What are your thoughts on sort of pure estrogen birth control? This is what I learned when I was in college is that birth control is basically tonic estrogen. So constantly taking estrogen, estrogen, women are taking estrogen so that they don't get the estrogen priming of progesterone, you're not getting any ovulation.

And I've known women that have been taking, or that took oral contraception, as like estrogen pills basically for five, 10, 15 years. Are there long-term consequences of this as it relates to pregnancy, PCOS, menopause? If so, what are some of those consequences? What are your concerns? What do you like about oral contraceptives?

What do you dislike about them? - I like how balanced you ask that question. So women who take oral contraceptives, as long as you're describing like 10 years or longer, we call those Olympic oral contraceptive users. In terms of benefit, I think that, especially when they first came out and even now, it gives women reproductive choice, and that's essential.

As you may know, our reproductive choice has been declining recently. So I'm a big fan in that regard, and we've got a lot of data to show both the risks and also the benefits of it. So I'll speak first into the benefits because I'm gonna get on a soap box a little bit about the risks.

So we know that it reduces the risk of ovarian cancer. So there's something about this idea of incessant ovulation that is not good for the female body. So if you look at, for instance, women who are nuns, who don't take oral contraceptives and they have a period every single month of their reproductive lives, they have a greater risk of ovarian cancer.

So if you look then at women who have several babies and they've got a period of time when they're pregnant that they're not ovulating, and then they breastfeed for some period of time, they have a lower risk of ovarian cancer. So oral contraceptives help with reducing ovulation and reducing risk.

We know that if you take the oral contraceptive for about five years, it reduces your risk of ovarian cancer by 50%. And that's significant because we're so poor at diagnosing ovarian cancer early. There's really no method that's really effective. We use CA-125 and ultrasound screening, especially in women who are at greater genetic risk.

But even that, often we diagnose it in a later stage. - Maybe just because that statement is gonna highlight for a number of people the question of what are some of the earliest symptoms that people can recognize without a blood test? So is ovarian cancer, is it gonna be pain?

- So the problem is the symptoms are so vague and they're so nonspecific. One of the most common symptoms is bloating. And we've already talked about constipation. We've talked about how women have this longer GI track. And so bloating is a really common experience for most women. You can have bulk symptoms, feeling like your lower belly is kind of pressed out.

So the way that we inform women in terms of watching for this is to get regular gynecologic exams for women who are at high risk or they have, for instance, an ultrasound for some reason and it shows a mass that we're concerned about. There's a way to triage that in terms of what kind of evaluation that they need.

And that's the situation where you might get a blood test called the CA-129. CA-125. Yeah, the problem is the symptoms are so vague. It could be, it depends on how big the tumor is, how much bulk you have, what it's pressing on. - So if taking estrogen and thereby reducing the frequency of ovulation lowers the risk of ovarian cancer, should women that are, even women who are not sexually active, so they're not actively trying to get pregnant or avoid getting pregnant, but if they're not sexually active, then the probability of conceiving unless they go through some IUI or some other route is very low as far as I know.

That's what I was taught in high school anyway. Would they be wise to suppress ovulation for periodically using hormone-based contraception just so that they can offset the risk of ovarian cancer? - That's a very rational question. And I would say that's what mainstream medicine has had at its back to recommend oral contraceptives, not just for women who are seeking contraception, but for acne, for painful periods, for really kind of the drop of a hat, they're prescribing oral contraceptives.

That's what I was taught to do. But there's so many consequences. And I think the issue here is more about consent because in OB/GYN, and I started out as a board-certified OB/GYN and I now mostly see men, but I was taught as an OB/GYN to convince women to go on the oral contraceptive.

And I think a lot of that is pharmaceutical influence. So maybe we could talk about the risks and why the answer is no to your question. - As we do that, could I just ask, is the so-called ring, it used to be called the NuvaRing, maybe that's a brand name, but when I was in college, there was all this discussion about the ring, right?

By both men and women for reasons that don't belong on the podcast, use your imagination folks. So is the ring, obviously it's not oral, it's not oral hormone contraception, but it's hormone-based, right? The ring is releasing estrogen locally as opposed to taking it orally, but would you slot it under what you're about to tell us in terms of the concerns?

- So we have less data about the ring. So the oral contraceptive is two hormones, it's ethinyl estradiol, and it's a progestin. So it's not the normal progesterone that your body makes, that your ovaries make and your adrenals make, it is a synthetic form of progesterone. And it is the same progestin, similar, same class, that was shown to be dangerous and provocative in the Women's Health Initiative.

So I'm not a fan of progestins, I do not recommend them for any woman, unless the consequence of not taking them is surgery or some other, unless it gives them some freedom in some way. So I don't like progestins. The NuvaRing is estrogen plus progestin, but it's released transdermally through the vagina.

So given the way that it's delivered to the vagina, the doses are lower than what's taken orally. But in terms of some of the risks that I'm about to talk about, we don't know about much of the data. We think that it's similar, there's probably a spectrum of risk, and the NuvaRing is a little more towards the middle than what I'm talking about with oral contraceptives.

Are you ready for that? - Yeah, I'm ready for the risks. - Okay, so like with almost any pharmaceutical, the oral contraceptive depletes certain micronutrients. So magnesium, there's certain vitamin Bs that are depleted. It also affects the microbiome. That data is not as strong, but there seems to be some effect, and there's also an increased risk of inflammatory bowel disease in autoimmune condition.

It increases inflammatory tone. So the studies that I've seen increase one of the markers of inflammatory tone, high sensitivity to CRP, by about two to three X. It seems to make the hypothalamic-pituitary-adrenal axis more rigid so that you can't kind of roll with the punches and wax and wane in terms of cortisol production the way that you can off the birth control pill.

It can affect thyroid function. I'm thinking of the slide that I have that has like 10 problems associated with the oral contraceptive, but that's what I can remember right now. - That's very helpful. And it makes me wonder whether or not, if on the one hand oral contraceptives are protective in women against ovarian cancer, but then they have these other issues.

- Yeah, there's one other I wanna mention. - Please. - Anytime you take oral estrogen, it raises sex hormone-binding globulin. And you've talked to other podcast guests about this, Kyle, I think. Sex hormone-binding globulin, I think of as a sponge that soaks up free estrogen and free testosterone. So when you go on the birth control pill, you raise your sex hormone-binding globulin.

It soaks up especially free testosterone. And for some women, it's not a big deal. They don't notice much of a difference. But then there's a phenotype, maybe related to CAG repeats on the androgen receptor, who are exquisitely sensitive to that decline in free testosterone. So this then opens the portal of talking a little bit about testosterone in women.

So we've mentioned already that it's the most abundant, biologically the most abundant hormone in the female system. Even though men make almost 10 times as much or even more than 10 times, it is so important for women. It is essential to so many things, not just sex drive and muscle mass and seeing a response to resistance training, but also confidence and agency.

And so those women who are so sensitive to their testosterone level, they've got this high sex hormone-binding globulin, their testosterone declines. What they describe is vaginal dryness, maybe a decline in sex drive. But there's also this bigger issue related to confidence and agency, even risk-taking from studies that we've done with MBA students that I think is a serious problem.

Maybe the most important out of all of these things is that it can shrink the clitoris by up to 20%, 20%. - And that includes a regression of the nerves that innervate the clitoris, is that? - That's a very good question as a neuroscientist. - Yeah, I would think used to teach the neural side of reproductive health.

We need to do a series on sexual health. Maybe you would co-host that with me. - Sure. - We could certainly use your expertise. I think, yeah, that's a dramatic number. - Yeah, but then let's go back to the sacred marketing. If I've got a woman that I think should not be on the birth control pill, maybe she's taking it for acne, or she's taking it 'cause her periods were a little painful.

What I'm gonna do is say, let's leverage these other ways of making your period less painful. Let's take the message of your painful periods and figure out, okay, is it your inflammatory tone? And we give you some fish oil and SPMs, maybe a little aspirin when you've got your period.

Like, let's find some other ways to deal with it than to take the oral contraceptive, which you have not received informed consent about, because it can trick your clit by up to 20%. Now, that usually convinces most people to come off of it. - Is that reversible? - The elevation in sex hormone binding globulin does not seem to go away when you come off the birth control pill.

To me, that is the biggest problem with prescribing oral contraceptives. (upbeat music) (upbeat music)