Birth Control After Kids

Gillian Goddard:

So, we used to think that when you’re having an ovulatory cycle — a cycle in which you ovulate — you have to be having relatively frequent periods. And we thought that if you were going six months or more without a period, you probably weren’t ovulating before that period.

Emily Oster:

So then you wouldn’t be able to get pregnant?

Gillian:

Right. If you don’t ovulate, you can’t get pregnant. So the key here is whether we’re ovulating or not. However, there are some studies that show that more than 25% of cycles that are six months in length or longer actually are ovulatory cycles. Meaning that 14 days before that period, whenever it is, you actually did ovulate.

Gillian:

There’s not a lot of evidence that they increase the risk of cancer — and we’re particularly concerned about breast cancer in this situation — unless you have a strong family history of pre- or perimenopausal breast cancer. If you have a strong family history of pre- or perimenopausal breast cancer, those are often estrogen-receptor-positive breast cancers, meaning the cancer cells actually respond to estrogen.

Emily:

So who is this option good… Is this a common option you see your patients using?

Gillian:

It is, and I think there are some people for whom it’s a fantastic option. Some women find that birth control pills are really helpful for treating severe symptoms of PMS. This can also sometimes be called PMDD, or premenstrual dysphoric disorder, where they can have significant changes in mood and things that really impact their functioning around their period. And birth control pills can be a great treatment for that.

Emily:

Because it has the estrogen that supports that hormonal balance?

Gillian:

Because you basically get a stable dose of estrogen and progesterone all month long without the rises and falls of a natural menstrual cycle, and that stability can really help people feel a lot better.

Gillian:

I would say most women are largely still using IUDs and birth control pills. I think a lot of times it’s because they’re using them not so much as contraception but to treat other things. And the fact that they’re contraception is kind of a bonus. I think more and more couples are considering vasectomy and using vasectomy. And I’m excited to see that more and more people see this as a possibility.

Emily:

It seemed fair.

Gillian:

Seemed fair, yeah. I mean, it is a very interesting question why. What is it? In some ways, it’s completely unsurprising to me that people feel uncomfortable about this, and you understand there’s scissors near your penis with things that you could imagine being uncomfortable about. But I think it would be great if this was something that was more widely discussed, at least as a possibility.

Emily:

I mean, scissors near your penis or a bowling ball coming out of your vagina. Everybody’s doing something for the team.

Emily Oster:

This is ParentData. I’m Emily Oster.

Emily:

Gillian, thank you for joining me.

Gillian:

I’m so excited to be here.

Emily:

Me too. Okay, so can you start by introducing yourself a bit?

Gillian:

Sure. My name is Dr. Gillian Goddard and I’m an adult endocrinologist in New York City and an adjunct assistant professor of medicine at NYU.

Emily:

Please tell us what an endocrinologist is.

Gillian:

So yes, a lot of people don’t know what an endocrinologist is, but the easiest way to think about endocrinology is we are doctors for all the glands in your body and all of the hormones that those glands make.

Emily:

And when you say you’re an adult endocrinologist, one could be a younger person endocrinologist?

Gillian:

So there are also pediatric endocrinologists. And pediatric endocrinologists tend to deal with different issues because kids have different hormone problems than adults do.

Emily:

So I’m very excited about this podcast, but I wanted to say at the top, I am also excited about other collaborations. So you are the newest newsletter writer for Parent Data. You’re writing a newsletter called Hot Flash, which is about the post reproductive years. And if people are interested, they can subscribe at parentdata.org and read about their boobs and all kinds of other really important topics. And we’re going to touch on all this a little bit today, but welcome to the Parent Data team, Gillian.

Gillian:

I’m so excited to be a part of the team.

Emily:

Okay, so let’s start at the beginning or I guess not at the beginning because it’s in the middle. But when we say the post reproductive years, so your newsletter is going to be about the post reproductive years, what do you mean by that? What’s the timeframe? Why would we care about that as a time of life?

Gillian:

Sure. So I think of the post reproductive years for most of us as our very late 30s, 40s and early 50s. Basically, from the time we have our last baby and we’re not planning to have a pregnancy again until menopause. And I think those years are really important because I think people don’t fully understand what’s going on with their hormones during those years and they don’t know quite how to address it.

Emily:

Yeah, I think we’re used to thinking about the life of our hormones as puberty and then there’s pregnancy, if you choose to do that. And then there’s menopause and this idea that things would be fluctuating and changing and doing weird stuff and things would feel weird in a period that I thought would be relaxed. I thought I was like, I did puberty, it was awful. I did pregnancy, that was better. And I thought I was likely to chill until menopause. And that turns out to be not always true.

Gillian:

I would say that’s definitely true. My experience was the same. I thought my 40s were going to be this wonderful nirvana of health and productivity and I was surprised when I started not feeling so well when I was only 42 or 43.

Emily:

So let’s do a little bit of definitions now. So people have heard of, obviously people know what pregnancy is and we’re going to have to define that, but we talk about perimenopause and we talk about menopause. Do those have specific definitions?

Gillian:

They do. So I think it’s interesting to think about four different stages typically from your very early 40s through your 50s. The first stage is something called the late reproductive phase and that most women enter between 40 and 45. This is a time when we’re still having regular periods, but we can start to get symptoms like hot flushes around our periods and our periods can get closer together, they can be heavier. And we can have other changes that can really make us not feel so great. Sleep disruption, sore boobs, headaches.

Emily:

So we’re going to talk about birth control today. That’s our primary topic. But I think it’s worth then asking in this long period that you’re talking about, the late reproductive perimenopause, early perimenopause, late perimenopause, can one still get pregnant?

Gillian:

There’s some really interesting data looking at how many ovulatory cycles women have in these different stages. And we used to think that if you were going more than six-

Emily:

Sorry, we should back that. Start that again and say what an ovulatory cycle is.

Gillian:

So we used to think that when you’re having an ovulatory cycle, a cycle in which you ovulate, you have to be having relatively frequent periods. And we thought that if you were going six months or more without a period, you probably weren’t ovulating before that period.

Emily:

So then you wouldn’t be able to get pregnant?

Gillian:

Right. If you don’t ovulate, you can’t get pregnant. So the key here is whether we’re ovulating or not. However, there are some studies that show that more than 25% of cycles that are six months in length or longer actually are ovulatory cycles. Meaning that 14 days before that period, whenever it is, you actually did ovulate.

Emily:

All right. So that’s a good segue because we’re going to talk about what kind of… I know I need birth control. What kind of birth control, and this is something of course most of us have been familiar with and thinking about since, let’s say, our early 20s. But I think the way that we think about it is differently.

Gillian:

So you already mentioned one, which is vasectomy. You can have a tubal ligation or you can have your tubes removed. That’s called a bilateral salpingectomy. You can use an IUD. There are two main types of IUDs. There’s progestin alluding IUDs, and there are copper IUDs. Progestin alluding IUDs last up to seven years depending on the type. Copper, 10 years. And then things that you might have used in the past like birth control pills might also be an appropriate option.

Emily:

There are actually a big range of other things. So what about something like an implant?

Gillian:

Sure. So there are progestin alluding implants. The most well-known one is Nexplanon. It is a small piece that’s inserted in your arm and it secretes progestins, which are progesterone into your circulation and blocks you from ovulating and also blocks the buildup of uterine lining. So there’s not really anything for an embryo to implant in.

Emily:

So the other thing that people will sometimes talk about is, we’re not supposed to call it this. So I grew up calling this the rhythm method, but that’s not what we’re calling it anymore. But a natural family planning approach. I would have thought of, and a spoiler, I would’ve thought based on what we said earlier in the conversation, that that’s not a great approach, that that’s relying a lot on knowing a lot about your cycles and when they become more irregular it might fall down in its acceptability. But I’m curious if that’s right.

Gillian:

So I would say in general, natural family planning is among the least reliable options. And yes, it absolutely relies on you being very aware of when you are ovulating because the goal is essentially not to have vaginal intercourse around the time of ovulation. So you have to be very, very aware of when you’re ovulating and as our cycles are going through all these changes, some of our usual signs that we’re ovulating can change a little bit and be harder to miss.

Emily:

So I want to think about these four probably the most common long-term solutions people are going to use. And just talk through a little bit like when would they be useful. But also people hear a lot about this like, what is the risk of this? It’s going to have this downside or this downside. And so I just actually really want to get into some of those. So the four I really want to focus on are birth control pills, IUDs, tubal ligations, or the other word you used that I’m never going to be able to say and vasectomies.

Gillian:

So there’s not a lot of evidence that they increase the risk of cancer and we’re particularly concerned about breast cancer in this situation, unless you have a strong family history of pre or perimenopausal breast cancer. If you have a strong family history of pre or perimenopausal breast cancer, those are often estrogen receptor positive breast cancers, meaning the cancer cells actually respond to estrogen.

Emily:

So who is this option good… Is this a common option you see your patients using?

Gillian:

It is, and I think there’s some people for whom it’s a fantastic option. Some women find that birth control pills are really helpful for treating severe symptoms of PMS. This can also sometimes be called PMDD or premenstrual dysphoric disorder where they can have significant changes in mood and really things that really impact their functioning around their period. And birth control pills can be a great treatment for that.

Emily:

Because it has the estrogen that supports that hormonal balance?

Gillian:

Because you basically get a stable dose of estrogen and progesterone all month long without the rises and falls of a natural menstrual cycle and that stability can really help people feel a lot better.

Emily:

Interesting. Okay. Next up, IUDs. That’s what I have. So spoiler, I have Mirena. So that’s the progesterone-eluting.

Gillian:

Yes. A Mirena is a progesterone or progestin. Progestins are like progesterone. It’s a progestin-eluting IUD. It’s one of the ones with a little bit of a higher dose of progesterone and that actually means it lasts longer. So up to seven years with a Mirena, those are fantastic because they last so long. So if you are 38 or 39, when you have your last pregnancy, you have two Mirenas and you’re probably at menopause and you’ve thought about it quite minimally in the interim, which is great.

Emily:

So I don’t get a period on this. How common is that?

Gillian:

It’s quite common with a Mirena. It’s less common with some of the lower dose IUDs like the Kyleena, is a lower dose option. Some women have breakthrough bleeding, some women have periods, but many women will not have a period at all when they have a Mirena and that is another fantastic benefit, especially for women in their 40s when periods can often get heavier.

Emily:

So okay, on the one hand, yes I do, it is a fantastic benefit. But on the other hand, how will I know when I am in perimenopause for real, for real because I’ve just got this great thing that means I never have my period? I could be having it any time. Maybe I’m having it, I don’t know my cycle-

Gillian:

That’s absolutely correct. Because the thing to remember about Mirena and other progestin-eluting IUDs is that they only affect the lining of your uterus. So in theory, the progestin is such a small dose that it’s not significantly circulating in your bloodstream, it’s just keeping the lining of your uterus really thin.

Emily:

So in terms of downsides, are there downsides risks, things that you’d be concerned about with an IUD or people you’d say this isn’t a good option for them?

Gillian:

So progestin-eluting IUDs tend to be quite safe. The dose of progestin is small enough that they’re considered safe for women even at high risk for hormonal cancers like breast cancer. There’s a higher risk of ectopic pregnancy with progestin-eluting IUDs. So a pregnancy outside of the uterus, but that’s still quite rare and it’s not something that would keep me up at night.

Emily:

People do point out that it can be quite painful to have them inserted.

Gillian:

It can be painful to have them inserted. I think that the women who experience the most pain tend to be women who have never been pregnant. The process of giving birth changes the shape and opening of your cervix. And so afterwards, inserting something through the opening of the cervix is difficult.

Emily:

It’s all stretched out anyway. Yeah, no, I actually think there’s another piece of that, which is what I thought you were going to say, which is that part of what I think is tricky about pain is if you don’t know what to expect, it’s worse. And when I had an IUD after I had a baby, they were just like, “It’s a really bad uterine contraction.” And then I was like, “Oh, okay.” I know what to expect. “Oh, that’s what it is. Okay.” I lived through 27 hours of those, so it’s totally fine.

Gillian:

No, there’s definitely an aspect of that as well. You can always take six to 800 milligrams of ibuprofen right before you go to your visit, and that definitely helps.

Emily:

Okay, so IUD, it’s like set it and forget it, right?  Set it and forget it. 

Gillian:

Sure. So it is a surgical procedure. Many women will have a tubal ligation or the long scary word I used before salpingectomy, which just means tubal removal. Many women will have those done as part of a C-section. So they know they’re having their last baby, they know they’re having a C-section and they decide that they’ll do a tubal ligation or salpingectomy as part of that process.

Emily:

The success rate, I assume, is like once you have had this, that’s it, we’re done with this?

Gillian:

Yeah. So in the case of a tubal ligation, they’re literally cutting the fallopian tubes and closing both ends. So if you picture, if you cut through a hose, you would then sew off both ends of the hose. You’re very unlikely at that point, to get pregnant. The success is over 99%. In the case of a salpingectomy, what you’re doing is you’re literally removing the tube from where it inserts into the uterus.

Emily:

Why?

Gillian:

Well, it turns out that ovarian cancer probably shouldn’t be called ovarian cancer. It should probably be called fallopian tube cancer. Most what we call ovarian cancer really arises from the tissue of the fallopian tubes. And so if you remove that tissue, then you remove the opportunity for it to become cancerous.

Emily:

Can I ask an incredibly stupid question, which possibly in this podcast will be edited out?

Gillian:

Always.

Emily:

But then when I ovulate, do the eggs just build up in some part and just sit there like a little pile of eggs?

Gillian:

No.

Emily:

It just feels like they would just keep hitting the end and then have nowhere to go.

Gillian:

So I think it’s important to think about a couple of things, a couple of anatomical things. So one is, the fallopian tubes are not actually attached to the ovaries. There’s an open end that looks like one of those wavy guys at car dealerships with the waving fingers.

Emily:

Oh, like a balloon guy?

Gillian:

Yes. So those wavy fingers guy, the egg, into the fallopian tube, but the fallopian tube is just open into the pelvis and the eggs are just ovulating into the pelvis. So it’s possible that your eggs is not getting into the tube anyway. And in fact, they’ve shown studies where women have had one tube removed maybe because they had an ectopic pregnancy and they ovulate from the egg on the side where the tube was removed and still get pregnant, which means that that egg made its way all the way around to the other fallopian tube to get into the uterus.

Emily:

Okay. I’m glad I asked. I learned a lot. I didn’t know that thing about it. I didn’t know any of that basically. Okay, let’s get to the last thing. So everything else up until this point, and for most couples, if we put aside condoms, every birth control decision has fundamentally been responsibility of the female partner in a female and male coupled. And now we have the opportunity for him to take some leadership and have a vasectomy. So can you first describe a bit what happens in a vasectomy?

Gillian:

Absolutely. So a vasectomy is an office procedure. It doesn’t need to be done in an operating room. It’s done in a special exam room in the doctor’s office using local anesthesia. And it’s done by a urologist. The urologist basically makes a very small incision on the underside of the scrotum and identifies a specific tubule called the vas deferens. The vas deferens carries sperm from the testicle to the semen.

Emily:

You say after a couple of months. Why is that?

Gillian:

Because men make sperm constantly and those sperm spend time over the course of a couple of months in various parts of the testes, the vas deferens, and then waiting to go into the semen and you have to deplete the store of sperm on the semen side of your cut before the sperm will no longer be present in the semen.

Emily:

By having a lot of sex?

Gillian:

No, you do not need to have a lot of sex. It just happens with time. Usually about two months.

Emily:

So actually I have gotten this question frequently from people. My partner says that the doctor told them we have to have sex every day in order to diminish this sperm more quickly. But I guess that’s not-

Gillian:

That sounds like a pipe dream.

Emily:

It sounds like a pipe dream and it’s like something… Okay, all right. So you wait some time and then typically people would have a test at the end of a couple. There would be some way to evaluate that?

Gillian:

Yeah, I would highly recommend having the semen analysis after two months to confirm that there are no sperm in the semen before I relied on a vasectomy for contraception.

Emily:

What is the recovery like from a vasectomy?

Gillian:

I can speak best from my secondhand personal experience. So vasectomy is my husband and I’s preferred choice for contraception. We have an 8-year-old and older children and we are not having any more children. He went to dinner that night. So he had a vasectomy at, I don’t know, 10 in the morning.

Emily:

Minimal. So the one question I get quite a lot from people about this, including from some people who asked me to ask you. Asking for a friend, is the question of long-term pain. So I have at least one person who told me, “I had a vasectomy and I had some long-term pain.” And his view was that that happens to a lot of people. As far as I could tell, that was not based anything in particular.

Gillian:

I would say that that is a very rare occurrence. The pain is typically very minimal and short-lived.

Emily:

So another question about vasectomies is are they reversible?

Gillian:

They can be. There are a couple of different techniques. Some techniques are more or less successful. Some techniques show a reversibility of only 30 or 40% and some techniques have been in the hands of some surgeons upwards of 90% effective. If you’re not 100% sure you’re done with kids, one option for men undergoing vasectomy is to bank sperm. So most urologists will offer you the opportunity to bank some sperm before you do a vasectomy on the off chance that you would ever want to achieve pregnancy again.

Emily:

Okay. So why do you think more people… Do you have a sense of how common, if we think about these four long-term birth control categories, what you see either in your practice or in the data, about how many people are using different options?

Gillian:

I would say most women are largely still using IUDs and birth control pills. I think a lot of times it’s because they’re using them not so much as contraception, but to treat other things. And the fact that the contraception is kind of a bonus. I think more and more couples are considering vasectomy and using vasectomy. And I’m excited to see that more and more people see this as a possibility.

Emily:

It seemed fair.

Gillian:

Seemed fair. Yeah. I mean, it is a very interesting question why? What is it? In some ways, it’s completely unsurprising to me that people feel uncomfortable about this and you understand there’s scissors near your penis with things that you could imagine being uncomfortable about. But I think it goes, it would be great if this was something that was more widely discussed, at least as a possibility.

Emily:

I mean, scissors near your penis or a bowling ball coming out of your vagina.

Gillian:

Right. I totally [inaudible 00:31:27].

Emily:

Everybody’s doing something for the team. Okay. Everybody’s giving it the office. 

Gillian

I’m so excited to be here. I really love talking about these subjects and I really want to make people feel that they can ask any questions. There’s nothing off limits. We can talk about all of this and I’m right there with you. I’m going through this stage of life myself, and so we’ll all navigate it together.

Emily:

And it’s so weird. Why can’t we sleep? That would be for the next episode. But what is it with the hot sleeping and just the waking up at 2:00 AM and not being able to go back to sleep?

Gillian:

We’ll definitely talk about it.

Emily:

That was last week for me. Anyway, okay. Thank you, Gillian.

Gillian:

My pleasure. Thanks for having me.

Emily:

ParentData is produced by Tamar Avishai with support from the ParentData team and PRX. 

Penelope:

Right, mom.

Emily:

We’ll see you next time.