Transcript | Ep. 138: Birth Control Explained

Jen: People should always know they shouldn't be held hostage by their birth control. If they're having side effects they don't like, they are absolutely entitled to stop their birth control at any time for any reason.

[theme music]

Caroline: Hey y’all, and welcome to Unladylike. I’m Caroline.

Cristen: I’m Cristen. And y’all, we gotta talk about birth control. So a little bit about me, I started hormonal birth control when I was 18, heading to college. And I stayed on it pretty much uninterrupted until last Fall.

Caroline: Well, why’d you stop?

Cristen: Honestly, I really just wanted to know what my body would feel like off of it in the narrowing window of time I have left before perimenopause comes a-knockin, Caroline. So what about you?

Caroline: I got on the pill when I was 18. And then when I was about 28, I got my first of three IUDs. And Cristen, I love ‘em. Like, I never wanna get off of my hormonal IUD. Like I, while I have had thoughts of like “huh, I wonder if my…” fill in the blank, mental health, energy, weight, sex drive, any of that would be diferent off of birth control, for me I’ve never had a negative issue with it, and all of the positives are really what keeps me on it. I kind of - I just want to keep going and getting IUDs until it’s time to coast into menopause.

Cristen: Well and here’s the thing, going on and off birth control isn't always so easy breezy -- especially with hormonal birth control, which we’re focusing on this episode. The side effects can really be a mixed bag. Here's Unladylike listener Helen:

Helen Voicememo: I’ve always had pretty good skin but after getting a hormonal IUD a couple years ago I got really bad breakouts on my chest and back.

Cristen: Birth control-related acne is a pretty commonly known side effect. And same with mood changes. An Unladylike listener named Isabella shared: I have taken birth control pills for years throughout my life and stopped taking it out of fear that it negatively impacted my mental health.

Caroline: Birth control side effects can also negatively impact your sex life. Here's listener Nico:

Nico Voicememo: So my experience with birth control is that I went on the NuvaRing when I got married, and little by little I had more episodes of painful intercourse, and I had no idea that my nuva ring could possibly be the cause behind it.

Caroline: And speaking of the NuvaRing, listener Emily told us that after five years of using it, “an ultrasound identified a blood clot in my right thigh that doctors determined was caused by my birth control.”

Cristen: Which: scary! But when listener Kym had to switch methods because of a blood clot as well, she told us, “I jumped on the Essure Implant. It's been the best thing I've ever done for myself!” And y’all, the possible side effects aren’t all bad, either. Hormonal birth control might clear up your complexion or improve your moods. Listener Patrycia wrote to us: ”I suffered from horrible, horrible cramps and heavy periods for 13 years, but then I went on birth control, and it has been an (all-caps) LIFE SAVER.”

Caroline: All of these experiences, the full range, they’re all valid. But one reason we wanted to talk about hormonal birth control was to address some of the less helpful information we've seen circulating online — specifically, hormonal birth control fearmongering. Like, just the other day, I came across this long thread of tweets about birth control and mental health in particular. And one woman kind of unhelpfully said, "it's fucking insane how young women get on birth control and how much it changes you as a person,” like, as if that’s just a given!

Cristen: Now we are all for healthy skepticism and doing your research! But blanket statements like that are totally misleading because not all hormonal birth control methods are the same, and assuming that they all do the same thing to every BODY is inaccurate.

Caroline: To help us make sense of the ins and outs of hormonal birth control, we are talking with nurse practitioner and nurse midwife Jen Robinson. We found Jen through a UC San Francisco program called Beyond the Pill. Its focus is training providers to improve birth control counseling and patients’ experiences. Jen’s gonna guide us through choosing our hormonal birth control choices and how to navigate potential side effects.

Cristen: It’s also important to know how we got here. So a little later in the episode, author Elinor Cleghorn is giving us a rather shocking history of the very first kind of hormonal birth control, the pill.

Caroline: All to find out: How do we choose our birth control choice?

[stinger]

Cristen: First things first, C. “Birth control” is a very broad term. It’s kinda like saying you watched Netflix. Like OK, watched what? Like are we talking a TV show? A movie? So, “birth control” refers to any method of preventing pregnancy after penis-in-vag intercourse. So, condoms, IUDs, fertility awareness, etc. It’s all birth control.

Caroline: We can divide birth control into two main categories: non-hormonal and hormonal. So, in the non-hormonal category, you’ve got sterilization, which means either getting your tubes tied or getting a vasectomy. Non hormonal options also include condoms, diaphragms, cervical caps, sponges, spermicides and copper IUDs.

Cristen: You get a sponge! You get a sponge! Then, there’s hormonal birth control, which again, is what we’re focusing on this episode. Your pills, patches, rings, shots, implants, hormonal IUDs and emergency contraception. Hormonal birth control works by essentially tricking the body into thinking it's pregnant and shutting down ovulation. That way, if/when sperm comes a-knockin, there’s no egg around to fertilize.

Caroline: But our flow chart continues because hormonal birth control also breaks down into two main types: there’s progestin-only and there’s combination, which has progestin and estrogen. And this is where potential side effects can start to get confusing. Because remember, y’all: Every BODY responds differently to different hormonal birth controls. So let’s get to our birth control expert, Jen Robinson.

Cristen: Yes, let's. Jen primarily works in adolescent gynecology in the Albuquerque area. But regardless of a patient’s age or life circumstances, whenever Jen sees someone who wants to go on birth control, she always starts with the same question.

Jen: “What's the most important thing for you in considering birth control?” And sometimes my patients say, “I don't know what you mean, Miss,” which is really cute, and then I have to give them examples like, you know, “Some people are looking for an option that will be really effective at preventing pregnancy. And some people are looking for treatment of their period cramps. Some people are wanting to stop bleeding altogether from their periods. Some people want to have a period every month. Those are just some examples. What sounds like something that your is important to you?” And that is, if people only come away with one thing, that's the most important thing. Rather than launching into talking about every single option that exists, we can really individualize our counseling around what's important to the person in front of us.

Caroline: Well, how do you approach the conversation when a trans or nonbinary patient comes to you looking for birth control options?

Jen: Yeah, I like to approach my conversations with my gender nonconforming or trans or non-binary patients the same way that I would with a cisgender person, is just “What are you looking for? What's your goal?” A lot of people, but not all, have worsening dysphoria with periods, but some don't. So some people are seeking menstrual suppression. Some people are seeking pregnancy prevention. And the main thing that I want my folks to know who are gender nonconforming, trans, non-binary, is if you're taking testosterone, it is not going to be a pregnancy prevention on its own. And so if you're going to have the kind of sex that could result in a pregnancy and you're taking testosterone, even if you're not getting regular periods because of the testosterone, you could still become pregnant. And so considering an option for pregnancy prevention is really important because it's it's not a safe thing to become pregnant on T.

Cristen: So let's get into kind of the possible side effects. Big question, what are the possible side effects like positive or negative of specifically hormonal birth control?

Jen: So in that hormonal birth control category, I always break it down combined versus progestin-only. So the combined or the estrogen and progestin options, which would be the combined pill and the birth control patch and the birth control ring, the positives for a lot of people are that it can help to stop irregular bleeding sooner than some of the other methods and give people more predictable monthly bleeds should they choose that.

Caroline: Different types of combination birth control — that’s the kind with both estrogen AND progestin — can also decrease acne, period cramps and PMS symptoms.

Jen: The disadvantages are that if you have an increased risk of having a blood clot or you have certain medical conditions or are taking certain kinds of medications, it's possible that those combined methods are not safe for you to take.

Caroline: As for progestin-only birth control like the implant, hormonal IUD and some forms of emergency contraception, the risk of harmful side effects is lower. Yay!

Cristen: But their most common side effect is breakthrough bleeding. Boo! That could be light spotting or a heavier unplanned flow. And a fun fact about me, y’all: I ruined an ex boyfriend’s sheets right after I got my hormonal IUD. And in retrospect, I don’t give a shit because he was kind of an asshole. Jen says that the breakthrough bleeding usually stops over time, which, for what it’s worth, mine did.

Caroline: I'm curious about the concerns that you might hear from your patients around birth control options that stop bleeding versus those that don't. Because I'm in my late 30s, and honestly, it was pretty recently that a friend of mine was like, “Wait, you don't have to have a period every month? You can. You can take the like, just skip the placebo week on your birth control pill pack” or whatever. So what what do you hear from your patients about? Like, do I need to menstruate? What does it mean to stop? Is that unhealthy? Like, what are their concerns?

Jen: What I do is I pull out my uterus model when I'm talking to people, which I often do, and I show them the inside lining of the uterus. And I say, you know, “On the hormonal birth control methods, the hormone tells the inside lining of your uterus to stay thin and not grow. And so we know that if you're not having periods and that's because of the birth control that you're using. The reason is there's not a bunch of blood building up in there to come out. And so, yes, absolutely. If you stopped having a period and you weren't on a medicine that we knew was causing that, I would definitely want to figure out, “Well, what's going on?” But if we know that the reason is the hormone is telling the inside lining of your uterus or the endometrium to stop growing while you're on this medication, then it is not a dangerous thing if that's what you want. And then also acknowledging not everyone wants to skip periods. But some people do. And how would we ever know if we didn't ask them what they wanted as part of our visit?

Caroline: As a provider, Jen wants to match the patient’s priorities with the safest method for them. And that involves more questions since your medical history helps determine whether certain birth control methods could pose any health risks.

Cristen: So questions like: Have you ever had a blood clot? Do you get migraines with aura? Are you taking seizure medications?

Jen: With the estrogen-containing contraception, we always want people to know it can increase the risk of a blood clot. So that's really rare, but that's why we ask those questions to make sure someone doesn't have an increased risk of that happening because with the estrogen-containing combined birth control, that is an increased risk.

Cristen: Still, those side effects comparisons aren’t cut and dried because, say it with us now, every BODY responds differently to different hormonal birth controls. Plus, everyone’s health needs are different. So, someone who has endometriosis may want to take birth control to decrease pain, more so than prevent pregnancy. Or someone with polycystic ovarian syndrome may want to find the best hormonal option to deal with excess hair growth

Jen: So it always comes back to what's important for the person sitting in front of me.

Caroline: What if your priority is not so much physical, but a concern around potentially aggravating or worsening any existing mental health issues?

Jen: Yeah, so important. And I'll do some self-disclosure that I can't take hormonal birth control without becoming a total monster. Super anxious, super angry. And that is my lived and personal experience. So I'm coming with my own personal experience that I have to just know and be aware of that if I kind of used that experience and like, transposed it onto someone else, I could be really hesitant about offering hormonal contraception options to people who are concerned about the side effects. But what I've learned to do is just be like, that's just my experience. This person in front of me isn't me. And there's no- as long as someone can consent like is psychiatrically able to consent to care, there is no medical reason why someone would not qualify for certain birth control options based on mental health stuff. Now, sometimes people with different mental health conditions are taking medications that are for seizure disorders. And in those instances, some seizure medications, also used for psychiatric stuff, can interact with birth control, or the birth control can interact with that medication. And that makes it more of a complicated conversation. But in terms of if someone has depression, anxiety, bipolar disorder or some other thing going on, and they're concerned about how it might affect their mood, the vast majority of people do not have that experience that I had. But when people come back to me and they say, “Oh, I'm having a really hard time emotionally with, you know, ever since I started this method,” I'm like, “I believe you. I believe what you're telling me, you can stop this method at any time for any reason.” With the exception of the Depo shot, which I can't like suck out of people's bodies for, you know, three months after we give it.

Cristen: Birth control providers believing patients is pretty fucking radical. And we'll get more into choosing to stop using hormonal birth control later on with Jen. But first, did y’all know that the first FDA-approved birth control pill was tested on Puerto Rican women without their consent? It's true. And truly fucked up.

Caroline: When we come back, it's time for a hormonal birth control history lesson.

Cristen: Don’t go away.

[stinger]

Elinor: Throughout medicine's history the responsibility for fertile health, reproductive health has really been placed like squarely at women's feet.

Cristen: We’re back. And this is Elinor Cleghorn, author of Unwell Women: Misdiagnosis and Myth in a Man-Made World.

Elinor: With the advent of contraception again, women have borne the burden of this responsibility. And of course, that meant that they would also have to bear the side effects, the consequences of taking a new and relatively poorly tested medication, such as the contraceptive pill.

Cristen: For Elinor, it’s no wonder there are so many fears and misconceptions around hormonal birth control. Side effects have been a relative crapshoot ever since its arrival in 1960 when the FDA greenlit Enovid, better known as The Pill.

Caroline: The woman most responsible for making The Pill happen in the US was a complicated figure named Margaret Sanger. Sanger was a nurse turned birth control activist who founded Planned Parenthood.

Cristen: Sanger’s vision of sexual and reproductive autonomy was revolutionary — and also laced with eugenics. She saw birth control as the path to societal "betterment." Which was a polite way of saying population control for poor, less educated and/or disabled people.

Elinor: She wanted to think about something that women could take really easily that would be like pretty much foolproof, that men didn't necessarily have to know anything about that would put birth control entirely in the hands of women. And this is when she started to dream up this idea of having a pill that could control fertility and enable women to limit their families.

Caroline: Contraception was still illegal in most states, so when Sanger and her team began developing the pill in the 1950s, they couldn’t run large-scale clinical trials in the U.S.

Elinor: So in a letter to one of the pharmacologists who was in charge of developing the pill, a funder who'd worked with Sanger had suggested that what was needed was, and I put this in quote marks “a cage of ovulating females to experiment on,” which is a really horrific sentence. So where did they find this cage of ovulating females? They went to Puerto Rico, the island that's an occupied territory of the US, where birth control was not illegal.

Cristen: A network of family planning clinics already existed on the island, but the main form of birth control was sterilization — partly funded by the American government. Then in 1956, researchers recruited more than 200 Puerto Rican women, primarily from poor neighborhoods, to try out a new kind of birth control - the pill.

Elinor: And they were told it would have fewer side effects, and it would mean they could effectively limit their families. What these women were not told by the community nurses, physicians and sort of health social workers on the island were that they were not explicitly told that they were subjects in a clinical trial.

Caroline: The Puerto Rican women did not know they were actually taking an experimental drug.

Cristen: A year into the study, the doctor overseeing the research on the ground reported back that the pill was 100% effective in preventing pregnancy. She ALSO told the researchers that there were "too many side reactions to be generally acceptable." In fact y’all, 22 percent of the women who'd originally volunteered for the study dropped out because of side effects.

Elinor: There were side effects that ranged from, you know, loss of libido to headaches and pain, but also more serious side effects such as blood clots. And two women associated with the trial died, but their deaths were not investigated in relation to the pill trial. They were sort of written off as being nothing to do with the pill trial and to do with other factors. And the pharmaceutical company didn't conduct autopsies or carry out proper, detailed investigations into the deaths of those women. What we also see is that the side effects that women involved in these trials were then reporting to the nurses were very often minimized in the clinical data because of racialized perceptions about Latinx women being, and I quote “very overemotional,” you know, paying too much attention to their bodies, being almost hysterical about their bodies. So it was very easy for the pharmaceutical company to sort of turn down the lights, dim down the severity of the side effects that were coming up in the Puerto Rico trials because they could blame it on racialized attributes of the women involved.

Caroline: To be clear, the pill they were testing in these trials is not the pill we use today. In fact, progestin levels in the trial pills were about 10 times higher than today’s pill. And estrogen levels were three times higher.

Elinor: So this was extraordinary amount of synthetic estrogen for a person to be taking into their body. And these side effects, of course, are ones that we then saw later on in the early decades of the pill and are still, you know, highly associated with taking the contraceptive pill.

Cristen: Despite all the red flags that came up in that initial trial, the FDA approved the pill in 1960 — but only for married women. Contraception was so controversial at the time, it took a dozen more years for The Pill to be made available to single ladies, too.

Caroline: Nevertheless, The Pill was an instant blockbuster.

Elinor: In the early years of the pill, there was a lot of positive press in the women's press, for example, talking about this, you know, revolutionary new medicine that could enable you to choose when and even if you ever had a child, could enable you to continue your career, to enjoy sex without the threat of pregnancy. You know, it really was a game changer for certain women. But then, more and more women were coming forward and talking about how they were getting these side effects. So ranging from things like loss of libido and headaches and, you know, weight gain, if that was something that concerned a woman, to much more serious side effects like thrombosis, pulmonary embolism. And around the women's press and also in, you know, the national press, there was this sort of turn where it was beginning to be realized that these side effects were, you know, being greatly experienced. They weren't just ones-off, you know, women, they were being experienced by many women.

Cristen: By 1962, the FDA had learned of 26 women who’d reportedly experienced blood clots — including six who died. And yet two years later, they approved the pill for long-term use. By then, 4 million women were taking it.

Caroline: But those millions of women weren’t being informed about the possible side effects. Then In 1969, health journalist Barbara Seaman published a groundbreaking book called The Doctor’s Case Against the Pill. It exposed the risks of blood clots, heart attacks and other dangerous side effects caused by the pill’s high levels of estrogen.

Elinor: Thanks to the efforts of Seaman, but also to women who were active in the burgeoning women's health movement, there were a series of congressional trials held in 1970 in which, you know, essentially the pill was put on trial, and these hearings were set up to determine whether the pill was safe, whether it should be taken by so many women, whether its estrogen levels should be reduced. And there was an endocrinologist present at one of these hearings who remarked that the women of America were essentially being experimented on. And that their hormonal, you know, their endocrinology, which is their you know hormonal base in their bodies, was effectively been tampered with with no real evidence and that this was, you know, a huge public health crisis waiting to happen. So during these trials, evidence was heard from both sides. But of course, surprise surprise that no women initially were invited to testify at these hearings.

Cristen: A few women were in the room listening — namely, members of a radical feminist group called DC Women’s Liberation. Several of them had experienced negative side effects of the pill and were furious not only that the health risks hadn’t been disclosed, but also that their doctors had dismissed their concerns. As they watched the proceedings, they finally just couldn’t take it.

CLIP: 1970 Nelson Pill Hearings

Alice Wolfson: We are not going to sit quiet any longer. You are murdering us for your profit and convenience!

Senator Nelson: We are not going to permit the, uh, proceedings to be interrupted in this way. If you ladies would, ah...sit down.

Protestor: Our lives have been interrupted by taking this Pill.

Senator Nelson: We’re conducting…

Alice Wolfson: I don’t think the hearings are any more important than our lives.

Elinor: It's fascinating to see this room full of men debating women's bodies. And then these incredible women standing up and sort of disrupting the trial and demanding that they're heard and protesting the complete lack of female representation in those rooms. So sadly, the trials did not become more diverse, they were then, after that closed to the public. But the findings of these trials were good because it was deemed that the FDA should put side effect leaflet in every packet and also in time recommended that the estrogen levels and progesterone levels were radically reduced, so the outcomes were favorable even though there was a woeful lack of any women’s voices at all.

Caroline: DC Women’s Liberation was part of a new resistance to the medical patriarchy. After the men-only Senate hearings, they held their own birth control forums, calling on women to come together to learn about the pill and talk about their experiences.

Elinor: the women's health movement kind of grew from this really galvanic energy, especially around the pill trials that, you know, gathering together and coalition in community in order not just to protest against, you know, the system, but also to create sources of knowledge to enable women to speak together. And in doing so, to be able to educate women across the country about their bodies, about their sexuality, about their fertility. And this was really crucial to the women's health movement, this sort of energy of self-education, of self-help and of reclaiming women's bodies back from, you know, the sterile expertise of male doctors.

Caroline: We have waaay more hormonal birth control options today than we did back then, and birth control pills are much safer. For folks taking oral contraception, the rate of blood clots over the course of 10 years is less than 1% - which is actually LOWER than the risk of blood clots during pregnancy.

Cristen: But even though oral contraceptives are much safer, nearly a third of women prescribed them stop taking it in the first year because of unwanted side effects.

Caroline: So one of the most chilling lines in your book is today, the effects of oral contraceptives are still not fully understood. Why do you think that is?

Elinor: I think it's for a lot of reasons. I think that women's health or the effects of medication on women's bodies and minds have never been prioritized in medical research. They've never been prioritized in terms of more clinical research around, for example, the effects of different medications on our bodies. So I think there's a legacy of that, their legacy is just not enough time and attention spent on really exploring what the effects of the contraceptive pill might be. I also think it's that the kinds of symptoms the pill is commonly associated with. So I'm talking about kind of symptoms that affect well being. So those could include, of course, loss of libido, mood and mental health changes. Sort of feelings of depression, low mood, maybe some pain, joint pain, migraines. These are symptoms that have all been very easy to dismiss in the past and they're symptoms that are commonly dismissed in women and young girls when they go to the doctor. So it's been very easy to sort of write off these symptoms as just not needing medical scrutiny and attention.

Caroline: But, what about the men? And the people with penises? Where's the birth control for them?

Cristen: Great question, Caroline! So, there was a World Health Organization trial for birth control for cis men in 2016. And initial results suggested it would be 96 percent effective in preventing pregnancy. But the trial was stopped after a bunch of guys dropped out.. Because of the side effects

Elinor: So it's completely maddening that the symptoms that women are just supposed to shoulder and bear, you know, not being able to enjoy sex fully is a huge issue for health and well-being. For women, it's not important. It's something we should bear. But for men, it means that it would be deemed, you know, utterly irresponsible to give them a medicine that would, you know, damage the precious male sex drive. So that's, I think, where we, you know, it's so rooted in also rooted in sexism. It's rooted in our attitudes towards what we value in terms of bodies and health and well-being

Cristen: Speaking of values, here's a final telling statistic. Less than 2 percent of the money pharmaceutical companies make from contraception goes back into research and testing.

Caroline: We’re going to take a quick break.

Cristen: When we return, we're checking back in with nurse practitioner Jen Robinson to find out what to expect when you decide to stop taking hormonal birth control altogether.

Cristen: Stick around

[stinger]

Caroline: We’re back with nurse practitioner Jen Robinson, and we’re talking about going off or changing up your hormonal birth control. As we just learned, women really had to fight for their right to informed consent when it comes to hormonal birth control side effects. Another issue folks are still having to deal with is healthcare providers not listening when folks tell them they're unhappy or concerned about their birth control method. Instead, they're often told to wait it out.

Cristen: But our birth control expert Jen Robinson is all about method switching. If one method isn’t working, try another! No need to suffer.

Jen: It can take a long time for people to figure out what works for them. And the bottom line is, it's their body, it's their life. It's not ours to control. It's not ours to say, oh, why don't you just sign this contract that you're going to keep this implant in your body for a certain period of time, which we know is happening with implants and IUDs. And so if someone's coming in, even if they got their IUD yesterday, even if they got that implant earlier today, they're really freaked out or they don't want it for any reason at any time. They don't even have to justify it to us. It's their body and it's our job to to help them access removal whenever they want, if that's the situation.

Cristen: OK, I have to quickly ask you then, have you heard any patients asking about DIY IUD removal?

Jen: I love talking about DIY IUD removals! So I think that it is something super empowering and super important for people to know. It is an option. You can try to take your own IUD out.

Cristen: Really?

Jen: Yes.

Caroline: I’m clenching.

Jen: And there's a really awesome document from one of my favorite websites called the Reproductive Health Access Project on IUD Self Removal. So we know that not everyone who tries to take out their own IUD is going to be successful based on a few different factors. Here's another little self-disclosure. I didn't know that my uterus was in a position that is a variation of normal, but made it tricky for me to remove my own IUD. And so I have removed many, many, many IUDs from many different people over the years. But I was unable to remove my own because of my uterine position, so I had a colleague help me out after unsuccessfully removing my own IUD. But yeah, I think it's just so important for people to know what's available. I will say I do not recommend implant self removal. That is something that really needs to be done in the clinic.

Caroline: Oh god.

Jen: But IUD self removal, go for it. If you're if you're down and and that feels like the right thing for for whoever has an IUD. I think that's great.

Cristen: Something not great we wanted to ask Jen about is folks who have trouble getting pregnant after going off birth control.

Caroline: We’ve heard from a lot of Unladylike listeners in their 30s who've experienced this and were totally blindsided. And a lot of Jen's teenage patients tell her they've heard from friends or on TikTok that hormonal birth control makes you infertile. But that’s not true.

Jen: So the reality is that for every hormonal birth control method other than the Depo-Provera shot, their ability to become pregnant should return within a month and usually much sooner than that. And return to fertility is different for everyone because we know approximately one out of 10 people trying to conceive are going to have a hard time. And so for a lot of people, they don't know what their chance of conceiving would have been before they started birth control. And so we say that their ability to become pregnant should go back to whatever it was before they started birth control unless they've had changes in their health during the time that they were on hormonal birth control that wasn't related to their birth control. So a development of a thyroid issue, people could have polycystic ovarian syndrome and not know it. People can have lots of changes in in their gynecologic health that don't have anything to do with their birth control. For example, if they've gotten pelvic inflammatory disease, they could have some fertility problems related to that. So I think there's just generally not enough information available to people about return to fertility that's accurate. And some providers might not even think about talking about it before starting birth control.

Caroline: So one thing that Cristen and I have also noticed is sort of this uptick in discussions around what is natural.

Jen: Mm hmm.

Caroline: All natural and wanting to be all natural, whether that's in your food or what goes on your skin or the type of birth control that you are using. So. In your professional opinion, what qualifies as quote unquote natural birth control, and and is it the same thing as non-hormonal birth control?

Jen: This is another great opportunity to reflect back to the patient because there is no medical definition of what natural means in terms of birth control. So I would say, tell me more about what natural means to you. Tell me more about what you'd like to try out or avoid. So. I think if someone was like it means no hormones at all, I don't even want to talk about a hormonal option, then I would be like, all right, cool. We don't have to talk about hormonal options. There are lots of non-hormonal options we can talk about. And if someone's like, well, I just want to have a period every month. And then I would explain, well, there are methods that can help you have your own period every month that, you know, don't interrupt whatever your body is doing on its own. And then there are methods that can create a monthly bleed. So I would just reflect back to the patient. Tell me what that means to you, because there's no like medical definition of natural.

Cristen: So we've also heard from some listeners who are kind of anti-hormonal birth control and have told us like fertility awareness - tracking your ovulation - like non- any non-hormonal options, that’s what we should be doing because it is more feminist and you're claiming autonomy over your body, you know, which I can appreciate-

Jen: Mm-Hmm.

Cristen: And I wonder from your professional opinion, um is is fertility awareness a reliable form of birth control?

Jen: Yeah, I think it's so great for people to have that as an option. However, something did kind of strike me with what you said that we should only be talking about fertility based awareness because it's more feminist.

Cristen: Mm-Hmm.

Jen: Is it being feminist to tell people that they only have one option? I don't think so. I think that it's feminist to say this is what's available to you, and I support what you feel is the best thing for you and your body. So I would not say let's talk about the feminist options for birth control, let's say let's talk about how we can help meet your priorities and your needs, whether that's selecting birth control or not, whether it's stopping birth control. whether it’s starting birth control. It’s all about what’s important to the person in front of me. And not like someone's perceived feminist agenda of actually limiting options. So I would say I've had many patients express interest in fertility based awareness and I just get really curious, like, tell me more about what you're doing, tell me more about how you see this fitting into your life.

Caroline: Fertility awareness involves tracking your menstrual cycle to figure out when you’re ovulating and avoiding unprotected penis-in-vag sex during that window. That tracking can include taking your temperature every morning, charting your menstrual cycle on a calendar or checking your vaginal discharge every day. The methods are most effective when used together.

Jen: I think that I just want people to have enough information about that option if that's what they're going to consider. Because some people, a lot of people come to me and they're like, OK, my app told me, I'm ovulating every 14. You know, whatever the 14 day after my period starts, that's when I'm fertile. And it's like, whoa, that is not the case for every single human with ovaries. We don't always ovulate at the same exact time every month. There are a lot of factors that can impact whether we ovulate or not. That can be stress, illness, lots of other things. And I would really encourage people to know that it's less reliable to just count on an app that's guessing of when you're ovulating and more reliable to look at the methods that take more information into account about your own body. So absolutely, fertility based awareness can be a really great option for people that want to do that, especially if they have open communication with a partner or partners and the ability to have autonomy about when they have sex and when they don't. We're talking about penis in vagina sex in this instance. But it's really complicated, and I think a lot of people that work in health care don't get enough information about fertility based awareness. And we don't have a medical system that's set up for long enough visits for us to do the education, even if we did have all the information that we needed. So I think that it's a great example of an option for pregnancy prevention that makes a lot of people feel uncomfortable because there's a lot of misinformation even about what it means.

Caroline: What do you see as the future of birth control, like, what is your hope for the future?

Jen: I would say my hope would be for people providing reproductive health care to just ask their patients what's important to them. And I think unfortunately, that seems like it would be revolutionary in a lot of settings, but really focusing on what's important for the patient and really supporting the idea of switching from one method to another and removing IUDs and implants whenever people want. Those are really, really important, like fundamental tasks that we have not always done super well in in health care.

Caroline: To learn more about Jen Robinson and Beyond the Pill head to beyondthepill.ucsf.edu. For birth control resources, bedsider.org is a fantastic resource that Jen recommends. You can find Elinor Cleghorn at @elinorcleghorn on Twitter or pick up her book Unwell Women: Misdiagnosis and Myth in a Man-Made World at your local bookstore.

Cristen: And as always, you can get in touch with us on instagram, facebook and Twitter @unladylikemedia. You can also support Caroline and me by joining our Patreon; you will get our undying love and gratitude, and also weekly ad-free bonus episodes like our recent look into what’s going on with teen girls, Tourette’s Syndrome, and TikTok. Find it over at patreon.com/unladylikemedia.

Caroline: Nora Ritchie is the senior producer of Unladylike. Michele O’Brien is our associate producer. Gianna Palmer is our story editor. Shruti Marathe transcribes our tape. Our music is by Flamingo Shadow, Amit May Cohen and Sarah Tudzin. Mixing is by Andi Kristins. Sound design and additional music is by Casey Holford and Andi Kristins. Executive producers are Peter Clowney, Daisy Rosario and Unladylike Media.

Cristen: This podcast was created by your hosts, Cristen Conger

Caroline: And Caroline Ervin of Unladylike Media.

Cristen: Next week ... it’s time again for Ask Unladylike. We’ll be covering divorce, dress code sexism and Caroline unveils a special game just for me!

Caroline: Y’all can listen, too. You don’t want to miss this episode! So make sure you’re subscribed to Unladylike. Find us in stitcher, spotify, apple podcasts or wherever you listen to podcasts.

Cristen: And remember, got a problem?

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