The Health Curve

Birth Control Explained | Stacey Silverman-Fine MD, OBGYN at Maven Clinic (Women's Health Series)

• Dr. Jason Arora • Season 1

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Birth control shouldn’t be confusing.

In this episode of The Health Curve, I sit down with Dr. Stacey Silverman Fine, OBGYN at Maven Clinic, to break down how today’s most common birth control options actually work — from pills, patches, and rings to hormonal IUDs, copper IUDs, implants, and the Depo shot. We talk through how they differ, what to expect when starting one, and how clinicians help people choose a method that fits their health needs, preferences, and lifestyle.

We also get into the non-contraceptive benefits many rely on — like help with heavy periods, painful cramps, acne, PMS, PCOS, endometriosis, and perimenopause symptoms. Stacey shares clear, evidence-based guidance on mood, weight, safety, long-term use, and how to think about trade-offs. We also clarify the difference between emergency contraception and the abortion pill, and discuss the safety of IUDs for people who haven’t had children.

If you’ve ever felt unsure where to begin with birth control, this conversation aims to offer grounded, straightforward information to help you feel more confident in your choices.

If this episode was helpful, subscribe to The Health Curve and share it with someone who might benefit.

SPEAKER_00:

Hi, Stacy. It's really good to have you back on the Health Curve. Thank you for joining me. Looking forward to talking about birth control today.

SPEAKER_01:

Thank you, Jason. It's wonderful to be back. I'm really excited to be here to be talking about birth control as well.

SPEAKER_00:

Okay, so let's just start with the big picture and some basic definitions for people. So what are the main types of birth control and how does each of them work?

SPEAKER_01:

So maybe we'll start with hormonal birth control. That would be number one. And when we talk about hormonal birth control, we have multiple different types that fall under this, right? So we can have birth control pills or patches or rings. And essentially these all work the same way. They have similar side effects and benefits. The way in which they differ is how they get to the hormone into the body. So a birth control pill is a pill that you need to take around the same time every day. A birth control patch is a transdermal patch that's worn on the skin that we change once a week. And then we have a birth control ring that goes into the vagina that is actually changed once a month. So that is the first type of hormonal birth control. Essentially, when we look at these, they all are about 97 to 98% effective if taken or used correctly. They all work by delivering estrogen and progesterone into the body in low levels and block ovulation. So that would be the first, in my mind, form of birth control that we would talk about hormonally. Now, we could move on to other hormonal birth control pills and when I think, or hormonal contraceptive options, I should say. And when I think of these, I think of your hormonal IUDs. In addition to this, I would think of your implants that go in the arm. So we have three different types of progesterone IUDs. We have one here in the United States called a marena. We also have a chylina, and we have a skyla. I should also say we also have one called Lileta. So really there's four types of progesterone IUDs. And essentially they all have different doses of a hormone called levonogesterol in varying doses that gets delivered directly into the uterus with minimal systemic absorption. And these guys work essentially to thicken the cervical mucus, therefore interfering with sperm transport. They also thin that uterine lining, creating a really unfavorable place for implantation. And so that is really how those work. The next one that I like to talk about that's hormonal is called an implant. And this is, you know, some people will call this an IUD for the arm, but it's essentially a rod for the arm, right? And essentially it's a flexible rod. It's about the size of a matchstick. It's inserted under the skin, usually in the upper arm. It contains a progesterone here called etonogester, which is a little bit different. It's released throughout the body. It interferes with ovulation. It also thickens the cervical mucus and interferes with sperm transport. And it also thins the lining of the uterus. And then the last type of hormonal birth control is something called depoprovera. This is a contraceptive shot that is given every three months. It contains a hormone called depomidroxy progesterone acetate that interferes with ovulation. It also thickens and decreases cervical mucus, interfering with sperm transport. It also thins the uterine lining. So all of these are hormonal options. Now, the last type is a non-hormonal. And that is a non-hormonal IUD that comes to mind here. This is a copper IUD that actually has been on the market for quite some time. And essentially, what this does is it works by creating an unfavorable environment in the uterus due to the copper. It thus interferes with sperm transport and possibly helps prevent implantation. There's no hormones and therefore your cycles will still come. And so that is another form of non-hormonal options. And then of course we have all of our barrier methods where we're talking, you know, a male condom or a female condom, or we're talking about spermicides and spermicidal gels, et cetera.

SPEAKER_00:

That's a really helpful overview, Stacey. Thank you. Before we get on to helping people choose what's right for them, you know, we I think we should talk about the fact that a lot of people assume birth control is only about preventing pregnancy and that a lot of people use it to manage heavy periods, acne, endometriosis, I believe, P costs and more. How do you think about these non-contraceptive benefits? And what are some of the trade-offs of using birth control for these things?

SPEAKER_01:

So I think the non-contraceptive benefits are huge. I think, you know, when we're looking at various populations, there is a large percentage of individuals that are using hormonal contraceptive, not for the contraceptive benefit, but for the cycle benefit. And just like you said, all of those things. In addition, you and I have discussed this previously, but birth control pills and birth control ring are the mainstay of hormonal management of perimenopause. So I think really here, the hormonal contraception options that we just discussed really have huge non-contraceptive benefits. When we look at birth control pills and birth control patches and birth control rings, there's also a risk reduction in ovary and uterine cancer we're taking. So we do have some patients that come to us that are at elevated risk for ovary or uterine cancer and are on these hormonal methods for risk reduction for cancer. And so, really something really quite important and quite staggering when you look at the statistics.

SPEAKER_00:

So when I think about how our listeners can navigate this, I think of three groups. So one is people who are trying to pick the right birth control for themselves for the purposes of contraception. One, two being people who want to do this for non-contraceptive benefits, such as cycle management. And then the third being people who want both. So how do you help people start to think about this in those three groups? How can they pick the right one for them and what are the trade-offs?

SPEAKER_01:

So for contraception, really here, when we're talking about contraception, we have to really come up with what really works for the individual. And so this really needs to be a one-size-fits-one. It really needs to be an individual conversation with a provider to determine what works best for somebody's lifestyle. Somebody may not want to take a pill every day for contraception. They may prefer a patch or they may prefer a ring in the vagina, or they may want a more long-acting contraceptive option here, in which case those IUDs really come into play here because they give that long-acting contraceptive benefit. In addition, you know, we really need to think about are they having other things at the same time? So, yes, contraception is one, but we need to take the whole picture. Are they having really crampy periods? Are they having heavy periods? Are they having substantial PMS? Are they having acne? Are they having other things that are going on that we need to really target that? And, you know, when we think about those IUDs that are providing this long-acting contraceptive benefit, the hormonal IUD is also giving us that bleeding benefit, but it isn't going to help for the PMS. It isn't going to help for acne. It isn't going to help for those other systemic things because of the minimal systemic absorption. So I think really that really needs to come into play here as we're discussing these individually with individual people.

SPEAKER_00:

Right. And so how does an OBGYN make make the trade-offs with the patient? Like how would you think about this for a patient who has come in and is saying, look, I want just contraception and I want to minimize the other things that this might do? Like how would you advise a patient to think through that?

SPEAKER_01:

Yeah. So when I think about somebody who really isn't having any issues and really is just looking for contraception here, Jason, we usually we'll start with really kind of the least invasive thing first, which would be a birth control pill or a patch or a ring. An IUD is really a procedure to have these put in. And so for some, that can be much more involved. It can be much more uncomfortable. And so I really think about a birth control pill or a birth control patch or a birth control ring because those can be started and stopped at any time if somebody doesn't like them. And when we're trying to decide between are we going to use a birth control pill or are we going to use a birth control patch or are we going to use a birth control ring, it's really more in terms of what makes sense to that individual. Are they comfortable taking a pill every day? Do they take other medication that it would be easy for them to take this at the same time? Or would they be more comfortable changing a patch once a week? I do state often that the patch is fairly large and the color of the patch is not entirely neutral color. It's not a clear patch. So sometimes that comes into play here. And then the vaginal ring, as it goes in the vagina, some are very uncomfortable with that. And I can usually tell when I'm talking to an individual, if they're making a face as I'm talking about a ring going in the vagina, then I know that's not going to be the best option for them. However, what we found is that biologic females in general love the power of suggestion. And so a lot of times, if their friends are using it and it's working for their friend, they're more opt to try it. So there are some college campuses where the vaginal ring, contraceptive ring, is used a ton. And mostly that is because multiple people are using it on that campus, right? And so it's been adopted very well. Lots of people are using them. So other people are more willing to try as well.

SPEAKER_00:

And then Stacey, can you explain what a vaginal ring is exactly? Because I'm sure there are lots of listeners who aren't entirely sure what it is or what it does.

SPEAKER_01:

Yeah. So a vaginal ring here under the brand called Nuva Ring, also with multiple generic names as well, is a ring that goes in the vagina that's very small and very skinny. And once put inside the vagina, people do not feel it. And it releases a low dose of estrogen and progesterone into the body in a steady fashion over three weeks' intervals. So that ring stays in place for three weeks. After three weeks, you do have to reach inside and pull it out and remove it. It gets thrown away. It stays, there's no ring inside for that week. That's the week that you have your menstrual period. And then a new ring gets placed. These rings can actually stay in place with intercourse, or they can be taken out and left out for about three to four hours without interfering with contraceptive benefit and then put right back in.

SPEAKER_00:

Okay, so for contraception alone, the mental model, if you will, is least invasive first and try and see what the impact is going to be and see if it does affect anything else and how easy is it to administer. Does it fit into the patient's lifestyle? That's how patients should think about that first group or that first approach, right?

SPEAKER_01:

Absolutely. And it should be noted, Jason, that none of these are going to protect against sexually transmitted infections. And so this is where we really need to tell people we really need barrier contraception for that as well. We really need to be thinking about condoms and making sure that we're protecting against sexually transmitted infections as well.

SPEAKER_00:

Okay. And so if we think about the second group now, people who are approaching this only for the purposes of managing non-contraceptive issues that might be related to their cycle or otherwise, how should they approach this in their mind? And what are the kinds of trade-offs that they have to make between their different choices?

SPEAKER_01:

So I think if we're looking for the non-contraceptive benefits, I would assume here, you know, we can start with abnormal uterine bleeding, whether that be heavy bleeding, prolonged bleeding. We can also talk about menstrual cramps. I will tell you hormonal contraception is where we really need to be. So whether that be a birth control pill or a patch or a ring, or one of these hormonal IUDs that go into the uterus, or potentially the implantable rod, or potentially deprivera. We really need to manage this hormonally. And really, when I look at this kind of counseling as well, it's a combination of graduated approach, right? So again, something that can be started and stopped easily if they don't like it, versus if we're coming in for an IUD, then you know we're having a small procedure and then needing to have it removed if you don't like it. Generally, we'll do that. We'll also want to balance other healthcare issues that are going on. If somebody has high blood pressure, for instance, they may not be able to use a birth control pill or a patch or ring. If somebody has migraines with aura, same thing, can't use a birth control pill or a patch or a ring. So those might be individuals that we would counsel more towards IUDs and specifically hormonal IUDs.

SPEAKER_00:

Okay, so then we go on to the third group people who might want both from this. They want the benefits of birth control and help with managing the menstrual cycle. How should they think about this? And what are the trade-offs between the options?

SPEAKER_01:

So I think this is also a really similar approach. You know, essentially we're looking to go through from, you know, I kind of consider it a top-to-bottom approach. And really we need to figure out do they want long-acting contraception? So maybe this is an individual, for instance, who is done with childbearing, really wants something quite easy to use, doesn't want to have to think about it on a day-to-day basis, is having some heavier, crampier periods, and has had a valuation. There isn't any specific pathology going on there that needs to be managed. That might be somebody that I would pivot directly to an IUD, a long-acting contraceptive option for them that would give them both the contraceptive benefit as well as the cycle control benefit as well. So I think it's really, again, the same kind of discussion. Again, the one thing that I always tell patients is that when we're putting IUDs in the uterus, we're really getting more local control. So we're going to be managing bleeding, we're going to be managing cramping, we're going to be giving great contraception, but we're not going to be giving benefits for PMS. If you're getting mood changes with the cycle, if you're getting breast tenderness, if we're getting cystic acne with the cycle, those hormonal IUDs aren't going to assist with that versus the oral contraceptive pill, the oral contraceptive patch, the oral contraceptive ring. We'll give all of those. When we're looking at the pill versus the patch versus the ring, you know, really we have to remember there is some user error here. It relies on the individual being able to remember to take that pill every day or, you know, change the ring. For me, when I talk to patients about the ring, I say, you know, that would be a reminder on my phone. Because I think when we start getting into two weeks, three weeks, we kind of lose sight as to like, wow, when did that ring go in? Was that last week? Was it the week before? So I think we really need some mental reminders on either a phone or a calendar or alerts or something here to remind individuals. So again, it's really a lifestyle issue as well as hormonal benefit and contraceptive benefit.

SPEAKER_00:

We'll get back to this conversation in just a moment. But if you're finding this episode helpful, here's a quick ask. Take a second to follow or subscribe to the Healthcare podcast wherever you're listening. And if someone else in your life would benefit from this episode or any of the others you've heard, please send it their way. All right, let's get back to it. Hey, I want to move on to talking about risk now and things people hear about taking various forms of birth control or using various forms of birth control. So you you heard people say it's gonna mess up your mood, you're gonna gain weight, even some people say it causes cancer. Can you break down what's true and what's not and what we're still learning about some of the risks and trade-offs?

SPEAKER_01:

Absolutely. So I think birth control pills are probably fraught with the biggest myths of all. And I do think for some, we do see mood changes on birth control pills. It's affecting our hormones, and hormones definitely control our mood. And there are multiple different types of pills, just like multiple different shampoos and soaps and, you know, what have you. You know, someone may like one, someone may not like another. And so sometimes it's a little bit of trial and error to find the right pill for the right individual. But in general, what we tell people when we're talking about a birth control pill or a patch or a ring is it can take up to three to four months for your body to get adjusted. And in the interim, you can have some mild breakthrough bleeding. You can sometimes sadly see an increase in acne, which can be really frustrating if that's what they want improved to begin with. We can see as well an increase in loading and some mood changes. And again, a lot of individuals want birth control pills because they do help with acne. So, again, what I caution people about is that it can take three to four months for the body to adjust. And then after that, everything seems to calm down. Sometimes it can be a little rocky for those three to four months. And if it's really rocky, then we might need to make a pivot sooner. But really, we tell people to kind of stay with it if they can. Now, the biggest myth is that birth control pills cause weight gain. And it in our older doses of birth control pills, where the estrogen dose was much higher than it is today, we did see quite a bit of bloating and sometimes weight gain. Now, with our lower dose options, we don't see this really very much at all. Now, that doesn't mean that someone can't be a one-off and that somebody might have something that characteristically we don't really see. So we just tell patients, you know, everybody's an individual. We're not really seeing weight gain with the lower dose options. But if you do, it might be time to change as well. The other thing is that we do know that birth control pills and patches and rings can increase blood pressure. So I usually do recommend if we do have a new new start and there's maybe a family history, that they maybe check a blood pressure to just make sure that everything is okay there. Again, high blood pressure is generally a contraindication to going on these hormonal birth controls. Smoking if you're over 35, migraines with aura are also all contraindications to taking these hormonal birth control pills or patches or rings.

SPEAKER_00:

Right. Okay. So how would you sort of advise people as like a takeaway to say, well, okay, so when it comes to risk, there is some, but I mean, you have to just try and see, or how would you phrase this bit, Stacy?

SPEAKER_01:

So the last risk or myth that I hear a lot is that birth control pills cause cancer. And there's actually really strong data to show that birth control pills, and this includes our birth control patch and birth control ring, lower the risk of ovary and uterine cancer. And the data is really staggering. It's 50% reduction in ovarian cancer at five years of use. And it actually goes up to a little bit more than that at seven plus years of use. So there really are some benefits there. There have been very small number of studies that showed that there might be a slight increase risk to the breast and to breast cancer on these methods. And it's interesting to note, though, that the risk reduction in ovarian uterine cancer far outweighs any risk to the breast. And so I think I touched on this previously. If we do have somebody that is at higher risk for breast cancer, ovarian uterine cancer, we will still use birth control pills or patches or rings for the risk reduction that we're seeing in ovarian uterine cancer. And so I think when we're really trying to weigh the risks and benefits and alternatives of these, we really need to kind of take an individual approach here. You know, when we look at also the hormonal IUDs, a lot of patients are very concerned about the discomfort with placing these. And there is some data that shows that these can be extremely uncomfortable procedures for some. And there has been a push now to make sure that we're really addressing pain with these procedures. And so I do think now that we're shifting more towards making sure that if somebody does want a long-acting contraception, that we really are addressing pain and taking methods to make sure that their pain is relieved. There is a very big myth surrounding IUDs that IUDs also cause infertility. And this really came from an old IUD called the Dowcon Shield. And this was a very kind of interesting IUD in that the string that was attached to this IUD that went in the uterus was what we called a polyfilament string. In other words, it was one string made up of a bunch of little tiny strings. And if somebody had or got a sexually transmitted infection while this IUD was in place, that polyfilament string was a beautiful nidis for infection. And so that sexually transmitted infection could get up into the uterus and actually cause severe infection into the uterus and the tubes and the ovaries and the pelvis and later result in infertility. Our current IUDs are all monofilament strings. We're really good about making sure that we're counseling appropriately and screening if we're worried about a sexually transmitted infection and really making sure that we're putting these in the right individuals as well.

SPEAKER_00:

Are there any other myths or major pieces of misinformation on birth control that you want to address for our listeners?

SPEAKER_01:

I think one of the other myths that I think of is that people are worried that they need to have a period every month on a birth control pill. And it's interesting, if we're not on a birth control pill and we're of normal menstruating age, yes, there is something important about shedding that uterine lining about once a month. But if we are on a birth control pill or a patch or a ring or we have one of these hormonal IUDs in place, or that rod in the arm, or depo provera, what's happening here is that uterine lining is being kept really thin. And so we're not needing to really shed that uterine lining once a month. The concern with not shedding is that a uterine lining can get overly thick and predispose us to a uterine cancer. But with these hormonal options, again, that uterine lining is kept really thin. So really don't have to have that period every month. And I think that's probably one of the biggest myths that I hear.

SPEAKER_00:

Okay. Are there any other myths or bits of misinformation you'd like to address now?

SPEAKER_01:

I think that's the those are the main ones. Can you think of one that maybe I left out or something that comes to mind for you?

SPEAKER_00:

So there were a few that came up from some of our listeners. So let me follow away with these. So one that I have is you need to take breaks from birth control to let your body rest and reset. Is that true?

SPEAKER_01:

That is absolutely not true, Jason. We do not need to take breaks.

SPEAKER_00:

Another one we've had is that IUDs aren't safe unless you've already had kids. Is that true?

SPEAKER_01:

It is absolutely not true that IUDs are only safe if you've had children. And in fact, the progesterone IUDs, the different ones that exist, are specifically different in terms of the size. So the Mirena IUD, which here in the United States is the initial one of these progesterone IUDs, was the biggest of the IUDs. It had the most levanogesterol in it. It was also a bigger IUD. And some of the issues we had is that this bigger IUD was sometimes too big for people that didn't have children. And so what came out after this was an IUD here called Skyla. And that was a smaller dosage rather than having 52 milligrams of levanogesterol, it actually had 13 and a half milligrams, and it was a much smaller IUD. And that was specifically geared towards those people that hadn't had childbearing before. What happened then is because it was a much lower dose of progesterone, it didn't give as much cycle benefit as the morena. And so what they came out with was a middle-of-the-road IUD called a chylina that was 19.5 milligrams of levinogester, but was the same size as the Skyla. So truly, these IUDs can safely be placed in those that haven't had children before.

SPEAKER_00:

So another question that we had is that people are trying to understand the difference between emergency contraception and the abortion pill. Is there a difference? And if so, what is a difference between the two?

SPEAKER_01:

There is a difference here between emergency contraception and abortion pills. So abortion pills that people are thinking of are medications that actually help to terminate the pregnancy and cause uterine contractions, et cetera. When we're looking at emergency contraception, what we're doing is giving higher doses of hormones to actually interfere with ovulation, right? And also potentially implantation. So totally different doses, totally different mechanisms of actions. And basically, again, that emergency contraception is a method that's preventing pregnancy after unprotected intercourse, but before implantation occurs, versus abortifacience or the abortion pills are actually medications that are used to terminate already an established intrauterine pregnancy once it's implanted.

SPEAKER_00:

Fantastic. Stacey, thank you so much for joining me again. As always, it's a real pleasure. And I'm sure our listeners will get a lot of benefit from this episode. Thank you.

SPEAKER_01:

Thank you, Jason. Always a pleasure to be here.