08.100 | is that birth control is basically tonic estrogen.

00:00:11.140 | So constantly taking estrogen, estrogen,

00:00:12.840 | women are taking estrogen

00:00:14.140 | so that they don't get the estrogen priming of progesterone,

00:00:19.140 | you're not getting any ovulation.

00:00:21.780 | And I've known women that have been taking,

00:00:25.140 | or that took oral contraception,

00:00:27.780 | as like estrogen pills basically for five, 10, 15 years.

00:00:32.780 | Are there long-term consequences of this

00:00:35.480 | as it relates to pregnancy, PCOS, menopause?

00:00:39.820 | If so, what are some of those consequences?

00:00:42.740 | What are your concerns?

00:00:45.200 | What do you like about oral contraceptives?

00:00:46.960 | What do you dislike about them?

00:00:49.240 | - I like how balanced you ask that question.

00:00:51.360 | So women who take oral contraceptives,

00:00:54.880 | as long as you're describing like 10 years or longer,

00:00:58.160 | we call those Olympic oral contraceptive users.

00:01:02.720 | In terms of benefit, I think that,

00:01:04.940 | especially when they first came out and even now,

00:01:07.160 | it gives women reproductive choice, and that's essential.

00:01:11.260 | As you may know,

00:01:12.160 | our reproductive choice has been declining recently.

00:01:15.320 | So I'm a big fan in that regard,

00:01:16.840 | and we've got a lot of data to show both the risks

00:01:20.800 | and also the benefits of it.

00:01:22.820 | So I'll speak first into the benefits

00:01:25.000 | because I'm gonna get on a soap box a little bit

00:01:30.000 | about the risks.

00:01:31.680 | So we know that it reduces the risk of ovarian cancer.

00:01:35.400 | So there's something about this idea of incessant ovulation

00:01:39.760 | that is not good for the female body.

00:01:42.320 | So if you look at, for instance, women who are nuns,

00:01:47.320 | who don't take oral contraceptives

00:01:51.160 | and they have a period every single month

00:01:53.020 | of their reproductive lives,

00:01:54.820 | they have a greater risk of ovarian cancer.

00:01:57.300 | So if you look then at women who have several babies

00:02:02.300 | and they've got a period of time when they're pregnant

00:02:05.340 | that they're not ovulating,

00:02:06.420 | and then they breastfeed for some period of time,

00:02:08.620 | they have a lower risk of ovarian cancer.

00:02:10.820 | So oral contraceptives help with reducing ovulation

00:02:15.640 | and reducing risk.

00:02:17.380 | We know that if you take the oral contraceptive

00:02:20.860 | for about five years,

00:02:21.860 | it reduces your risk of ovarian cancer by 50%.

00:02:24.660 | And that's significant because we're so poor

00:02:28.580 | at diagnosing ovarian cancer early.

00:02:31.300 | There's really no method that's really effective.

00:02:33.740 | We use CA-125 and ultrasound screening,

00:02:37.300 | especially in women who are at greater genetic risk.

00:02:40.180 | But even that, often we diagnose it in a later stage.

00:02:43.760 | - Maybe just because that statement is gonna highlight

00:02:46.580 | for a number of people the question

00:02:48.620 | of what are some of the earliest symptoms

00:02:52.100 | that people can recognize without a blood test?

00:02:53.960 | So is ovarian cancer, is it gonna be pain?

00:02:57.120 | - So the problem is the symptoms are so vague

00:02:59.700 | and they're so nonspecific.

00:03:02.120 | One of the most common symptoms is bloating.

00:03:05.140 | And we've already talked about constipation.

00:03:06.700 | We've talked about how women have this longer GI track.

00:03:10.780 | And so bloating is a really common experience

00:03:12.940 | for most women.

00:03:14.420 | You can have bulk symptoms,

00:03:15.980 | feeling like your lower belly is kind of pressed out.

00:03:20.020 | So the way that we inform women

00:03:25.020 | in terms of watching for this

00:03:26.700 | is to get regular gynecologic exams

00:03:31.300 | for women who are at high risk

00:03:32.620 | or they have, for instance, an ultrasound for some reason

00:03:35.100 | and it shows a mass that we're concerned about.

00:03:37.420 | There's a way to triage that

00:03:38.720 | in terms of what kind of evaluation that they need.

00:03:41.400 | And that's the situation where you might get a blood test

00:03:43.900 | called the CA-129.

00:03:46.100 | CA-125.

00:03:47.100 | Yeah, the problem is the symptoms are so vague.

00:03:52.400 | It could be, it depends on how big the tumor is,

00:03:55.180 | how much bulk you have, what it's pressing on.

00:03:59.060 | - So if taking estrogen

00:04:01.560 | and thereby reducing the frequency of ovulation

00:04:05.300 | lowers the risk of ovarian cancer,

00:04:08.140 | should women that are,

00:04:09.700 | even women who are not sexually active,

00:04:11.340 | so they're not actively trying to get pregnant

00:04:13.860 | or avoid getting pregnant,

00:04:15.300 | but if they're not sexually active,

00:04:16.580 | then the probability of conceiving

00:04:18.420 | unless they go through some IUI or some other route

00:04:21.700 | is very low as far as I know.

00:04:23.760 | That's what I was taught in high school anyway.

00:04:26.740 | Would they be wise to suppress ovulation

00:04:30.460 | for periodically using hormone-based contraception

00:04:33.940 | just so that they can offset the risk of ovarian cancer?

00:04:37.620 | - That's a very rational question.

00:04:39.300 | And I would say that's what mainstream medicine

00:04:41.900 | has had at its back to recommend oral contraceptives,

00:04:46.860 | not just for women who are seeking contraception,

00:04:49.060 | but for acne, for painful periods,

00:04:53.540 | for really kind of the drop of a hat,

00:04:56.380 | they're prescribing oral contraceptives.

00:04:57.900 | That's what I was taught to do.

00:04:59.620 | But there's so many consequences.

00:05:01.580 | And I think the issue here is more about consent

00:05:05.020 | because in OB/GYN,

00:05:08.660 | and I started out as a board-certified OB/GYN

00:05:11.860 | and I now mostly see men,

00:05:13.500 | but I was taught as an OB/GYN to convince women

00:05:17.820 | to go on the oral contraceptive.

00:05:19.340 | And I think a lot of that is pharmaceutical influence.

00:05:22.240 | So maybe we could talk about the risks

00:05:25.060 | and why the answer is no to your question.

00:05:28.540 | - As we do that, could I just ask,

00:05:30.120 | is the so-called ring,

00:05:32.020 | it used to be called the NuvaRing,

00:05:34.220 | maybe that's a brand name,

00:05:35.060 | but when I was in college,

00:05:36.140 | there was all this discussion about the ring, right?

00:05:38.220 | By both men and women for reasons that don't belong

00:05:41.300 | on the podcast, use your imagination folks.

00:05:44.460 | So is the ring, obviously it's not oral,

00:05:47.820 | it's not oral hormone contraception,

00:05:49.780 | but it's hormone-based, right?

00:05:51.060 | The ring is releasing estrogen locally

00:05:53.300 | as opposed to taking it orally,

00:05:54.380 | but would you slot it under what you're about to tell us

00:05:57.180 | in terms of the concerns?

00:05:58.420 | - So we have less data about the ring.

00:06:02.100 | So the oral contraceptive is two hormones,

00:06:05.900 | it's ethinyl estradiol,

00:06:09.120 | and it's a progestin.

00:06:11.620 | So it's not the normal progesterone that your body makes,

00:06:16.220 | that your ovaries make and your adrenals make,

00:06:18.060 | it is a synthetic form of progesterone.

00:06:23.060 | And it is the same progestin,

00:06:26.800 | similar, same class,

00:06:29.220 | that was shown to be dangerous and provocative

00:06:31.300 | in the Women's Health Initiative.

00:06:33.080 | So I'm not a fan of progestins,

00:06:35.860 | I do not recommend them for any woman,

00:06:39.020 | unless the consequence of not taking them

00:06:41.940 | is surgery or some other,

00:06:44.560 | unless it gives them some freedom in some way.

00:06:49.820 | So I don't like progestins.

00:06:52.480 | The NuvaRing is estrogen plus progestin,

00:06:57.480 | but it's released transdermally through the vagina.

00:07:01.220 | So given the way that it's delivered to the vagina,

00:07:08.580 | the doses are lower than what's taken orally.

00:07:11.740 | But in terms of some of the risks

00:07:13.340 | that I'm about to talk about,

00:07:14.320 | we don't know about much of the data.

00:07:16.900 | We think that it's similar,

00:07:18.180 | there's probably a spectrum of risk,

00:07:20.540 | and the NuvaRing is a little more towards the middle

00:07:23.820 | than what I'm talking about with oral contraceptives.

00:07:27.460 | Are you ready for that?

00:07:28.380 | - Yeah, I'm ready for the risks.

00:07:29.780 | - Okay, so like with almost any pharmaceutical,

00:07:34.460 | the oral contraceptive depletes certain micronutrients.

00:07:38.500 | So magnesium, there's certain vitamin Bs that are depleted.

00:07:42.220 | It also affects the microbiome.

00:07:48.020 | That data is not as strong,

00:07:49.600 | but there seems to be some effect,

00:07:50.980 | and there's also an increased risk

00:07:52.600 | of inflammatory bowel disease in autoimmune condition.

00:07:56.060 | It increases inflammatory tone.

00:07:58.740 | So the studies that I've seen increase

00:08:01.620 | one of the markers of inflammatory tone,

00:08:04.980 | high sensitivity to CRP, by about two to three X.

00:08:08.280 | It seems to make the hypothalamic-pituitary-adrenal axis

00:08:13.420 | more rigid so that you can't kind of roll with the punches

00:08:18.300 | and wax and wane in terms of cortisol production

00:08:20.820 | the way that you can off the birth control pill.

00:08:23.260 | It can affect thyroid function.

00:08:26.860 | I'm thinking of the slide that I have

00:08:29.900 | that has like 10 problems

00:08:32.420 | associated with the oral contraceptive,

00:08:33.860 | but that's what I can remember right now.

00:08:35.860 | - That's very helpful.

00:08:36.900 | And it makes me wonder whether or not,

00:08:39.160 | if on the one hand oral contraceptives

00:08:41.940 | are protective in women against ovarian cancer,

00:08:44.220 | but then they have these other issues.

00:08:45.580 | - Yeah, there's one other I wanna mention.

00:08:46.980 | - Please.

00:08:48.140 | - Anytime you take oral estrogen,

00:08:50.540 | it raises sex hormone-binding globulin.

00:08:52.980 | And you've talked to other podcast guests about this,

00:08:55.460 | Kyle, I think.

00:08:56.900 | Sex hormone-binding globulin, I think of as a sponge

00:09:00.320 | that soaks up free estrogen and free testosterone.

00:09:05.000 | So when you go on the birth control pill,

00:09:06.800 | you raise your sex hormone-binding globulin.

00:09:09.100 | It soaks up especially free testosterone.

00:09:12.480 | And for some women, it's not a big deal.

00:09:15.880 | They don't notice much of a difference.

00:09:17.840 | But then there's a phenotype,

00:09:19.620 | maybe related to CAG repeats on the androgen receptor,

00:09:24.160 | who are exquisitely sensitive to that decline

00:09:27.320 | in free testosterone.

00:09:29.240 | So this then opens the portal of talking a little bit

00:09:32.020 | about testosterone in women.

00:09:34.040 | So we've mentioned already that it's the most abundant,

00:09:37.360 | biologically the most abundant hormone in the female system.

00:09:40.960 | Even though men make almost 10 times as much

00:09:43.480 | or even more than 10 times, it is so important for women.

00:09:47.360 | It is essential to so many things,

00:09:49.360 | not just sex drive and muscle mass

00:09:51.640 | and seeing a response to resistance training,

00:09:54.520 | but also confidence and agency.

00:09:57.320 | And so those women who are so sensitive

00:10:00.280 | to their testosterone level,

00:10:01.440 | they've got this high sex hormone-binding globulin,

00:10:03.960 | their testosterone declines.

00:10:06.360 | What they describe is vaginal dryness,

00:10:10.240 | maybe a decline in sex drive.

00:10:12.600 | But there's also this bigger issue

00:10:14.800 | related to confidence and agency,

00:10:16.440 | even risk-taking from studies that we've done

00:10:18.920 | with MBA students that I think is a serious problem.

00:10:22.060 | Maybe the most important out of all of these things

00:10:25.600 | is that it can shrink the clitoris

00:10:27.200 | by up to 20%, 20%.

00:10:30.840 | - And that includes a regression of the nerves

00:10:33.640 | that innervate the clitoris, is that?

00:10:36.400 | - That's a very good question as a neuroscientist.

00:10:38.600 | - Yeah, I would think used to teach

00:10:40.920 | the neural side of reproductive health.

00:10:43.000 | We need to do a series on sexual health.

00:10:44.440 | Maybe you would co-host that with me.

00:10:45.680 | - Sure.

00:10:47.080 | - We could certainly use your expertise.

00:10:49.160 | I think, yeah, that's a dramatic number.

00:10:53.200 | - Yeah, but then let's go back to the sacred marketing.

00:10:55.680 | If I've got a woman that I think

00:10:57.480 | should not be on the birth control pill,

00:10:58.880 | maybe she's taking it for acne,

00:11:00.200 | or she's taking it 'cause her periods

00:11:01.840 | were a little painful.

00:11:02.960 | What I'm gonna do is say,

00:11:05.080 | let's leverage these other ways

00:11:07.160 | of making your period less painful.

00:11:09.400 | Let's take the message of your painful periods

00:11:12.680 | and figure out, okay, is it your inflammatory tone?

00:11:16.080 | And we give you some fish oil and SPMs,

00:11:18.000 | maybe a little aspirin when you've got your period.

00:11:20.040 | Like, let's find some other ways to deal with it

00:11:22.240 | than to take the oral contraceptive,

00:11:24.320 | which you have not received informed consent about,

00:11:27.480 | because it can trick your clit by up to 20%.

00:11:30.760 | Now, that usually convinces most people

00:11:32.840 | to come off of it. - Is that reversible?

00:11:35.360 | - The elevation in sex hormone binding globulin

00:11:38.680 | does not seem to go away

00:11:40.760 | when you come off the birth control pill.

00:11:43.440 | To me, that is the biggest problem

00:11:46.440 | with prescribing oral contraceptives.

00:11:48.840 | (upbeat music)

00:11:51.440 | (upbeat music)

00:11:54.040 | [MUSIC PLAYING]

Benefits & Issues with Birth Control | Dr. Sara Gottfried & Dr. Andrew Huberman

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