What doctors wish patients knew about birth control

AMA News Wire

What doctors wish patients knew about birth control

Aug 1, 2024

Social media platforms—particularly TikTok—have become hotbeds of misinformation about birth control, with highly persuasive videos vilifying hormonal contraception.

Myths and misinformation in circulation have caused significant concern among physicians as they see an increasing number of women discontinuing their contraceptives.

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In this installment, Kimberly Dawn Warner, MD, an ob-gyn and chair of government relations at Colorado Permanente Medical Group, and president elect of the Colorado Medical Society, debunks many of the birth-control myths that have been circulating on social media.

Colorado Permanente Medical Group is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“Patient-centered contraceptive counseling is so important,” Dr. Warner said. This means uncovering what patients want from birth control, their lifestyles, if they are thinking of getting pregnant, if they want their periods to stop and if they want other benefits from the contraception such as improvement in acne, decreased length of or pain from periods.

“It’s really important that we have those conversations upfront with our patients around all of this,” she said. “Have a discussion with your doctor about what your goals are so we can get an idea of what you want from birth control.”

There are many different types of birth control available. These include long-acting reversible contraception options such as implants and intrauterine devices (IUDs). Oral contraceptives, also called birth-control pills, are also an option.

“When we talk about efficacy, the standard is if you had 100 fertile women not using birth control for one year, 85 would get pregnant,” said Dr. Warner. “With implants, vasectomies, tubal occlusions, IUDs—the methods that don’t have human error associated with it or birth-control pills taken perfectly—there is a less than 1% chance of pregnancy.”

“Then pills not taken perfectly, you put the patch on a little late, the birth-control ring or you were delayed in getting the injectable—things that might have a little bit of human error involved—about 4% to 7% pregnancy rate,” she said. “And then condoms, diaphragms, sponges and withdrawal: over 10%.”

Some people believe that taking birth control will make it harder for a person to get pregnant in the future. That is false.

“What makes it harder to get pregnant is aging,” said Dr. Warner. “Our fertility starts to decline as we age, so that has an effect on getting pregnant, but usually you restart where you left off.”

The exception is injectables because they “can delay your ovulation once you stop it for up to 18 months,” she said. “So, it affects fertility for that amount of time, but then you reset to right where you were before starting birth control.”

“It is a foreign body in the uterus, so we have a good discussion with patients about if they are a good candidate for an IUD and what they want from it,” Dr. Warner said. “We have the hormonal IUD, which can last about seven years and we have the copper IUD, which can last about 10 years.

“Do you want that length of birth control? Some women just want it for two or three years in between their kids. That’s great. It’s all about the counseling, but there are risks of insertion,” she added. This may include “infection, bleeding, perforation of the uterus, putting a hole in the uterus at the time of insertion, so sometimes the IUD ends up in the abdomen, but this is very rare.”

“If you have multiple sexual partners, it is probably not a great idea because you have increased risk of sexually transmitted infections, which can go up around the IUD and cause an infection in the uterus,” Dr. Warner said, noting “with any form of birth control, any new sexual partner, please use condoms to decrease risk of sexually transmitted infections and get tested regularly.” 

One misconception is that IUDs cannot or should not be used prior to having had a baby.

“The thought is that the uterus is bigger after you’ve had a baby—it’s been stretched out,” Dr. Warner said, adding “the cervix has been dilated before, so the insertion might be easier, and the expulsion of the IUD might be less.”

That may be particularly true “postpartum, because the cervix has been dilated fairly recently and the uterus is still a little enlarged,” she said. But none of that should be taken to imply that IUDs are off-limits to other women.

“IUDs are great,” Dr. Warner said. “We put them in teens, and we actually have a little bit smaller IUD because some women just have a smaller uterine cavity,” Dr. Warner said. “Anybody can get an IUD who is the correct candidate in the first place.”

She added that “for teens who have not had their cervix dilated before, we use numbing medication and dilate a little bit. It’s all about how you counsel your patient and what they’re anticipating.”

While taking the pill or any hormonal birth control does not directly cause weight gain, there are methods that may cause it in some people.

With birth control pills, “mostly it’s water-retention weight, so there’s probably a two- to three-pound increased weight gain, particularly when you start birth-control pills,” Dr. Warner said, noting that progestin, a synthetic form of progesterone, can lead to increased appetite, which may lead to weight gain.

This includes the birth control shot, hormonal IUDs and certain pills. But many people use these methods without gaining weight too.  

“That is why I always tell my patients that it makes you more hungry and that makes you gain weight. It’s not the actual medication,” she said. “Birth control in terms of water retention weight and then progesterone components of other hormonal methods can make you more hungry, leading to weight gain.” 

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“The main myth out there is that birth control causes breast cancer,” Dr. Waner said. “Estrogen can stimulate already existing breast cancer. So, if you have breast cancer or you’re a breast cancer survivor, we do not put you on birth-control pills.”

“But there is no restriction needed with a family history of breast cancer or person history of the BRCA genes in women. We can still give them birth-control pills,” she explained. “We do have decreased risk of endometrial cancer and decreased risk of ovarian cancer. And the longer you use the pills, the more protection that gives you.”

“If you’ve been on birth-control pills for 10 years, your risk of endometrial cancer decreases by 50%, ovarian cancer by 27% and colon cancer by 18%,” Dr. Warner said.

Another myth that is circulating is “that all antibiotics can decrease  the efficacy of birth control pills and that’s not the case,” Dr. Warner said. “There’s one particular antibiotic called Rifampin which we use for treatment of tuberculosis

“That one will affect the efficacy of birth control pills, but in general, antibiotics do not affect birth control pill efficacy,” she said.

“Women with depressive disorders can use all methods of birth control,” Dr. Warner said, emphasizing “it’s all about counseling and noting this might increase mood changes. So, we need to be aware of that.”

“One of the benefits of birth-control pills is they decrease premenstrual dysphoric disorder. This is caused by fluctuating hormone levels throughout the cycle. Birth control pills create  an even level of estrogen and progesterone,” she said. “So if the depression is menstruation-related, it can get better.”

“Well-treated depression is incredibly important for women on birth-control pills,” Dr. Warner said.

“The reason you take a birth-control pill every day is because of the half-life that is needed to maintain the level of estrogen and progesterone to inhibit ovulation. That’s the way birth-control pills work,” Dr. Warner said. “You don’t need to ‘cleanse’ because it’s out of your body pretty quickly.”

“We really recommend if you are sexually active, not intending to get pregnant, to stay on your birth control,” she said. “Don’t just stop for a couple days or a month. Continue on it.”

There are some people who should not be on birth-control pills or who need further monitoring. For example, women with “depression need further monitoring,” Dr. Warner said. “If you’re an over 35-year-old smoker, we don’t give you birth-control pills, combination hormones, because it can increase the risk of stroke and clot.”

Additionally, if your hypertension is not controlled, “we don’t give it because of your increased risk of stroke,” she said.  “If you have lupus, we  do not recommend birth control pills because you have an increased risk of stroke and clot too.”

“If you have something called thrombogenic mutations … that can increase your risk of clot and stroke too,” Dr. Warner said. “Have you had a prior stroke, clot or myocardial infarction? We don’t recommend birth-control pills. We want you on progesterone-only methods instead.”

It is also important to share if you have migraines, especially when it is with aura where “you have the visual changes, or light sensitivity symptoms,” she said. “Those are because of the blood vessels in the brain are spasming. That accounts for about 25% of women with migraines. Then the migraine without aura, 75% of women.”

If you have migraines with aura, we do not give combination birth control pills because of their increased risk of possible stroke. But migraine without aura is safe,” Dr. Warner said.

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As with other medications, there are some side effects to expect with birth control pills such as “irregular bleeding, nausea, depression or mood change,” Dr. Warner said. With “irregular bleeding, sometimes we just need to get you through a certain period of time—three months on a pill—or change the dose of the pill.

“You might need a little bit more estrogen, a little bit more progesterone or a different kind of progesterone to make sure that you don’t have that breakthrough bleeding,” she added. “The copper IUD—so, nonhormonal IUD—can lead to heavier, crampier, longer periods, but is a great method of birth control” because of its efficacy.

With “the hormonal progesterone IUDs, initially there may be irregular bleeding as that uterine lining is thinning when implanted. But then we can say you’ll have either just lighter, shorter, less crampy periods or maybe no periods at all the longer it’s in place,” Dr. Warner said. “Injectables and implants, irregular bleeding is the No. 1 reason women take them out or stop them.”

If any of these side effects do occur, it is important for patients to talk with their physician, who can “tweak dosages,” she said.

“The most important thing is having that relationship with your doctor and talking about everything that you want from your birth control,” Dr. Warner said.