Episode 35: Birth control methods explained! With Obgyn Matt Zerden, MD

On this weeks episode of Ask Dr Jessica, we welcome Dr Matt Zerden, an OBGYN  who practices in the research triangle of North Carolina.  In this episode we discuss all of the various types of birth control methods available. We review the pros and cons of methods such as birth control pills, IUDs, implantable devices, rings, patches, condoms, the rhythm method and abstinence.  

Dr Matt Zerden attended college at University of Pennsylvania, attended Harvard University for medical school and he completed his residency in OBGYN and fellowship in complex family planning at University of North Carolina.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children.  Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner. 

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The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditi...

Transcript

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Hello and welcome to this week's episode of Ask Dr. Jessica I am your host, Dr. Jessica Hochman. This week. I'm excited that my guest is a good friend of mine, Dr. Matt Cernan. Dr. Xherdan is an OB GYN who attended Harvard Medical School, and he also completed a fellowship in complex family planning at the University of North Carolina. In today's episode, we are going to talk all about the various types of birth control methods that exist, including birth control pills, IUDs, implantable devices, rings, patches, condoms, the rhythm method and abstinence. Now I have to say one of my favourite parts of podcasting is creating opportunities to talk to my favourite people. I have so many wonderful memories with Matt and his wife, Lisa, back when I lived in Boston. In fact, as a side story, the first night I met my husband in 2004. I immediately visited Matt and Lisa to tell them all about this great guy that I met. So needless to say, we have a lot of history. So now I hope you enjoy this discussion with Dr. Matt Cernan. Hello, and welcome to this week's episode of Ask Dr. Jessica, I am thrilled for this week's guest. I have my dear old friend, Dr. Matt Xherdan. He's an OB GYN in North Carolina. And we're going to talk today about different methods of contraception. How are you doctors are doing? I'm doing great. Happy to be here. So before we get into our discussion, I just quickly wanted to tell everybody listening a story about you and how much I've appreciated you for so many years as a friend so you can understand how wonderful of a man, Dr. Xherdan is. So when I went to medical school, I was living in Boston. I'll make the story quick, I promise. But I moved there in the summer. And it was a really humid, humid time of year. And I lived in an apartment that was on the fourth Storey with no elevator. And it was so humid. I had no car. And Matt and his lovely wife, Lisa were my only friends in Boston. And Matt took me with his wife in his car to target helped me purchase a air conditioning unit. Because I didn't have air conditioning in my apartment, drove me back to my apartment, he walked up four flights of stairs with a very heavy air conditioning unit and he installed it in my apartment. And I will tell you from that day on he has been a hero in my eyes. So just wanted to remind you of that story even remember doing that I have big memories of I remember your nice apartment in Boston and I remember humid days, and it's hard to be up there without central air. So so at least I'm I'm eternally grateful since so thank you so much. Alright, so Matt is a very accomplished OBGYN. And I thought we would talk today about contraception. I know a lot of parents don't know how to start that conversation with their teenagers especially I thought we would go through the different types of contraception that are out there and how parents should sort of think about this topic. So first, tell us what you do. Sure. So I'm an as I said, OBGYN, and I work in Central North Carolina in the triangle area, and I am I take care of deliveries and labour and delivery, and gynecologic emergencies in a hospital. And then I'm also the Associate Medical Director of Planned Parenthood in my region and do a lot of sexual reproductive health care through them. Where I work. I feel like most families think about birth control pills as the first go to, that seems to be the most common question that comes up starting birth control pills and question about birth control pills. And I know there's a lot of other options that exist. But well, let me just, let's say a one quick step back. And I know this is a hard topic, often for parents and adolescents to talk about. But if you can't talk about it with your healthcare provider, then it can it can set up for a bad situation. So just some background statistics, I think you shared with me this before we started, approximately a quarter of all pregnancies in the United States are among us teens. And then we've got very good data to say that about 40% of teenagers at some point are having sex and many aren't contraceptives or aren't contraceptive with safe, reliable methods. So I think just realising for parents out there that it's probably is happening or it's going to happen, and you need to ask about it and make sure to create the space to talk about it with your provider. Do you just ask people in general what is what do people use? Birth control pills are often what comes to mind. But it's important to be aware that the American Academy of Paediatrics, which is my resource when I'm taking care of adolescents recommends us first line what are called long acting reversible contraceptives and that includes the IUD intrauterine device of which there are five on the market and the contraceptive implant, of which there's one called the next one on So, so those are and the reason to the other important point is there's no one perfect method. So when patients patients come in, or their parents come in with them and say, Well, what is the best? What do you recommend? And I say, Well, we, I think we really need to dive a little bit deeper. And what's important in medicine, we always, we often think of what is most effective as what is best. And that's why we really like these long acting reversible methods. But it's not for everyone to have something in their body, like an IUD or an implant. It's not for someone to take a pill every day, or wear a patch, or have a vaginal ring in or get a shot. But you do need to do something. And normally, that involves either one of these methods or putting on a barrier, like a condom. So that's normally the way I started is asking about what they know, and what's important to them. That's a great way to start the conversation. Do you feel like in your mind, let's say you meet somebody who's coming in, they're sexually active, do you? And you're not sure, I mean, I think the hard part about teenagers is that the pill is so common, but it's really hard realistically to trust that a teenager is going to take a pill every single day and not skip. Do you do you have a favourite method, you know, all things being equal. So I do if if if it's not, if it's something that is the patient's willing to try, I like these long acting reversible methods. So either again, then the implant which goes in the arm, it's about the size of a matchstick. And and it lasts for the FDA says three years, but it really probably lasts more like five years. So it lasts for years at a time. And what's really nice and what often adolescents are okay with this too is it doesn't require a pelvic exam. And the other side of the long acting reversals are the IUDs. So that these do does require a pelvic exam. And it goes in with a procedure that's pretty similar to a pap smear. If people think about it like that, it requires a speculum exam. But those also lasts for years at a time. And then exactly like you're saying, once it's placed doesn't require the patient, or the family to remember to do anything, you don't have to pick up a prescription every, you know, week or month, take a pill, put again, put on a patch once a week, or put in a vaginal ring, or get an injection once a month, once every three months, which is what all the other hormonal methods require. So it's so interesting, because I feel that next one on the way you describe it, it sounds like a wonderful option to not need to have a pelvic exam. Is the procedure fairly simple? I mean, can you explain a little bit more what that would look like for a patient? Sure. So outpatient procedure come in, we talked about it, they sign a consent, and then it's a small numbing shot, but typically lidocaine, and then you know, that feels like a be seeing. And then the rest is just a little bit of pressure takes about a minute, put a bandage on them. And then it goes in the arm, between the elbow and the shoulder on the inside. And they should be able to feel it. But it shouldn't be visual. You know, if you're out in a bathing suit or anything else, it's not like people should be able to tell that it's there. But the user, the patient can feel their arm and feel that it's there. And that's for all those reasons. It's actually why of the most people in the United States who use one of these long acting methods that's reversible, the larks use an IED. But amongst adolescents, it's much more common to use this next one on. And if a teenager pushed hard enough, could they could they take it out? I mean, what are the, like harms that you see from it? Sure. So as long as they keep the bandage on for that one day, it very unlikely to come out, you have to break the skin back open. So so that's good that it won't happen unintentionally, or just if you bang your arm, but that is one drawback is that you need it typically a healthcare provider to remove it. So that that, for some is a barrier. But really the biggest issue is that it can cause irregular bleeding. So it's just hard to predict what it's going to do for some patients, they won't have any more bleeding and that's totally safe, but you can't predict it. Others will have less bleeding, but sometimes you also have spotting throughout the cycle. And that's the reason that often adolescents get frustrated with it. They don't like the uncontrolled bleeding, possibly having some spotting, that's the main drawback. Okay, and weight gain does that happen with the next one on now, weight gain is really has never been associated with any birth control method except the Depo Provera which is an injectable contraception. So it comes as basically a shot of intramuscular injection that patients squat every three months. That's only one for some doesn't cause weight gain at all. But it has been linked to weight gain and gain in studies. Okay, so I think so as far as this to sum up the next one on it's a good outpatient procedure fairly, fairly simple. It doesn't require a pelvic exam, you can leave it in for a few years, and the main drawback is menstrual irregularity. That's exactly right. Okay, so, so since you brought up the Depo, Provera shot and the side effects, can we talk about that a little bit more? Is that a, is that something that people can go to their OBGYN For? Can the shop be given at the pharmacy? Like, how does somebody get the Depo Provera shot and what does that look like? So it differs a little bit by region and there's a there was a recent move to be able to do it, to send it home. And if you felt comfortable doing a sub q injection, you can do it but that's very hard. Most people aren't typically doing it at home. So it does require a trip to a healthcare facility. And these can be your local health department's federally qualified health centres, you know, primary care paediatrician offices just as long as they offer it, it can be done as often done there. But you do need to come back every three months. And for some, some patients really they like it, it's, you know, again, it is somewhere in between the long acting like it doesn't last for years, but also doesn't require you to do something every day, like take a pill. So it's in between. And the only The other downside of that as every other method, it's either in your body or you're taking a pill, and then as soon as you stop, you can get pregnant depo, sometimes the Depo Vera will hang in your body for longer than you can only rely on it for three months. But sometimes, afterwards, if you're actually trying to get pregnant, it can prevent you from getting pregnant for up to a year, a slightly longer, so it doesn't have that easy on off switch. That's really interesting. I find if I bring that one up, as soon as I say, there's a potential side effect of weight gain, the conversation tends to end. Yeah, yeah. And again, that's not for everyone. But it's like we see it in studies enough to know that it's certainly you know, it does happen. And so it's only like three to five pounds, right? It's not, it's not a tonne of weight, it's not a tonne of a tonne of weight. But obviously, individual results do vary. And unfortunately, I've had some patients who have gained, you know, more than that, but many who rely on it for years and have never had any weight gain. So you just don't know until you try it. Interesting. And so right, so the next one on and the Depo are the two that go in the arm. And then just to round out our conversation about the long acting reversible contraception, which, you know, I really like and I want, I feel like it's like you said everyone knows about pills. I don't think everyone knows about these IUD. So there's five on the market, four out of the five have hormones in them. And I actually I would recommend it with hormones unless it's got a very low dose, and I explain it in a similar way. Now, you know, if you take asthma medicines, if you have an asthma attack, you take an inhaler, that way, the medicine goes mainly to the lungs, and doesn't have to go all through the body. Like if you were to take a pill, like a pill of a steroid. And so by the same token, the IUDs, it's got a tiny amount of medicine that's in the it's in the actual structure, the IUD, and it's really releasing a small amount just into the uterus. So most of the time, there aren't a lot of systemic side effects. There aren't a lot of headaches, or fatigue or changes in any of the other bodily systems. It's really just impacting the uterus. And typically it's reducing periods and menstrual blood flow to either either completely eliminating it or making it much lighter. And that's totally safe. And most patients really enjoy that. And how long can they keep the IUD in? Depending on the type three to five years, and the one without hormones can be up to 10 years, but you don't have to think about it. You don't have to get prescriptions or go to the pharmacy or remember to do anything. It's just in your body and working. It's what we call it's forgettable. And Matt, it's correct me if I'm wrong, but it's a very popular birth control method in Asia Correct. I know it's much more popular. I've read that it's much more popular there than it is the United States. Which is interesting to me. Exactly. There are regions in the world where it is ubiquitous where everyone's using it here. Pills seem to be very popular and actually for women that are you know, in their late 20s or 30s and 40s sterilisation is really popular here. But China has, I think 50 types of IEDs I mean, there's the market is filled with them, and so lots of different options throughout the world. Another common misconception is that for IUD placements, they should be done after women have had babies already. Tell us about this like what age Do you recommend IUD placement? Is there an age that's too young? Certainly you want to wait until, you know after periods begin. But there really isn't as long as Once a patient once someone is having regular periods, then you can you know, and they can absolutely have an IED place. There is no age that's too early. So if a teenager is sexually active, they can use an IUD as their first method of birth control. absolutely safe. Yeah, absolutely. And that's why American Academy of Paediatrics they say, this IUDs or firstline, they should be offered to to adolescents along with everything else. Now, quickly, you mentioned that the non hormonal type of IUD, why should a patient think about one versus the other? Are there other reasons why somebody shouldn't want the hormones. So ultimately, what I found is there's you know, are a few patients, especially coming from certain cultures, or certain personal preference, where it's, if it's really important to have a regular period every month, then you want the one without hormones. But barring that, I think most people like the, quote unquote, side effects, or the secondary effects of the hormonal ones, which is either reduce mints menstruation, or reduce blood loss during period or no blood loss at all, like baby go years without having your period. And again, that's totally safe. So just to kind of sum it up, so the hormonal IUDs, you can leave them in for about five years. And the side effect is that you might have an absence of your period or lightened periods, and then the non hormonal, you can leave it up to 10 years, and you'll still get your regular menstrual flow. That's right, it won't change the frequency of your periods, you'll still have them every month. That's exactly it. And And what about the procedure of placing them? What What should? What should somebody expect? Is it is it expected to be uncomfortable? Is it simple? What, what does it look like? Right? So I mean, it does require a pelvic exam, placing a speculum, and you know, you have the wide array of patients that you take care of, not all 15 1719 year olds will be able to tolerate that. But it's, it can, it should only take about a minute, some minor cramping, and all that we recommend is to take ibuprofen or an Aleve, you know, either just before or after to help with that cramping. You know, as I said, there is there is no one perfect birth control method. It's about what the patient wants, what the patient's needs are, what their expectations, what they can handle. And so I wish that these methods that are the most effective at preventing pregnancy, had, you know, didn't require anything to get them in. But unfortunately, you got to find a way to get them in the body. And that can be challenging for some, but most get through it very easily. It sounds so nice to then not have to worry about it for so many years. Right? Set it set it and forget, it's a big plus, set it set it and forget it. I like that. And it will you know, it is also just worth saying here. And you know, probably an important point to wrap up on is these methods, everything that we're talking about in terms of the effectiveness for preventing pregnancy. You know, they work really well, but they don't protect against sexually transmitted infection spreading. So you have this in place, typically, to help prevent a pregnancy and especially, it's great if you have a monogamous partner and been tested. You both have been tested before the couple gets together to make sure that I have diseases. But if you are having multiple partners or aren't sure about your partner's fidelity, then you should also be using a barrier methods, typically a condom to prevent sexually transmitted infection spreading. Absolutely double double double cover. Right. That's right. That's right. Yeah. And going back to birth control pills, I know a lot of us that are listening are familiar with birth control pills. Are there any anything we should think about in terms of what type to pick? A lot of people have questions about, you know, they want the low hormone birth controls. Why Why should one think about? You know, and I think people think when they hear low that low means better. So can you explain the difference between the two and why? Why someone might want one versus the other? Yeah, so there's so many birth control. I think there's over 50 You know, formulations that you can, you can get and so, what I typically start with was a mono phasic. And that's a fancy word for just meaning the amount of oestrogen and progesterone is the same throughout the cycle. Sometimes there's also tri phasic but muscle monophasic and that most of the ones with low have low in the name and I I tend to avoid the ones with lowest oestrogen because they can produce breakthrough bleeding, which I think is can be a nuisance. And I think especially for adolescents are a little bit more sensitive to that. So I typically just middle of the road monophasic pill. And, you know, I think ultimately just the best thing to do is to go in and speak to your provider and just go ahead and try something. And make sure it's covered by your health insurance plan affordable. There's a few that are on a Walmart $9 list if if insurance coverage is is difficult, and just choose one of those and just try it out. And if doesn't work, go for a second one, it's a little hard to predict how people are going to respond. But in general, they all work. They all work well. And I would avoid the very lowest oestrogen formulation that most people don't have any significant side effect from any type of pill. But when you get something, I would say just try something. modulate the either the progesterone that you're using, or the amount of oestrogen that's in there. And hopefully, you'll get a reduction in whatever's bothering you, or switch to another formulation. Yeah, the patch and the vaginal ring, they those typically give you more of a steady state of the hormones. And so that's sometimes it's the change, you take it every day. And so there's, you get a lot as its first being digested, and then trails off over the next 20 hours. So the the oestrogen, the patch is, it's on for once you change it every week, and it stays on the skin, but it gives you a pretty smooth level as does the vaginal ring. I find this to be not as popular Do you? Do you find that as well, I think most people end up starting with the pill and then deciding to change it up. If it didn't work for them, they're having a tough time taking the pill, they're forgetting a lot, or they're having some one of these side effects. So I think that I think that's right, it's not normally the first but there's no reason why you can't they're great methods if they work for you. And in terms of the vaginal ring, is that method is is that method work very well in terms of the rink staying in place. Mostly, I think that's what a lot of parents worry about that how can you stay there? I think a lot of people, parents and patients were you know, my gonna feel it is gonna get in the way of sex is it. But really, once you place it in the vagina, it normally just stays there. I think the hard part about adolescence is feeling self conscious during sex wanting to take it out. And the more times you take it out less likely you're going to remember to put it back in. And then once you have that absence of it in places when you're risk of unintended pregnancy. Okay, and that's what we're trying to avoid. Oh, boy. That's right. Any other points about the birth control pill that I forgot to mention? Or ask about? No, I think you know, there's all kinds of apps and ways to help people remember to take a pill every day change a change a patch, change a ring. But I think ultimately, there's good pill takers, people who reliably do that, I think probably, if you're going to be a good pill taker, as an adult, you're probably good pill taker as an adolescent, or vice versa. So it's worth it to, you know, try and try and use some of these apps and things that can, you know, alarms that but it's just ultimately not going to work for everyone. And so some of this is a little bit of trial and error. Now, what about a teenager that forgets to take the pill for a day or two days, when is there a risk of pregnancy truly increased, if it's just a day, you can double up two days, you can, again, double it up the next day. But once you start getting to that, you know, missing it three days in a row, you've really given your body a long window without the hormones that are going to try and regulate prevent pregnancy. So she should be using some backup methods. And I think that also then tails nicely into the topic of emergency contraception, which is its own long topic. But just for people to be aware of, you know, we've got four great options for emergency contraception. So if you're, if your birth control method fails, whether that's a condom breaking or missing three pills, you can do things. And several of them are over the counter that don't require a prescription, you got Ella and plan B, if you're taking birth controls, you can Google and see whether or not some birth controls, you can take several in a row on the same day. And that can act as emergency contraception. And then also the non hormonal IUD, which we were talking about before, is very effective as emergency contraception and, and all those can be done in the five days following up to five days following the unprotected or the intercourse that's placing them at risk. So that's it's just important for everyone to be aware of that there's lots of options out there. But there's a myth that goes around that if women take the birth control Now and might affect their fertility in the future. Can you comment on that at all? I can't. Yeah, no, there's no truth to any of these methods, causing any impact in fertility. So the only thing as I mentioned, once the the Depo, sometimes will stay in your body longer than you want. But as soon as it leaves, you will return to your fertility. And that's true for birth control pills do not influence any future fertility, neither do the IUDs. The next one on the pill, patch a ring, it's all temporary. Once it leaves your body, it will return to your normal fertility. Yeah, my OB explained it that the reason why you really have to take it every day is because literally after 24 hours that leaves your system. And that's how fleeting the the the effects are. So it's not going to have any long lasting effect in terms of fertility just after that 24 hours. It's out of your system. That's exactly it. All right, any any other birth control methods that we didn't talk about that you think we should bring up, I heard rumblings about a male type of contraceptive Is that Is that true is that so there's lots of research on that. And what I'll say for this conversation, it's hard enough to get an adolescent female to take a pill every day, if you want to trust the adolescent male to do something on a regular basis. You know, that's, that's on us. I was an adolescent male once and I don't think I don't think that's what we want to be relying on. I think it's just important to, you know, it's not uncommon for adolescents, teenagers to think that pull out pulling out will work. But we know that there's semen in pre ejaculate, and it's particularly often hard for, you know, for the male partner to control when they're going to release. And so that's never been shown to be effective. And the rhythm method also requires quite a lot of knowledge of the cycle. And especially adolescence, as the period is being established, it's notoriously irregular. So there's all kinds of challenges to being able to do that effectively. And it really places adolescents at risk. So you want to be using, you know, condoms or barrier methods, at the very least. And then one of these other methods that we've talked about, to really help prevent pregnancy. And of course, our favourites, always abstinence. But as you said, 40% of teenagers are having intercourse anyways, I wish. I'm just thinking as I start to have a you have a teenager, I have a teenager. Yeah. And I mean, abstinence is the only thing that will guarantee prevention against pregnancy, but it's often unrealistic. And yeah, I think we don't do our teenagers a disservice if we don't educate them well. Right. That, and I agree with you. So now, what about from the parents perspective? If a teenager wants to start a birth control pill? Do they have to tell parents? What are the rules around? Sharing information? I mean, I, from my personal perspective, I always encourage teenagers to talk to their parents, I don't like when there's information that's not being shared, especially. I mean, I feel like it's just better when everybody is aware of what's happening, and there's no secrets. But I guess legally, what are what are parents allowed to know about their teenagers? Right. So I think that your things do vary state by state. So we can't make any blanket statements about what every parent or adolescent can and can't do across United States. But most states allow for adolescents to make decisions about for contraception on their own without their parents being aware. And I think in your intro to that question, I think it's very important for there to be good communication. But that's not always possible. We know not always, you know, the family dynamics are not always supportive. And sometimes there's a guardian, and there's different families, you know, are aren't always simple. And you can't always have that good communication. So certainly opening it up in the visit to allow for a good communication between the Guardian, the parent and the adolescent, but ultimately creating a private space for the adolescent to speak with their provider and make their own decisions. So you just want to make sure you address that within your practice. Let them know the limits of what what you can do. And that's why it's good to know about again, there's a $9 a month pill on the Walmart $94, but it's technically nine. So that's a pretty reasonable amount for that a teenager should be able to pay, if they're putting this in their own paying for it's out of their own pocket. So is there anything any other thoughts that you have that we should share to any families listening about? Birth control that we haven't covered yet? Yeah, I'll go back to the principles of just, you know, be aware that even if you don't think it could be my teenager, that they're thinking about it, they're, they're likely going to or thinking about experimenting, so to have the conversation. And if you really don't feel like you can at least drive them and sit in the parking lot and have them go and visit provider, who will discuss it with them. And just make sure that, you know, the challenges of an unintended pregnancy or sexually transmitted infection are very real. And so, you know, I still remember I had a really good friend in high school. And he was one of four boys. And in the, you know, there was a big bucket of condoms that the mom would put fill up. And there was no questions asked, and even his friends, we were told, Hey, this is where this is, you can go grab it, and I think you know that attitude, kids are going to are going to experiment with sex. And if they're not, if you don't make it easy for them to be careful, then the consequences of of unintended pregnancies and infections are going to occur. And so we should make it easy for them to talk about it and make access to these methods as easy as possible. And I think about it a lot, because on one hand, I don't want to be permissive. But on the other hand, you have to be realistic, you don't want to have your head in the sand and then have have a problem. Or, you know, have have something happen that we weren't, weren't expecting. That's right. And I think we know from these studies that kids are going to have sex. And so the permissive that's why you have the conversation. Really make sure hey, I don't want you to have sex until you're ready until you can talk about it until you're in a safe relationship. But if you do, here's what you need to know. And here's how to keep yourself safe. My kids will be 29 and married right? With the soil, y'all, you know, right? Well think we can control it, but just think back to think back to yourself as an adolescent. And you know, it's, they're going through the same things we did. Absolutely. Thank you so much mad certain You're my hero. And if if people ever have questions about this, is there any resources they can go to or anything you recommend? There's a great website, bed cider.org. And I have no affiliation with it, but it's just a great resource. It's designed for adolescents, and those in their 20s It's kind of edgy, but it's all research based, very informative, and is a great resource. So bedside er.org Is is a great is a great go to source. I'll make sure and link it below. Awesome. Thank you so much. Yeah, sir. This was fun. Take care, Jess. Thanks for doing this. Thank you, everybody, for tuning into this week's episode of Ask Dr. Jessica. If you're enjoying this podcast, I would be so appreciative if you would leave a five star review. Your support really means the world to me, and I do read every comment. Until next week.