What is the Safest form of Birth Control

Contraceptives and hormone health with Dr. Sara Gottfried.

Birth control pills are one of the most commonly used forms of contraception, but they have clearly documented risks. In today’s podcast, Harvard-trained gynecologist Dr. Sara Gottfried shares the risks and side effects of oral contraception, and healthier birth control options.

In This Episode

Meet Dr. Sara Gottfried … 00:05:15
Oral Contraceptives/The Pill … 00:07:41
The Copper IUD … 00:11:04
Side Effects of the IUD … 00:15:46
The Hormonal IUD … 00:20:31
Ovulation vs. LH Tracking …00:22:35
Pelvic Pain … 00:25:04
Let’s Talk About the Thyroid … 00:33:53

What is the Safest form of Birth Control -

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Hi everyone. Today I spoke with Dr. Sara Gottfried about the safest forms of birth control. I’ll give you kind of the summary here. The copper IUD is the best all around consideration, and there are some notable side effects and risk factors for oral or hormonal contraception also known as “the pill”. This type of contraception may increase risk of blood clotting mood and balances, Crohn’s disease, fungal overgrowths, problems with thyroid hormone, problems with libido and clitoral stimulation. There is also an impact on vaginal moisture as a indirect result of the impact on what’s known as sex hormone binding globulin, and how that impacts free testosterone. The use of oral contraceptives may be justifiable in some cases and so she gives us a very well reasoned and rational overview. However, it does seem that the copper IUD is the clear winner in this comparison, and unfortunately the much more prevalent oral contraception does carry some significant risks, which she feels women are not really made aware of when embarking on hormonal birth control. So this was a very enlightening conversation.

We discussed a few other options, a few nuances regarding methods for contraception. We also discuss the impact, not that this was the main thrust of the conversation, but the impact of the gut on female hormones and also how women who are in the perimenopausal/menopausal transition are oftentimes offered birth control as a way of stabilizing their hormones. This is way too strong of an approach. We also discuss how oftentimes women who are in the cycling to menopausal transition that that perimenopausal time oftentimes only need just a gentle push. This is one of the reasons why, even though Healthy Gut, Healthy You is focused on gut health, I have a breakout section where I discuss Estro-Harmony and Progest-Harmony, which are two herbal blends that help to balance estrogen and progesterone respectively.

These work remarkably well when combined with the foundation of diet and lifestyle, and then with the appropriate supports for gut health. Really only the subtlest of pushes with these herbs can get a woman fully back to hormonal balance. Ostensibly, as we’re reading their symptoms as a gauge, I’m not really doing repeat testing. I’ve I found that to be not a very fruitful endeavor, but we could very easily say determine if someone no longer has hot flashes when she used have them nightly, or now has regular cycles when they were irregular previously or now has normalized bleeding. So we can fairly easily read if a woman seems to be exhibiting hormone balance. Oftentimes when you have the foundation of diet and lifestyle in place, plus some support for the gut and then a little push with some of these herbal remedies that tend to be, loosely speaking adaptogenic, meaning corrective, that is all that’s needed in most cases.


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What is the Safest form of Birth Control -
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So this was a great conversation with Sara and I hope if the topic of birth control and contraception is something that you are thinking about that you’ll get this episode of listen, because there is some debate on this issue. I wanted to have someone on who could really give us a very tenured, narrative on the topic and she really delivered. So I hope you will enjoy it. Also, remember if you are a woman, whether you are in your twenties or in your fifties, the Estro-Harmony and Progest-Harmonies can be helpful, especially again, when combined with the foundations of diet and lifestyle and the appropriate gut support for your system. These can really work remarkably well with just a gentle push. So I hope you’ll have a look at Estro-Harmony and Progest-Harmony, which are both available in our store.

➕ Full Podcast Transcript

Intro:

Welcome to Dr. Ruscio radio providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, please make sure to subscribe in your podcast player. For weekly updates, DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking to your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hi everyone. Today I spoke with Dr. Sara Gottfried about the safest forms of birth control. I’ll give you kind of the summary here. The copper IUD is the best all around consideration, and there are some notable side effects and risk factors for oral or hormonal contraception also known as “the pill”. This type of contraception may increase risk of blood clotting mood and balances, Crohn’s disease, fungal overgrowths, problems with thyroid hormone, problems with libido and clitoral stimulation. There is also an impact on vaginal moisture as a indirect result of the impact on what’s known as sex hormone binding globulin, and how that impacts free testosterone. The use of oral contraceptives may be justifiable in some cases and so she gives us a very well reasoned and rational overview. However, it does seem that the copper IUD is the clear winner in this comparison, and unfortunately the much more prevalent oral contraception does carry some significant risks, which she feels women are not really made aware of when embarking on hormonal birth control. So this was a very enlightening conversation. We discussed a few other options, a few nuances regarding methods for contraception. We also discuss the impact, not that this was the main thrust of the conversation, but the impact of the gut on female hormones and also how women who are in the perimenopausal/menopausal transition are oftentimes offered birth control as a way of stabilizing their hormones. This is way too strong of an approach. We also discuss how oftentimes women who are in the cycling to menopausal transition that that perimenopausal time oftentimes only need just a gentle push. This is one of the reasons why, even though Healthy Gut, Healthy You is focused on gut health, I have a breakout section where I discuss Estro-Harmony and Progest-Harmony, which are two herbal blends that help to balance estrogen and progesterone respectively.

DrMR:

These work remarkably well when combined with the foundation of diet and lifestyle, and then with the appropriate supports for gut health. Really only the subtlest of pushes with these herbs can get a woman fully back to hormonal balance. Ostensibly, as we’re reading their symptoms as a gauge, I’m not really doing repeat testing. I’ve I found that to be not a very fruitful endeavor, but we could very easily say determine if someone no longer has hot flashes when she used have them nightly, or now has regular cycles when they were irregular previously or now has normalized bleeding. So we can fairly easily read if a woman seems to be exhibiting hormone balance. Oftentimes when you have the foundation of diet and lifestyle in place, plus some support for the gut and then a little push with some of these herbal remedies that tend to be, loosely speaking adaptogenic, meaning corrective, that is all that’s needed in most cases.

DrMR:

So this was a great conversation with Sara and I hope if the topic of birth control and contraception is something that you are thinking about that you’ll get this episode of listen, because there is some debate on this issue. I wanted to have someone on who could really give us a very tenured, narrative on the topic and she really delivered. So I hope you will enjoy it. Also, remember if you are a woman, whether you are in your twenties or in your fifties, the Estro-Harmony and Progest-Harmonies can be helpful, especially again, when combined with the foundations of diet and lifestyle and the appropriate gut support for your system. These can really work remarkably well with just a gentle push. So I hope you’ll have a look at Estro-Harmony and Progest-Harmony, which are both available in our store. Okay. Let’s now go to the show.

Meet Dr. Sara Gottfried

DrMR:

Hi, everyone. Welcome back to another episode of Dr. Ruscio radio. This is Dr. Ruscio here with Dr. Sara Gottfried, and we are going to be discussing natural methods for contraception or prevention of pregnancy. I asked Sara to come on because my fear, my concern in this area is in the natural community sometimes there is this hubris of philosophy first science second. And I think Sara does a great job of kind of looking at both sides, but not leading with philosophy and kind of cherry picking for what evidence supports our philosophy. Rather having a really honest look at the, uh, the data. So Sara, welcome to the show.

DrSaraGottfried:

Thanks. Happy to be here.

DrMR:

Can you tell people just in brief, cause you’ve been on the show before, so people may have heard that one and gotten your background, but in case they haven’t, can you give us a real quick, backstory?

DrSG:

So I’m a gynecologist. A medical doctor. I went to the Harvard medical school, UCSF for residency. My focus is precision medicine for both men and women. I would say hormones are kind of the portal that I use and from which I see the world.

DrMR:

Alright, awesome. So definitely one of the best people to be picking their brain on this topic. This is something that has come up a few times in the clinic. Women have been asking me for my recommendations here, which this is an area I really don’t have a depth of knowledge. Obviously I know that cycle tracking, timing, can be, I believe, on par with as effective as condoms. But I also get questions of, are there any kind of natural hormonal birth controls? Is hormonal birth control as bad as it’s proclaimed to be? What about IUDs? Of course I hear things through the grapevine, but, and I might be a little bit cynical now, but so much of what I hear from some circles just seems to be so dogmatic where people are vehemently opposed to one thing or another. There may be evidence to support that, but I also can’t help but think how much of this is a philosophy first type of mentality. So kind of a broad interlude into the topic here, but where do you start with this conversation about natural or maybe even conventional contraception. Where do you launch in?

The Pill

DrSG:

Where to launch in? I would say I like to lead with the science. I think maybe beginning with the birth control pill is a helpful place to start because it kind of lays the groundwork for where we are right now with contraception and that gives us some information about how we might make smarter choices. So how does that sound to start with oral contraceptives?

DrMR:

Yeah, sounds great. Let’s do it.

DrSG:

So I overall I’ll give away my bias, which is based on the data. I think that oral contraceptives are the number one endocrinopathy in the United States, maybe the world. It’s an iatrogenic cause of hormonal disruption. I have a number of reasons for that, which I’d be happy to march through. In terms of oral contraceptives, it’s the most common choice. It’s something that I took when I was 16 years old. I took it through my twenties. So I have personal experience with it. The thing that I think is the most troubling about oral contraceptives is that most women are not given full informed consent about all of the risks, some of the benefits as well as the alternatives. So let’s go through some of those risks. The main risks that I think about is thromboembolic. So the increased risk of blood clots. This is somewhere between 1.5 to about 6 to 7x, depending on what’s in the birth control pill. So that includes some of the newer progestins that have a greater risk associated with them. Most people know that there’s some mood issues associated with oral contraceptives. What people don’t know is that the birth control pill is associated with a greater risk of Crohn’s disease. So I’m going to talk about the gut a little bit here. It’s also associated with fungal overgrowth. It impairs, in the immune system, Th17. It can cause problems with thyroid function. It leads to higher breast density. If we look at hormones in particular, what I see in my practice, and I know other practitioners who are listening also see this is that the birth control pill raises sex hormone binding globulin, and that leads to a reduction in free testosterone. So what happens as a consequence of that is the clitoris can shrink up to 20%. It can cause vaginal dryness in 20 to 25% of women and it can cause painful sex by depleting hormonal lubrication, right at the introitus, the opening to the vagina. So those are some of the reasons why I’m really cautious with the birth control pill. Maybe I’ll pause there and just see if you have any questions.

DrMR:

So fantastic to point these issues out for people. My thinking is part of the reason why women have kind of bought into birth control is 1) they’re trying to prevent pregnancy and they may be willing to take some risks to that end point and 2) to your other comment, they may not have been fully made aware of the risks that oral contraceptive carry. Regarding other options. IUDs are something that are becoming more prevalent somewhere hormonal, some are not. How do these look in your eyes?

The IUD

DrSG:

Well, I would say I’m a crusader for the non-hormonal IUD. I probably have put in about 5,000 of them. I think the IUD is such a good choice for women of all ages. The data shows that the copper IUD is as effective as getting your tubes tied. So it’s incredibly effective in terms of efficacy, more effective than the birth control pill. And once you decide that you want to get pregnant, you pull it out, you can get pregnant right away. Whereas with the birth control pill, it can take a few months for you to start ovulating again on your own. The other issue is that I like to look at satisfaction rates. We know that the birth control pill has lower satisfaction rates than the copper IUD. So when I look at satisfaction rates and then I compare it to use rates, there’s a total disconnect because people are not choosing to use the copper IUD. They are choosing to go with the birth control pill, maybe because of the acne benefit or they feel like their cycle is painful. And I just think it’s important to realize that we could take a step back and we could address those problems in a more natural way. And we know Omega-3s are incredibly effective at helping with dysmenorrhea. We know that cutting out gluten and dairy and healing your gut is a very effective way of dealing with acne. So I think we need to have this more functional precision approach to dealing with the root cause of what drives someone to the birth control pill.

DrMR:

Yeah. When you evaluate the symptoms or potential risks of things such as blood clots, mood swings, Crohn’s, fungal overgrowth, thyroid issues, problems with testosterone and the resulting clitoral and vaginal mucosal issues. It does seem that it’s not the best kind of a pro/con balance if your goal is just to improve your skin, especially when considering there’s a lot we can do with diet, supplements, and gut health. Again, I’m assuming that women are just not being given this education, at their doctor’s office, so they’re just kind of doing what everyone else is doing. I can see why you are a crusader. If I was working in your field, I’m sure I’d be banging my head against the wall all the time with why aren’t more women on the copper IUD.

DrSG:

Another important point here is that I’m not saying that the birth control pill should never be used. I would never say that, like, I think women need more choices, not fewer. There is a time and a place for the birth control pill. The situation where I prescribe it is in someone with endometriosis and we’re working on gut issues. SIBO is highly correlated with endometriosis. If it’s going to help you avoid surgery, I think that’s a reasonable time to use it. That, of course, is not the indication for the majority of people who are taking the birth control pill. I think our culture has gotten to a place where we just look at the birth control pill as a way of wiping out our periods and making them a nonissue. I would much rather that we focus on ways to make the period kind of reflect normal physiology so that it’s not painful and it’s not causing kind of inconvenience and disruption the way that some women experience it.

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DrMR:

Now with the, the copper IUD, coming back to that, just for a second, are there concerns? I’ve heard some women say will my partner be able to feel it? Can’t it be uncomfortable? Do some people get copper toxicity? How do you respond to these questions?

Side Effects of the IUD

DrSG:

Yeah, good questions. So when you have an IUD that’s inserted properly, and I have paid a lot of attention to this, Michael. When you cut the strings long enough, so that they’re coated in mucus and wrap around the edge of the cervix, your partner is not going to feel it. It’s not going to prick the penis. So that’s not an issue. After inserting 5,000, I can tell you, it’s just not a problem. The problem is when you get it inserted by someone who doesn’t have a lot of experience and they clip the thread that comes off of the IUD too short, that can poke the penis. So you don’t want that situation. When it comes to copper toxicity, I haven’t seen this to be a problem in my patients. I mean usually, and I’m sure you see this as well, when someone has an issue with copper zinc balance, it’s not usually from an IUD, it’s from other issues upstream. So the number of patients that I’ve seen with copper toxicity with an IUD, my numerator is zero out of 5,000. So I know it’s been reported in the literature and people talk about this, but I think it’s overblown.

DrMR:

Yeah. That’s fair. I think some of these things tend to get overblown just out of there being a mechanism. The “it’s copper, doesn’t that mean it should cause a problem” line of thinking. Similar, to use a trite example at this point, probiotics causing SIBO. The mechanism makes sense so I think that’s how that canard gained some much steam, but we have to look and see if this is something that is actually prevalent at all. So great point. So they’re not uncomfortable. They don’t cause problems. Well, are they uncomfortable for the woman? Can the woman feel the IUD once it is inserted?

DrSG:

Yeah, that’s an important point. So when you insert an IUD, it’s a little uncomfortable, you know, anyone opening up your cervix and putting something through it, it’s uncomfortable. It’s not as painful as having a baby, but if you’re putting a small IUD through the passage way, it can cause some uterine cramping, similar to menstrual cramps. That’s kind of the order of magnitude that women feel. I’ve had a few inserted myself and I can confirm that it’s nothing like labor. So it’s a little uncomfortable. It’s a little more uncomfortable in women who haven’t had a baby. So if your cervix hasn’t gone through that process of opening and closing, it can be a little more uncomfortable. Generally what I do is I have people take some anti-inflammatories before they have an IUD inserted and that’s generally sufficient to really help with the discomfort. I think it’s, it’s outweighed by the efficacy as well as the satisfaction rate that people have overall. Now, what happens with some women is that they can have some increased menstrual flow associated with the IUD being inserted. That’s probably because there’s some inflammation and a foreign body reaction. What I generally see is that it completely resolves within three to six months. If I have a patient who’s got heavy menstrual flow, then I might add some natural progesterone or something to try to reduce the flow. But it’s short-lived, three to six months. One of the things that I do, here’s a quick little pearl. I like to give a certain supplement that has Shepherd’s Purse in it which I have found reduces menstrual flow by about 50%. I usually find that that’s sufficient to reduce any increased flow that’s associated with the copper IUD

DrMR:

And with the discomfort, I’m assuming that’s just temporary for a matter of weeks or so after the implantation?

DrSG:

I would say for the most part, it’s just 30 minutes. That’s how long the discomfort lasts. If it lasts longer than that, then there could be a problem. One of the risks of having an IUD inserted is that it could be inserted in the wrong place. So you could go through the uterine wall. This is pretty rare, but that can cause increased discomfort. And one of the ways that you can check on that is to run a quick ultrasound and just make sure the IUD is where it’s meant to be.

DrMR:

Are there any side effects with this route?

DrSG:

I would say with the IUD, the main side effects are extravasation. No form of birth control is 100%, but this is 99.8% effective. It’s the best. Stands up against tubal ligation. I would say, increased bleeding and the discomfort with insertion or the other side effects.

The Hormonal IUD

DrMR:

Okay. And this is just for the copper. Just to make sure we’re clarifying this for the audience, you’re not advocating for the hormonal IUD.

DrSG:

So let’s talk about the hormonal IUDs. The way I think about the hormonal IUDs is similar to the birth control pill. I think there’s a time and a place for them. So when I have a patient who’s got really heavy menstrual bleeding or has endometriosis or there’s some way that we’re trying to create natural hormone balance, I will consider the Levonorgestrel IUD. It’s also known as the Mirena. The problem with it is even though the risk, the side effect profile is less than what we see with the oral contraceptive on paper, based on the post-market surveys, somewhere around 10% of patients will have symptoms of systemic progestin. So we should talk about progestins for a moment. Progestins are these synthetic forms of progesterone? So they’re not the same as natural progesterone. I’m a big fan of natural progesterone over the course of one’s life. I think it’s effective for both men and women, especially women who are in perimenopause. So synthetic progestins are much more dangerous and provocative. So in terms of these synthetic progestins Levonorgestrel is the one that’s released in IUD. The makers of the Mirena would say to you, it’s just released locally in the uterus, there is no systemic effect. But that’s not the case. I would say for women who are exquisitely sensitive, they can have some of these other side effects, like mood issues, like problems with developing ovarian cysts. So that’s what I tend to see with the Levonorgestrel IUD.

Ovulation vs. LH Tracking

DrMR:

Okay. Another question I have. How practical is the counting and ovulation tracking. I’ve heard that it is about as effective as condoms, but I have a hard time with the concept of user error. Like you would forget here and there and you know, is that enough to significantly increase the margin of error? What are your thoughts on that method?

DrSG:

Yeah, you’re right. I mean, the failure rate is about the same for using condoms as it is with ovulation tracking. The old school way of doing this was to look at your temperature and to see a spike around the time of ovulation and then to avoid sex around that time. What I find is that much more accurate than temperature tracking is to look for your LH surge. So this is the surge of luteinizing hormone that then causes release of the egg from the ovary. I think LH tracking is more accurate than ovulation tracking using temperature. So there are some people who do really well with checking their temperature every morning. I don’t have a lot of those patients. For whatever reason, they just don’t want to check their temperature. So they use LH kits. For someone who doesn’t want an IUD, what I like to do is to combine some of these modalities so that you’re using condoms together with what’s known as natural family planning, which is more this ovulation tracking. The other thing that I like about ovulation tracking is that it gives you a sense of really understanding your body. I think that’s something that’s really missing for a lot of us, men and women. I think that kind of mastery of understanding your own physiology and understanding, okay, I’m ovulating. No wonder I am wanting sex more, no wonder I’ve got a little twinge in my right lower quadrant. I think that kind of interoception where you really know your body is important.

DrMR:

You just gave me a question I would ask with my own selfish interests. Are you familiar with the people over at Clear Passage, Larry and Belinda Wurn who do manual visceral therapy for abdominal and pelvic adhesions?

DrSG:

No. Tell me more.

Pelvic Pain

DrMR:

They’ve done some really fascinating work and they’ve published, I think a couple of dozen research papers in peer review journals. One of the things that they essentially are finding is that scar tissue can form in the abdomen or pelvis and lead to, I believe what’s happening, some partial tubal occlusion due to the scar tissue that can be broken down with this fairly robust, intensive manual massage therapy techniques that they have. It’s not really massage. It’s more like targeted therapy, but it’s manual. And so one of the dots I’ve been trying to connect in the clinic is if a woman has exhibited issues with either cycle length or regularity, and she also repeatedly experiences pinpoint pain upon ovulation, if that correlates to someone who has scar tissue there that may be in need of remedy with visceral therapy like Larry and Belinda offer. Is there anything there? Because obviously there can be kind of this global pain and that wouldn’t seem that abnormal to me, it may just be due to the hormonal fluctuations and how it affects inflammation and nociception and motility. But if it’s always in the same lower right hand quadrant, lower left hand, is that suggestive at all of there being some type of scar tissue present? Or am I looking for an association there isn’t really an existence?

DrSG:

What I like about your question Michael, is that you’re thinking outside of the box. I think what happens for most women when they have pelvic pain is they go to their clinician and maybe they get an ultrasound. Maybe they don’t, maybe they just get an exam and they get put on a birth control pill. Let’s see if suppressing your ovulation helps you with your pain and no one bothers to look at the root cause. So I think your approach of asking the question, could there be something mechanical? Could there be some scar tissue? Could it be that there’s some adhesion to the bowel? Cause I think a lot of bowel complaints are overlaid with pelvic pain and it gets attributed as, you know, female pelvic pain when it could actually be related to the bowel. So when it comes to manual visceral therapy, I don’t have a lot of experience with it. I’ve certainly had it done on myself and I have noticed great benefits. I’ve seen it, I’ve referred some of my patients for it, like especially my patients who have endometriosis and I know they have scar tissue because they’ve had a couple of laparoscopies and we know that there’s, there tends to be scar tissue afterwards. In those folks, especially if they have a retroverted retroflexed uterus, I will refer them for manual visceral therapy. But I haven’t looked at the literature recently. My sense is it’s mostly anecdotal

DrMR:

I agree with you, I think manual therapies is an area where there’s not enough research has been published. What I found really attractive about Larry and Belinda’s work. They’ve published a number of papers and I believe this one just quickly pulled up on pub med, entitled “Treating Fallopian Tube Occlusion with a Manual Pelvic Physical Therapy”. Belinda F. Wurn, lead author. If I’m reading this correctly, I’m doing this quickly, but in a small sample size of 28 patients, 50% of them, 53% actually were able to become pregnant after the therapy. This is an emerging field, but it’s something that, to your point, I’m always trying to figure out is, is that pinpoint pain something that needs to be addressed rather than just paving over the pain by medicating. Perhaps this might be like a dashboard light flashing and telling us that there’s something else underneath the hood that needs to be addressed By doing that, you may improve the likelihood of fertility and also, stop the pain that they’re having. Two birds with one stone, so to speak. Okay. Just was curious to kind of pick your brain on that, knowing your area of specialty here.

DrSG:

Well in that particular study, I haven’t looked at the study, but it sounds like it was looking at women with infertility. So for women who have not able to get pregnant after they’ve been trying for 12 months, if they’re under the age of 35 or six months over the age of 35, often these women have what’s known as tubal factor where their tubes are not patent. So a fertilized embryo can’t get through the tubes. And so we are eager to have strategies that might help in that situation because often what ends up happening in mainstream medicine is that these women with infertility get sent to get in vitro fertilization. So I think if we can have more solutions such as manual visceral therapy, especially if they’re proven in prospective well-designed studies, I think that’s a huge value to the field.

DrMR:

Awesome. I’m assuming tubal occlusion or lack of patency is associated with pain? Is that accurate or did they not track that tightly?

DrSG:

It can be associated with pain. The most likely scenario is that it’s associated with a history of sexually transmitted disease or pelvic inflammatory disease. With STDs, you can have asymptomatic, chlamydia, for example, that can scar your tubes and lead to a lack of patency, but you never had symptoms. So it’s not always associated with pain. If there’s fluid built up in the tube and a lack of peristalsis, that’s what tends to trigger pain.

DrMR:

Is there any overlap, speaking of, kind of abdominal and pelvic inflammation. To your knowledge, is there any association with tubal occlusion and Crohn’s disease or just inflammatory bowel disease more broadly?

DrSG:

Yeah, that’s a good question. So in thinking through how to answer that question, it makes me think about altered immune function. So, Crohn’s disease as you well know, is an auto immune disease. We know that women have much higher rates of autoimmune disease compared to men. In general, they have stronger immune responses to vaccines and to exposure to viruses. I’m not aware of a correlation between Crohn’s and a lack of tubal patency. I’d have to take a look at that.

DrMR:

Okay. Yeah. I’m just kinda geeking out and picking your brain from every angle while I have you here.

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Let’s Talk About the Thyroid

DrMR:

One thing I did want to get your take on. This is a whole can of worms that we could do a whole episode on it in and of itself, but I know that we both look at issues regarding thyroid and I think we’ve both been similarly frustrated by some of the goings on, is there anything at the front of your mind regarding thyroid that you think is worth discussing?

DrSG:

I love talking about the thyroid. Well, I think, you know, going back to just oral contraceptives for a moment, and I should maybe broaden this to some of the other contraceptive methods, such as the patch, the contraceptive patch and the vaginal ring. What we know is that oral contraceptives, the patch and the ring, all induced liver changes such that you’re making more carrier proteins. So that includes TBG so that you’re soaking up free hormones. It includes sex hormone binding globulin. We talked at the beginning about how that is like a sponge that soaks up free testosterone. And that’s really a problem for women who are sensitive to it. If we could go a little bit further, can we geek out for just a moment?

DrMR:

We absolutely can.

DrSG:

So with sex hormone binding globulin. This is emerging as a really important marker for so many different things, for cardiovascular disease, for metabolic function generally. We know that the birth control pill raises sex hormone binding globulin. What I see in my patients is that there are some patients who have an androgen receptor that is super efficient. It’s like a Prius. So even if they drop below a certain threshold with free testosterone, when they go on the birth control pill, they don’t have symptoms and they don’t see what the big fuss is about. So there’s that whole subset of patients who just don’t have a problem with the birth control pill. They may have blood clots, or they may have other issues, but not usually testosterone related symptoms. Then there’s this other group of patients, another subset that have more of the “gas guzzling” type of androgen receptor, kind of like a Hummer. When you drop them below a certain threshold of free testosterone, because they’re on oral contraceptive, they really notice it. So they’re the ones who end up in the vulvodynia clinic. They’re the ones who have the vaginal dryness. They’re the ones who have decreased libido, which is the greatest irony, of course, because when you go on the birth control pill, you do it because you want to have sex usually. When your libido goes down, because you have no free testosterone, it’s just a sad state of affairs. So I think getting back to your question about the thyroid, I think we have to acknowledge the role of these contraceptive choices and how they can interfere with thyroid function, especially the Free T3 and T4 that are in the system. The other thing that’s important to realize, and this is the thing that maybe upsets me the most. When you come off the birth control pill, your sex hormone binding globulin doesn’t go back to normal. There’ve been not enough studies on this, but there’s one by Panzer et al that showed that your sex hormone binding globulin will go down, but not to your pre birth control pill levels. So I think that’s a really important piece of this conversation. A lot of people assume that that’s because of oral estrogens, but the sex hormone binding globulin also goes up with the vaginal ring and with the contraceptive patch. So we have to kind of consider all of these in the category of potentially longterm risks that may or may not be reversible.

DrMR:

And this observation sounds like it’s perhaps a bit newer. Um, are there any therapies that are being explored to help correct that imbalance in the sex hormone binding globulin?

DrSG:

I haven’t seen protocols that have really been proven sufficiently. There are a lot of ideas about what you may want to consider doing. The other thing that’s important with sex hormone binding globulin is that it does seem to be a marker of your thrombo-embolic risk. We track it for a lot of different reasons. I track it in my patients with polycystic ovary syndrome. I track it in pretty much any woman who’s over the age of 40 for cardiovascular risk. I wish that we had really good methods for reversing that elevation in sex hormone binding globulin, but we don’t. Maybe next time I come on your show, I’ll have an answer for that.

DrMR:

Yeah. Hopefully. All right. Well, this has been a great conversation. I am relieved to hear that this is not necessarily that complicated and there’s a really good clear choice for the majority of cases, not all cases, but it sounds like the majority of cases. The copper IUD seems to be the best way to go. I’d love for you to tell people a little bit more about, cause I know you’ve worked really quite fervently to put together books and other protocols for men and women. Obviously a lot of your offering has been related to female related health issues. So tell us about some of what you’ve been up to and where people can kind of track you down on the internet.

DrSG:

Yeah, well the best place to go is saragottfriedmd.com. That’s kind of the mothership. My first book, The Hormone Cure is probably the one that gets into the most details about the birth control pill. I’ll be talking more about the birth control pill in my new book. It’s not going to be out until next year, which is about fat loss and women.

DrMR:

And I know you do a fair amount of lecturing, anything interesting or novel there in the works?

DrSG:

Sure. Well, I always have lectures with, A4M, the American Academy for Anti-Aging Medicine. We’ve got a bio- identical hormone therapy conference that’s coming up soon. We’ve got an event later this week on environmental stressors that I’m giving a talk on, as well as cardiovascular disease and immune function issues in women. I’ll also be speaking about cardiovascular disease at their December conference. We don’t know if that’s going to be virtual or in person. Then I’ve got a few other talks for like the Personalized Lifestyle Medicine Institute. I love giving talks. So there are always a lot of those that are mentioned on my events page.

DrMR:

Awesome. Awesome. Cool. Uh, any kind of closing words you want to leave people with?

DrSG:

Well, I want to leave with, you know, not doom and gloom about the oral contraceptive, but to really say that women need more choices. While I’m a big fan of the copper IUD, I also think, for women who are really attentive, who want to do natural family planning and put that together with using condoms, that can be very effective. I like to define sex pretty broadly. You know, it may be that you just avoid intercourse around the time that you’re fertile, but you can still have outercourse. So I think those pieces are really important. The other final thing I’ll say is in perimenopause, we tend to push women now toward oral contraceptives. I think that that’s really doing women a disservice. Those are the women that especially need bioidentical hormone therapies. They’re in that critical window where they can maintain the benefits of endogenous estradiol levels.

DrMR:

Yeah. I mean, that’s a great point because we want to try to work with the system and not necessarily pave it over willy nilly, just because let’s say the potential side effect of problems with fertility after coming off birth control are no longer an issue in the perimenopausal age group. It doesn’t mean that we shouldn’t be trying to get as much benefit out of modulation of hormones as possible. So that’s a great point. I’m really glad that you brought that up.

DrSG:

Yeah. I would say women in perimenopause, they don’t need to be paved over. They don’t need a sledgehammer. They need like a little nudge. I think that’s much more effective.

DrMR:

Agreed. I’ve been blown away with how game changing just some of the simple herbal interventions that we use have been for women with hot flashes and brain fog and everything else. And that wasn’t even using an actual hormone. That was just rather like a serum estrogen receptor modulator like black cohosh or dong quai. To your point, just a little push was needed, not this paving over.

DrSG:

That’s right. Healing the gut can make a big difference. Doing the stress management work that all of us need to be doing all of those make a big difference. I’m a huge fan of chasteberry as a way of raising indogenous progesterone levels. Vitamin C does that too. So yes, there are a lot of natural options.

DrMR:

Yeah. I love it. Well, Sara, thank you for taking the time to speak with us and also thank you for being a rational voice of reason out there. Sometimes I feel like I’m the crazy person, but then I come across someone’s work like your own and it’s like, okay, you know, there are other people here who are clearly looking at this through a lens of rationality and reason I’ve just really appreciated your work and that levelheaded approach that you take.

DrSG:

Thank you, Michael. Happy to stand with you.

DrMR:

Awesome. Thank you again. Take care.

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