Dr. B on Menopause and Birth Control

Katie recently had a live chat with Dr. Rebecca Brightman about hormones and menopause. During their in-depth discussion, they also dove into the tricky matter of contraceptives: After all, hormonal birth control can subtly — or not so subtly — affect a woman’s health. Dr. B had some insightful points to make about how birth control, a history of breastfeeding, and past pregnancies (or a lack of pregnancies) can change a woman’s likelihood of developing ovarian or breast cancer. She also addresses the best time to ditch your hormonal birth control as you age. Plus, Dr. B sounds off on an issue that’s been on our minds since the overturn of Roe v. Wade: Are male contraceptives an option for the future?

Katie Couric: Let’s talk about the pill. That’s one thing that I think people do without thinking — they just stay on the pill. Let’s say they’ve had their children and they don’t want to have any more, should they be staying on the pill until they reach menopause?

Dr. B: So in the absence of any contraindications, I would say yes. Now as women age, there’s an increased risk of hypertension, blood clots, and high cholesterol. These things need to be evaluated, but in an otherwise healthy woman, without any contraindications, I will keep somebody on a low dose of the birth control pill up through menopause. Years ago, I would say, OK, 51 is the average age of menopause — let’s take people off then. Then it was a trial and error game that was very torturous for my patients because not all of them were menopausal yet. They’d bleed, then go back on the pill. So really, the prevailing philosophy is to keep people on the pill and that’s OK. If they’re the right candidates to keep them on the pill until they reach menopause, I will do that — I will use a low-dose birth control pill. Now, if I have somebody who started it in their 40s and they were menopausal at the time, I may switch them over to hormone replacement at a younger age. With my other patients, I will let them go closer to 55.

Doesn’t the pill have some health benefits? I know, for example, that people who never get pregnant (like lifelong nuns) have a higher risk of cancer. Will you explain that?

You’re absolutely right. So, the birth control pill’s mechanism of action is that it suppresses ovulation; they keep your ovaries nice and quiet. There is data to show that women who have used birth control pills lower their lifetime risk of developing ovarian cancer.

What about the risk of breast cancer?

Nuns, or people who’ve never been pregnant, are not necessarily at higher risk. If there’s an increased risk for women on birth control pills for lengthy periods, it’s very, very small. Again, that’s independent of family history. I don’t have an issue putting people on birth control pills. Some of my patients were at higher risk of breast cancer, for example, they have a hereditary mutation for breast cancer, maybe at increased risk for ovarian cancer, and they want to lower that risk, especially when they’re young and they have their ovaries. So these women are specifically on the pill. We know that being on birth control pills not only lowers the lifetime risk of ovarian cancer, but it also protects the uterine lining.

Sometimes women who don’t have kids are at higher risks of certain cancers. Why is that?

I would break it down into categories. We know that women who have had pregnancies — particularly before the age of 30 — and women who have breastfed have lowered their risk of developing breast cancer. It’s not completely understood. The ovaries are nice and quiet, but estrogen levels are higher during pregnancy. But then again, if someone’s breastfeeding, estrogen levels are lower. The interesting thing is that women don’t ovulate when they’re pregnant. That will be protective for the ovaries. Women who have never had children, women who have earlier periods, and women who go through menopause later do have a slightly increased risk for breast cancer.

Let’s talk about non-hormonal contraceptive choices. I’m asking for Elaine from Seinfeld: Whatever happened to the sponge, Dr. Brightman?

We used to joke as residents that the sponge is great for washing the baby. The sponge is really not the most effective birth control. It’s out, it’s available. But I really encourage my patients to pursue other options. Of course, not everybody wants to use something that’s hormonal. Obviously, there are condoms; condoms are the only form of contraception that will not only protect against pregnancy, but will protect against sexually transmitted infections. I always tell my patients that condoms and diaphragms have made a little bit of a resurgence. Cervical caps are non-hormonal, too. There are spermicides, also, and there’s a new sperm immobilizer that has been FDA-approved called FEI. It has to be inserted up to an hour before intercourse, but it’s been proven to be effective. It needs to be reapplied with each active intercourse, though. There’s also a non-hormonal IUD, which is very effective.

What about birth control for men? I know vasectomies are up particularly in the wake of Roe v. Wade being overturned. Will there ever be more measures for men?

So there are types of male contraception that have been studied. It’s very interesting when you look at some of the side effects. There’s moodiness, there are headaches, and some of the symptoms and side effects women have from birth control pills. Male contraceptives are not currently on the market in the United States. And the question is, will they ever be approved? Pharma hasn’t really jumped behind male contraception, although perhaps they will given what’s going on politically. I think the concern is that men will not readily accept male contraception, sadly enough.

Watch Katie’s full conversation with Dr. B below and be sure to register for part 2 of this event.