This is the first post in a series of three about birth control. It became apparent in Season One of the Fempower Health Podcast that there's a lot of questions and potential controversy about birth control.
I wanted to get an MD perspective, a period expert perspective, and then the last one ends with a new innovation in birth control for you to consider. Here, I talk to Dr. Sophia Yen, who is an adolescent medicine specialist and co-founder of Pandia Health.
Transcript
Georgie Kovacs: What are the benefits of birth control outside of preventing pregnancy?
Dr Sophia Yen: I listened to your interview with Dr. Briden, and I agreed with many of her points, and then she said some things, and I was like, I'd like to see the paper on that. I felt that there was definitely common ground on “to each their own.” But my belief is that the benefits outweigh the risks. The latest papers have said, the decrease in ovarian endometrial and colorectal cancer outweighs the slight increase in breast cancer.
Every time you have growth, you can have uncontrolled growth. And that is cancer. Every time you pop out an egg, you risk ovarian cancer. If we can quiet down the ovaries, be it through pregnancy or through the pill, the patch, the ring, or any other method that suppresses ovulation, we can decrease your risk of ovarian cancer by 50%. There is no other way to decrease your risk of ovarian cancer, other than taking out your ovaries, which I would not recommend.
The other thing is colorectal cancer. I find that fascinating. I think I heard on your previous podcasts that we, as women suck it up, we suffer. One in 10 women have endometriosis. One in 10 women have polycystic ovarian syndrome.
The pain of endometriosis is so horrific, and just because it runs in your family doesn't mean that it has to be. Life is actually better with the hormones being stable rather than up and down and up and down and up and down.
And so to me, if you're not trying to get pregnant, there's no point in building this lining and bleeding.
Georgie Kovacs: Why is it beneficial to not have a period? Isn’t that what women’s bodies are designed to do?
Dr Sophia Yen: We aren't supposed to be having as many periods as we're having. We're having 350 to 400 in our lives. And if you look at the Dogon tribe and Mali, which Dr. Beverly Straussman studies, the women are banished in the menstruation hut and they have a hundred periods in their lives.
We're having 350 to 400, because we have hyper-nutrition. We start our periods at 12, they start their periods at 15, 16, they have eight babies. We have two babies. They breastfeed for 12 months, exclusively. We breastfeed for zero, three or six, and they have seven or eight periods a year. We have 13 periods because as soon as you hit a hundred pounds or 22% body fat, that's when you get your period. As you know, we have tons of calories in the industrialized world and in the Dogon tribe in Mali, they don't have as many calories.
They're incessantly, pregnant or breastfeeding. How many periods do you have when you're pregnant? Zero.
How many periods do you have incessantly breastfeeding? Zero.
How many periods do we have over here? Where we're only having two children? Not saying we should have eight children, but I'm seeing the more natural state would be a hundred periods in our lives instead of 350 to 400.
Here, we have ovarian cancer, endometrial cancer. There, there is none.
And it's not like they're dying at 20. You know, we're comparing apples to apples. They too are dying at 70, 80 years old. And every single time you build that lining you risk cancer.
Georgie Kovacs: On the flip side, when women are struggling with PCOS, endometriosis, Hashimoto's disease, it just seems like medicine is “here is a problem, take a medication.”
The healthcare system is evolving where now, it's a 10-minute doctor appointment. It's not diving deep at the root cause. Also, there aren't enough clinical trials in women's health.
So now we have this situation where the trials aren't there and yet women are having to make these decisions with 10 minute appointments. You've got naturopaths that view it one way, you know, allopathic doctors have the traditional MDs, it's all about clinical trials and how do we know?
Dr Sophia Yen: I'm all about choice. It's about presenting the data out there, but looking at what has numbers behind it.
The pill, the patch, the ring, the IUD, the implant, all of those are out of your system within three days. The shot is a different matter because a shot sits in your fat and it could take nine months for it to get out.
The birth control pill, patch, ring makes you infertile while you're taking it, because that's the goal, that's birth control. 10% of women will get PCOS in their life, and the data shows this number does not increase because of the pill.
Georgie Kovacs: Much of the concern with birth control is the artificial hormones and what that can do to the body. Is it the way the clinical trials are designed that are not helping us get to the bottom of this, or is it that people potentially have more concern than there is?
Dr Sophia Yen: There are different approaches. When you are a naturopath (ND), your tools are this. So your answer to everything is this. When you're an allopath (MD), your tools are drugs and surgery. So your answer to everything is drugs and surgeries. And you believe in drugs because that's why you became an MD instead of an ND, right?
I think they can come together. If both sides bring the same scientific rigor and they absolutely can. I've absolutely seen studies where they did 50% sham acupuncture and 50% real acupuncture. I've seen 50% fake spinal manipulation and 50% true manipulate ideation, you know? And so if you do those studies with those numbers, then we can talk. But if you're not going to have the data, then we are just talking in the air, right?
We can't compare hearsay to data, and I think there's a concern about artificial hormones, but the question is, there's so many different hormones, there's so many different levels of hormones. That's the other thing I want to get across is that there are 40 different birth control pills. There are eight different progesterones. There are two or three different levels of estrogen and it matters how it comes to you. So if you get it, intra-vaginal only, it's a lower dose and it skips your stomach. If you take it by pill, it went through your stomach. If you use a patch, it's going to be a much higher level of estrogen. So one question you had brought to me is in choosing artificial hormones, how do I choose the one that's best for me?
The key is sometimes you have to trust the expert, but I absolutely agree that sometimes you, the patient, needs to be the expert.
If I were sick, I would want the most specialist or the specialist because they've been studying this thing and they don't have to know all hundred things. They know their one thing very well.
Georgie Kovacs: Women are still in a position where most have access to either no healthcare or if they do, they're going to the OB GYN, not the specialist. So if one were going to the OB GYN, who isn't the specialist, what should they ask? What is normal?
Dr Sophia Yen: First, what is normal? One of the number one causes of missed school and work in a woman under the age of 25 is her period, horrible pains, heavy bleeding anemia from it, migraines from it, depression from it. And that is sad to me because it's something we can absolutely treat. So if you are missing school or work because of your periods, please see a medical professional and get treated.
The first-line treatment is ibuprofen 600 milligrams, three times a day with food. Do not take it on an empty stomach, or you come back to me with an ulcer for up to five days and take it as soon as you know your period's coming. You want to stop the pain before it blows up like a giant monster. Okay. And so 600 milligrams, three times a day with food ASAP for up to five days that will decrease the amount of blood that comes out by 30% and therefore decrease the pain and decrease the overall situation, failing that, go see somebody.
Also, if you notice that your hands are cold, you're a little pale here and you're tired. You may have anemia. So please ask your physician to check you for anemia. If you're feeling cold, tired, and pale and craving meats all the time, then these are signs of anemia.
Iron deficiency happens before anemia and most doctors say they won’t check you for iron deficiency unless you have anemia. But as I mentioned before, there's been at least three studies that I could cite to you in children showing that if you're iron deficient, but not anemic, you're going to have mental performance. You'll be at a greater risk for lower IQ, lower math scores. And for young girls dropping out of school. So if you have that in your doctor's willing, you can check for iron deficiency, preceding anemia.
So if you ask me what is the best birth control method out there? The IUD with hormone is one of the best methods out there because of its efficacy, as well as the implant. And also just set it and forget it. The IUD with hormone five to seven years, the implant is three years possibly. I think the latest research showed it could even go out to five years.
Georgie Kovacs: Tell me more about how you help women decide which is best for them.
Dr Sophia Yen: So we at Pandia Health (birth control deliver) are here assuming, you know which one you want. Okay. That, and the reason is that I think 80% of the country is in a contraceptive desert where they can't access everything and all the options.
We are a stop gap until you can access the IUD or the implant, because obviously we can't do that by mail.
We're also here because different methods are good for different people. So the IUD with hormone only has progesterone, which is a great thing because it doesn't have the blood clot risk of estrogen. But it's a negative thing because as you mentioned, there isn't enough research. There isn't enough funding for women's health and birth control.
There's only one hormone in the IUD. And as I mentioned, there's eight different hormones that you can choose from. The hormone that's in the IUD is levonorgestrel, which is a very old school one and known to have more, what I call “man's side effects.” So it’s bad for your lipids, acne, hairiness, but it's a lower dose. So the women don't have as many side effects. And I haven't heard as many side effects, but again, if you're the one out of a hundred women that gets a zit and you get a zit on this thing, you're not going to like it.
The implant has a derivative of the progesterone that I like. So the progesterone that I would recommend, this is my gift to all your listeners is desogestrel. So norgestimate was the one that a lot of physicians still think they're cutting edge, but we found that it doesn't work as well in Asians, Latinos, and African-Americans. Desogestrel comes in a pill format. It is a reset control pill. It's estrogen and desogestrel.
The other tip for you all is I'm an adolescent medicine specialist focused on bone density is in the back of my mind, making sure that young women get 1200 milligrams of calcium each day, but also the bone density.
If your physician isn't as aware or again, there's controversy amongst physicians, the Children's of Pennsylvania Hospital is of one group and Stanford is of another group. I'm a Stanford.
So the Stanford docs believe if you are under 30, you should be on. If you're going to be on a pill, not saying you have to, but if you're going to be on a pill beyond one with at least 30 micrograms of estrogen, because less than that, it's bad for your bone density. They've shown that if you're at 20 micrograms and you compare it to somebody on 30 micrograms, your bone density is not good. Once you're 30 and above, we stopped putting on that bone density. And so then you can go on whatever dose of estrogen you want.
There's a new ring that’s been out for a year, and I thought it was amazing. You don't need to go and have this invasive procedure, but it’s about getting access.
Then I saw they advertised having the lowest hormone levels. However, the estrogen levels are 13 micrograms, but it should be 30. So if you're age 30 and above, go for it. If you're below age 30, I would worry. And as you said, we don't have the research. We haven't done the research to see what is the long-term effect of somebody being on 13 micrograms of estrogen. We know with the pill at 20 micrograms, it is not good for your bones. 30 micrograms would be better. When they tested, they weren't looking at bone density. These are the unintended consequences that we will know with time.
Georgie Kovacs: When a youth first gets her period, it takes even up to 10 years for it to normalize. There is concern that because of this lack of understanding, youth may be put on birth control too fast before the body can naturally get to its rhythm. Now, granted, I think everyone agrees if it's really bad periods, that's another question of what to do, but it shouldn't be assumed right away if it's bad that that's forever and to start the birth control pill. What do you recommend?
Dr Sophia Yen: In adolescent medicine, we teach all the pediatricians, but we don't teach family practice. We don't teach OB GYNs. We don't teach Internal Medicine. We do not teach those other specialties that it's totally normal to have wack periods for the first two years after you get your period. And if you really look at the research, the later you got your period, the longer you can have whack periods. That's why it took you so long to get your first period.
The rule of thumb is for two years after you get your period, it can be totally irregular. And just so you know, for most pediatricians are really afraid of birth control pills. So the goal is not to prescribe the birth control pill, but maybe a family practitioner, maybe an internal medicine, or somebody else is more comfortable because they do it in adults.
What we teach adults is, if a woman doesn't have a period for three months, she has polycystic ovarian syndrome, unopposed endometrial growth, and she's at risk of endometrial cancer. And so in the name of preventing endometrial cancer, they want to help you clean out to block that unopposed, endometrial growth, at least three to four times a year.
And so if you weren't a pediatrician trained by an adolescent medicine physician and you were like, Oh goodness, you started your period and you haven't had it for three to six months. You might have uncontrolled endometrial growth. Let's throw some birth control pill at you, but most pediatricians won't touch birth control.
Georgie Kovacs: What would be your guidance then for adolescents with irregular or heavy bleeds?
Dr Sophia Yen: Know that it can be totally irregular for the first two years. You do not need to go on birth control, pill, patch, or ring if it's irregular, But if it's happening like every week and she's resulting in anemia, tired, cold, or if there's excessive bleeding or it's so horrifically painful, she's missing school, then obviously you should do some treatment of some sort.
But if it's just irregular and has gone for three months or whatever, we write it off as fine for the first two years after the period is, as I mentioned, if you really want to get nitty gritty on the research, they've shown, if you start later, we'll give you three years to be whack.
Two years is the rule of thumb.
In terms of the amount of blood, if you're bleeding through your clothing, then either you weren't, you didn't have anything in you weren't prepared. The normal amount of blood is 30 to 80cc, which is two tablespoons.
Don't take aspirin because aspirin thins your blood. Although ibuprofen does a similar thing, it has effects on the muscle of the uterus and the contractions and stuff. And so by putting the ibuprofen, you actually have less blood loss.
If your daughter is bleeding through clothing, I'd actually say you should get checked for Von Willebrand disease. That is the first appearance of Von Willebrand disease in a young woman. And hopefully she didn't lose so much blood that she needs to be transfused. But that is like what the physician said, you need to draw the lab tests. And an ER doctor needs to draw the lab test for one real brand's disease before they treat you. Because once we treat you with hormones, it messes up the levels and they can't measure it accurately.
Georgie Kovacs: You mentioned brown blood. My understanding is if it's brown, it means it's left over from the previous cycle and that your uterus didn't properly clear out and in Eastern Medicine, this is not the best thing. What is the normal color?
Dr Sophia Yen: I haven't actually studied the color much of the blood. I have to just speak from personal experience. I've been on the birth control pill forever, so I don't have normal periods. Don't take my word on it, but I think it's the amount of blood and the speed of the blood.
Georgie Kovacs: There's still no perfect answer, but honestly, with women's health, I don't know how much there ever will be because each person's body is so different and we just do the best we can with the data. Hopefully, what women understand here is if you're still not feeling right with whatever you're doing, keep asking questions and keep seeking advice.
Georgie Kovacs: What is your greatest hope for women's health?
Dr Sophia Yen: If you're bleeding one week out of four, you don't have to. We have the technology to turn that off and it can decrease your risk of endometrial, ovarian and colorectal cancer. There's a slight risk of breast cancer. And you have to look at those risks and weigh them with your provider or with your own self and decide the benefits and the risks.
In my ideal world, we would have a safe way to turn off your periods. And then when you want to have a baby, bring it on.
Another ideal world is that we have enough money to fund all the birth control options that I would love.
Georgie Kovacs: Thank you. I really appreciate your time. And ladies, you now have all the sides, so it's up to you to, to now have that conversation with your doctor and do what's right for you.
Resources
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About Dr Sophia Yen
Sophia Yen, M.D., M.P.H. is the CEO and Co-Founder of PandiaHealth.com, birth control delivery. She has a passion for making women’s lives easier and preventing unplanned pregnancies and co-founded Pandia Health because she believes no one should suffer from “pill anxiety” - the fear of running out of birth control and the stress of having to obtain birth control each month.
Educating the public about cutting-edge, evidence-based medicine, she has spoken at SXSW, TEDxBerkeley, TEDxSiliconValleyWomen, high schools, Boys and Girls Club of the Peninsula and lectured physicians and students at various academic institutions from Stanford Medical School to UCLA Internal Medicine to UC Riverside to MIT and more.
About Fempower Health and Its Founder
Georgie is the founder and host of the Fempower Health podcast, a top 10 women’s health podcast with 5 stars on Apple. She is an advocate leveraging her 20+ years in healthcare and personal fertility journey to transform women’s healthcare, answering your health questions. She brings on top experts in women’s health with the aim of educating women about their bodies to have more empowered (and speedy) health journeys.