I get a lot of questions about birth control, but on my social media handles. - Don't we all, don't we all? - To be clear. It's a vast topic for exploration, but along the lines of what we're talking about now, I've heard, and I suspect it may not be true, but tell me, is there any evidence that taking birth control can disrupt the process that you just described?

And when we talk about birth control, we should probably define what we're talking about. So there are hormone-based birth controls, AKA the pill. There are also hormone-based birth controls that are not in pill form. There are IUDs that are copper IUDs. There are other IUDs. Let's just talk about hormone-based contraception in females, which many of them, as I understand, are estrogen mimics or estrogen themselves that suppress ovulation.

Do they diminish or increase the number of eggs that are taken from the vault? - Fantastic question. Let's talk about what people say is the pill. So let's specifically talk about combined oral contraception, the pill which has ethanol estradiol and some type of progestin. No, contraception does not change the release of eggs out of the vault.

They are occurring at the same process and the same pathway. You're not ovulating because that estrogen does prevent FSH from coming from the brain. So you have the group of eggs still come out of the vault. There's no FSH. They just all die. The next group comes out. So when you are saying, are you gonna run out of eggs faster?

Is it gonna harm your fertility? Does birth control impair the process? The answer is no. But there's a couple important caveats. One is that the birth control pills, especially if you take them continuously or for a prolonged period of time, the body's smart and the ovaries start to say, well, we're not really doing anything.

And one of those markers of ovarian reserve we have is AMH and that's anti-mullerian hormone. And AMH is made from the granulosa cells or the cells that surround every follicle. So in the shortest way possible, more eggs in the vault, more come out every month, higher AMH. Fewer eggs in the vault, fewer come out, lower AMH.

If your AMH is being suppressed because of the birth control pill, because it's decreasing the activity of those granulosa cells, you might get a low AMH value when you've been on the birth control pill for a long time. That is completely reversible. But it can be significant. So if somebody is wanting to get an AMH level, let's say somebody comes to my clinic, they're not trying to get pregnant and they're on the pill and they're considering freezing their eggs so we're going to check their ovarian reserve.

If we draw it, I always say this, AMH may be up to 30% lower than somebody who is on the birth control pill. So we can still draw it. And if it comes back in the normal range, we feel good. But if it does come back low, we're going to have to make a decision.

Are we going to stop the birth control pill for a period of some months, use alternative contraception if you don't want to be pregnant, and then repeat this test to see if this is a true low because we do see that young women do have low ovarian reserve sometimes, or was this just suppressed because you were on the birth control pill?

So we see it impact some of the hormone testing that we can do. And I think that's an important distinction. And we can see that the longer you take it, that potentially it might actually improve your fertility if you had underlying endometriosis or some medical conditions that we see associated with infertility.

So prolonged pill users can potentially improve their fertility versus people who are trying to get pregnant that same age who were not on the pill. Those studies are complicated, right? Because of selection bias. Because if you've been on the pill for 10 years, you're a little bit older. So is it that they were preventing pregnancy and the other group potentially had some exposures so they were inherently more infertile than the group that was on the pill?

But we do know that the pill doesn't cause infertility. And I use it all the time. All the time in IVF cycles, we put people on the birth control pill because we can actually synchronize that group of eggs that comes out of the vault to grow together. Because your body doesn't want to have 20 babies at one time, right?

And what we're trying to do with IVF, get 20 eggs to grow if that's what's out of the vault, really goes against the check and balance of the human body to not have 20 babies at once. - Why is it that males who take testosterone, synthetic testosterone, it shuts down their own testosterone production and sperm production, but females who take estrogen in the form of birth control pills, it doesn't shut down estrogen production by the ovaries?

- So I love this question. You know the answer, so I like it extra because I know you're asking. Spermatogenesis is a constant and ongoing process, right? So in women, you're born with all the eggs you're ever going to have. And what we're talking about is if we stop FSH at that moment, we're just impacting the ability to ovulate at that time.

But we're not changing this constant loss throughout the vault. Spermatogenesis, right? The sperm is made every single day, you're making brand new sperm. So 72 days for the sperm to be created in the testes and 18 days to find their way out the ejaculatory system. And so exposures that you have that stop the production of FSH and LH inhibit the development, the creation of new sperm.

So somebody who's been on testosterone will tell the brain, the brain doesn't know it's from your taking it. It says, "Hey, we have plenty of sperm, we're good. We don't need any more." So the brain then gets suppressed and doesn't make that FSH and LH, therefore not stimulating both for their testosterone production, 'cause you don't need that.

But testosterone production and sperm production go hand in hand. So therefore you're no longer making new sperm. And in fact, the longer you're on testosterone, the harder it may be to get sperm production to come back. And in 25% of people, they may not get it back if they've been on prolonged testosterone exposure.

So it's really because of what women will sometimes say is unfair, which is the fact that you're born with all these eggs and you run out of them. They accumulate the wear and tear of your life, right? We see egg quality being a huge issue and female reproduction, yet men get to have new sperm every 90 days.

They get to wash away whatever bad deeds they did and can change their lifestyle and their exposures and have very different sperm. But because of that same process, things that shut off the production of FSH, LH really impact sperm quite significantly. Is there any evidence that birth control, oral estrogen progestin-based birth control, just to keep it specific, can increase rates of cancers, can decrease rates of cancers, can lead to any sorts of disruptions in bodily function or health that's really like a rock solid result that's been seen by multiple studies, clinical trials, or are we still just in the dark about a lot of this stuff?

- Okay, so nothing is without risk. Getting pregnant's not without risk. Taking the birth control pill is not without risk. We do see that there's been a lot of not informed consent in people who are taking the birth control pill, meaning maybe they weren't educated about what all of their options were, the positives and the negatives about each one of them.

If we're gonna reference the convo to the pill, estrogen progesterone pill, important to understand that neither the estrogen nor the progesterone are the same estrogen progesterone that your ovaries make, right? It's ethanol estradiol, which your brain interprets as an estrogen, but other parts of your body may not. And then it's various types of progestins, some of which have even androgenic or male hormone-like properties, and some of which do not.

So there's a ton of variation, even the amount of ethanol estradiol that each pill has with your low low and your low pills having less, and even with the modern day average pill having a lot less estrogen than it used to. When you're on the birth control pill, your ovaries aren't making estradiol.

And that estradiol is important in growing the uterine lining, but also for the genital structures. And so we think about vaginal health and vulvar health, we certainly see that especially with continuous use. So if we distinguish, you take the pill for 21 days and you have a seven day break where you might bleed or you take sugar pills and then you take them again, a lot of people now are taking continuously where you have exposure to these compounds every single day.

- So in like the wheel, the little pouch with the wheel of different colored pills, may have seen these on the countertop in previous relationships. And then there's the ones that sometimes people just opt not to take because those are the, not the placebo, they're the sugar pills. There's no need to take estrogen during that phase.

And then they repeat. - Exactly. - Okay, but some people are taking estrogen all the way around the dial. - Continuously, it's very common right now. So people, and they're not wrong, they say, oh, well, why have a period in these little breaks? It's not really a reflection of my hormone status, which is accurate.

And so they're taking them continuously. You also have less pill failure pregnancies. So if you're using the pill for contraception, that can be a great strategy. But the longer you take them, we do see some vaginal and vulvar changes, right? And so atrophic vaginitis, people who notice increased sensitivity, decreased elasticity, increase discomfort with intercourse, increase in yeast infections, that can sometimes be seen because that environment is different.

Now, that's just one thing that can come from the pill. We also see the pill be lifesaving for other people. They have terrible PMS or premenstrual dysphoric syndrome where their mental health, when they change from high to low estrogen, it's always the change in estrogen that interferes, can cause some people to really have mental health issues that are so severe that having that stable hormone level is helpful.

And so the pill can be extremely beneficial for some people when it comes to mental health. It can be beneficial for people who have issues with very heavy periods and anemia. Instead of getting blood transfusions, taking the birth control pill might prevent the lining of the uterus from growing so much that they bleed so much.

Same thing with fibroids. People with PCOS. PCOS is polycystic ovarian syndrome. If we wanna put it very simply, you have a lot of eggs in your vault, so you release a lot of eggs every month. And what this does is the FSH signal gets diluted and so you're not responding to the normal signal and you don't ovulate.

And because the ovary is a hormone-making factory, it gets really bored when it can't make estrogen 'cause that egg's not growing, so it starts to make testosterone. So you start to see this androgen-dominant environment associated with lack of ovulation and having a lot of follicles inside the ovary that are not really responding.

- Androgenization, excuse me, androgenization of other tissues like body hair, deepening of voice. - Yeah, body hair. Typically the level of testosterone made in PCOS isn't truly deepening voice. It can if there is an ovarian tumor making testosterone or certain other conditions. But typically with PCOS, you see increase in body hair, increase in acne, and you can see some even like male pattern balding, some temporal balding of women, so some hair loss.

- Temporal balding, so like the widow's peaking? - Yeah, the widow peaking and then thinning out in these two areas. And then we see an increase in body composition towards the male level. So if we think about a male body holding your fat in your abdominal region, and if we think about the traditional female body holding more fat in the hips and thighs area, we see that when this hormone shifts in PCOS, you tend to get more abdominal fat distribution, which then leads to further insulin resistance and metabolic syndrome.

But in PCOS, because you're not ovulating, and those ovaries, each little follicle makes a tiny amount of estrogen. We'll say each little follicle, when it's not responding, will make one to two picograms of estrogen. But if you have 50 of them each month, you're having some constant estrogen exposure.

So that lining of the uterus is being constantly stimulated to grow, and you're never getting the progesterone to stabilize or the progesterone withdrawal to bleed. So endometrial cancer is much higher in people with PCOS who don't ovulate, and the birth control pill can prevent that. Any unopposed estrogen situation, because the body is made to have both estrogen and progesterone.

So we see an immense decrease in endometrial cancer, an immense drop in ovarian cancer. Ovarian cancer comes from the remodeling of the ovary. So every time you have a follicle grow, and it ruptures, and it makes the corpus luteum, and then it heals up, those are opportunities for those cancer cells to go away in that remodeling process and lead to ovarian cancer.

And because you're not ovulating on the pill, your incidence of ovarian cancer drops dramatically. 10 years of pill use has dropped the chance you get ovarian cancer by more than 90%. And of course, ovarian cancer is super hard to diagnose because the innervation to the peritoneal system is poor, and you don't have any outward signs often till late-stage disease.

That being said, could you potentially have an increase in breast cancer in some people? - By taking the pill? - By taking the pill. That's a concern, especially in people who might be predisposed to this for some other reason. - They might have BRCA mutations or something like that.

And then is there a situation where the pill certainly masks what's going on with your menstrual cycle? And I really think this is where women's health has a huge history in paternalism, meaning doctors will just tell people, this is what you're going to do. So your periods are irregular, here is the birth control pill.

And they're not explaining why or the pros and cons to it. And what happens is people are not being taught how their bodies work, and now they are because of your podcast amongst others. And now they're able to know that my period's a vital sign and I don't know what it is, because the pill is producing a different environment.

The pill's also been associated with potentially development of things like leaky gut or IBS. And so there is a definite change in your environment when you're on the birth control pill. Increased risk of blood clots because of how it's processed in the liver, increasing your clotting factors. - Can I just interrupt there?

You know, I'm aware that a fairly high percentage of people have mutations in Factor V Leiden, a clotting factor. Fewer people are, as we say, homozygous, have two deficient copies, mutant copies, I should say. But there are many people out there that have one mutant copy of Factor V Leiden.

And my understanding is that oral contraception in females can really exacerbate the Factor V Leiden mutation. Do you suggest that people get their Factor V Leiden genetics analyzed? I mean, it's pretty inexpensive to do, right? I think on a standard blood test, you can just ask for the Factor V analysis.

And it's not like a really in-depth thing. You don't have to fly to somebody that's a- - Yeah, it's a blood test. - Yeah, you don't have to fly to another country, you know, like you do for many things. - It's important to say that's not the norm, right?

Like that's not the recommendation. When you're talking about putting somebody on the birth control pill, you want to make sure they don't have high blood pressure 'cause it can increase their blood pressure. You want to make sure they don't smoke cigarettes because the combination of the pill and cigarette smoking can increase the risk of a stroke.

But the recommendation is not to screen them to see if they have any inherited clotting disorders. That said, if you ever have a blood clot on the birth control pill, 'cause you're traveling on a plane or you're just on the pill or you're living your life, you're now gonna get this extensive workup to find out if you do have that.

It's by no means wrong, and specifically you should, if anybody in your family has ever had a DVT, so a deep vein thrombosis, so a blood clot in their leg, or a pulmonary embolism or a PE, so anybody in your family has had one of those, you should 100% get worked up for clotting disorders.

And if you have something, like you carry Factor V, you should no longer take the birth control pill. And specifically the pill, because it's an oral pill and how it's metabolized in the liver is actually what is causing the change in those clotting factors because that's where they're made as well.

So it doesn't mean you can't take any form of contraception, but we do wanna make sure that we counsel you appropriately. (upbeat music) (upbeat music) (guitar music)