Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Today we're talking about birth control. We're taking a step-by-step approach to this important topic, separating fear-based myths and misinformation from the evidence-based facts and answering all the important questions.
For example, will birth control impact my fertility in the future? What can I expect regarding weight gain, blood clots, mood swings? Are there any health conditions that impact the use of my birth control? We'll also explore how to make the best decisions around birth control throughout your lifespan.
Whether you're in your late teens, six months postpartum, or in perimenopause, if you or someone you love has questions about birth control options or how to discuss this topic with their healthcare provider, this is an episode for you.

First, let me introduce my guest, Dr Natalie Crawford. Dr Crawford is a fertility doctor, health educator, and co-founder of Aura Fertility, a boutique fertility clinic in Austin, Texas. She has a whole-body approach to medicine using lifestyle and functional medicine with science-backed facts to help people conceive and to understand their bodies.

Dr Crawford has helped thousands of patients and followers learn about their bodies and their fertility, empowering them with education and learning to advocate for themselves in their own fertility journeys. She's also host of the As a Woman podcast.

Welcome to the WebMD Health Discovered Podcast.

Natalie Crawford, MD: I am so excited to be here. Thank you for having me.

Pathak: Before we begin exploring our topic for today, I'd love to ask about your own health discovery — around how you talk to your patients about birth control and the options that are available.

Crawford: I think one thing that I have realized is that probably of all topics, birth control is one of the ones that has the highest amount of misinformation online. This has really come from many physicians and health experts being a little bit later to the game when it comes to social media and spreading facts, yet other people who are not the expert having very loud voices, very big platforms, and speaking without any evidence to back them up.

And this has honestly made patients very fearful, especially when it comes to contraception. They're afraid about what it will do to their fertility. They're afraid about what it will do to their cycle — what it means for the future. I have questions all the time from patients who are hesitant to potentially use birth control when it, in fact, might be very helpful to them.

So I love that we're doing this episode today because I think it is one big myth and big confusion surrounding contraception. It's really important for people to understand their options and what different types of birth control are — and what they are not.

Pathak: I think that's a great frame for our conversation, so thank you so much for laying that out there. So let's pull on one of the threads you talked about — that there is a huge landscape of birth control options, ranging from over-the-counter pills to long-acting devices and non-hormonal options. So can you talk us through some of the major categories?

Crawford: I like to divide birth control options into really thinking about non-hormonal and hormonal as the first divisional category. When we think about hormonal options, this is going to be contraception that interacts or interferes with the normal brain-ovary communication or some part of the ovulatory or implantation cycle.

Most of them impact the ovulation cycle. I think in a one- to two-minute spiel to understand how these different forms of contraception work as we go through them, is to say really quickly: Normally, the brain sends out FSH, or follicle-stimulating hormone, which is the hormone that gets an egg to grow. An egg grows inside a follicle — so it’s a really well-named hormone.

As the egg grows, the egg is going to mature and make estrogen. That's feedback to the brain to then ovulate, and then after ovulation, progesterone is going to be made from that same follicle. For about a two-week time period, the cyst that makes progesterone — called the corpus luteum — will die, and the cycle starts over.

So a lot of times when we talk about hormonal contraception, we might be giving various types of estrogen, which are going to impact the brain so the brain's not going to send out FSH, or we're going to be giving various types of progestins or progesterone. The progesterone can actually change the integrity of the uterus, and some doses of progesterone impact how ovulation occurs as well.

So hormonal options are changing the spectrum of what is happening inside your body, whereas non-hormonal options are typically acting more as a barrier or changing the environment in another way — whether it's causing inflammation or it is working so that there's some blockage. Typically, it's the fertilization process itself. They're not impacting the ovulatory cycle.

There are many more hormonal options that exist. And then within them, there are extremely short-acting options, like progestin-only pills, to very long-acting options, like progesterone-based IUDs. So the decision on what to use is a really complex decision based on your stage of life, your goals, your medical situation.

But I think it's important to understand that there's a lot of individualized reaction and approach. So this blanket fear that “birth control is bad” doesn’t even make sense when we think about the fact that these hormonal options and these non-hormonal options work through different mechanisms. They're going to have different side effects, different risks. So we can't just group everything together as good or bad.

Pathak: When someone comes to your office, what are some of the things that you want to know about their goals, their lifestyles, their potential risks? That’s going to help you make that personalized decision together around birth control?

Crawford: Well, as a fertility doctor, I think obviously the first thing that I am personally talking to them about is not just contraception but family planning. In my perfect world, these two things go hand in hand. Are you wanting to have kids now? No? Great. Let's talk about contraception. Do you want to have kids one day? Yes? Okay. What is that expected timeline?

I really don't love to see when somebody might have a long-acting contraceptive option who really wants to start their family planning journey soon. That may not be the best decision. There might be some side effects that are still lingering for a while that could impede their ability to conceive if they went down that road.

So I think first, when you're having this discussion with your physician, knowing if you want kids or not — and the timeline for that — is always an important piece of the puzzle. Even if they don't ask, please share that information.

From there, I always want to know about their menstrual history. Are they having regular cycles? Are their periods heavy? Are their cramps problematic? Understanding if there might be any other medical things — we might want to choose a contraceptive option that could also help.

Many of the hormonal options can help some of these things. They might make your bleeding less, your cramps might be a lot better. It might help prevent complications that can come from PCOS or mood changes that can come, like PMDD. So we can also leverage not just contraception but also medical treatment for some of our gynecologic disease.

I want to have a good understanding of your menstrual history. Your doctor can only work with what you give them. So take a moment to think about that and track your own cycle if you have been — knowing if your cycle is regular or you have breakthrough bleeding, and what your cramp and bleeding pattern is like.

Outside of that, it is your extended history. Some big things that actually impact us when we're choosing contraceptive options are going to be some of the things that we do worry about — those more rare but serious complications from contraception.

So this is going to be things like personal history of a blood clot, because combined contraception can increase your clotting factors and put you at a higher risk of a blood clot — like a DVT (deep vein thrombosis) or a PE (pulmonary embolism). Whether that’s you or somebody in your family, that would be something to bring up.

If you have a history of a stroke, we're not going to want to use hormonal options that could increase your clotting factors. If you have migraines with an aura specifically — it's not an absolute contraindication, but it's something to talk about. So that would definitely be something you'd want your healthcare provider to know, and it's something I'm always asking.

And then also, any hormonally sensitive cancer — whether that's you, or if that's in your family, or any cancer-causing genes — is something we want to think about. So there are a few cases where we really do want to change the options that we might be using based on our medical history.

And then outside of that, a lot of it is trying to improve your quality of life. If we can help you with your family planning goals and make you feel better on the day-to-day, that is the ideal world.

Pathak: Can you talk a little bit more about the various non-hormonal options that are available, and what would lead you to decide on one versus the other of those non-hormonal options?

Crawford: The two most common non-hormonal options that are currently being used are a vaginal gel-based option and a copper IUD.

Now, the copper IUD is a longer-term option. So certainly if we are very remote from childbearing or if we have completed our childbearing, it can be something that can be really nice — not having to think about it or remember to use it.

The copper works by causing inflammation inside the uterus, which is very transient — meaning when the copper IUD is gone, that is no longer going to be a problem. But that inflammation does prevent you from getting pregnant. It can sometimes cause an increase in your bleeding — the amount of bleeding or the intensity of your cramping.

So I don't love that option for somebody who might already have really heavy periods or already have complaints within their menstrual cycle. I don't love that as the best choice. It's not an absolute contraindication though, so it is always something that we can think about — but that would kind of steer me away from that option in somebody who might be thinking that.

When it comes to contraceptive gel, it's actually one that you put into your vagina before you're having intercourse, that’s going to prevent contraception. So it is actually thinking about having to use it, having to feel comfortable inserting something into your vagina, having to have really good compliance.

So that might be a much better temporary option for us, right? We don’t want to have a long-term option, or potentially, if we do have any period-based symptoms like heavy bleeding, this gel is not going to interact with that. So it can be a nice option — but we have to have really good compliance with it.

And it can cause some vaginal irritation in some patients. Essentially, it’s a spermicide — killing sperm. So it is effective, but we have to have really great usage.

So thinking about stage of life, where you are — that is going to come into play. Your own reliance on the contraception — how reliable do you want it to be just on its own, or how much do you want to have to rely on you as the user using it correctly?

Pathak: That's really helpful, and I kind of want to circle back to a point you made at the very beginning of our conversation and connect it to something you just talked about. I think it's really interesting that it was really through women raising their voices and saying, “Hey, I just had an IUD placed and it was actually really painful”—so much so that we're now at a point where pain with IUD insertion is something that we are really advised to talk about with our patients. So can you talk a little bit about that specific side effect and just how you think about how women should be sharing what is going on with them with their healthcare providers when they get started on something?

Crawford: Absolutely. I think this does speak to the good that social media can do when it comes to breaking down stigma or maybe putting a true light on the patient experience. I've had an IUD— insertion is not pleasant, even as somebody who knows exactly what is happening. And it makes sense, because anytime we're putting something through your cervix, it is causing a reaction in your body. Your cervix is meant to protect—nothing going into the uterus. If we think about the physiologic mechanism of the cervix, yet when we put an IUD in, we put a catheter that’s a pretty decent size through the cervix, and then we inject or insert the IUD.

Pain should always be taken seriously, and for so long it hasn't been. You know, throughout my training, there have been numerous procedures where the standard of care was zero anesthesia at all. Certainly throughout time, what we have seen—and as I've gone into my own practice—is that every patient is different, but you have to believe their pain. Not all pain relief mechanisms are awesome, right? So we can inject lidocaine into the cervix and that can be really beneficial, but that can hurt as well. You can have a numbing spray that you can put on. There's some risk if that gets absorbed in certain ways, so there's an amount that you can use.

We're seeing a lot of offices tend toward Rous gas, which can be a fabulous option as it's very short-acting, especially for things like an IUD insertion, which can be extremely painful. And it's not just IUDs— it goes for endometrial biopsies and other in-office type procedures. But your pain is real. I think that a real conversation with your doctor, if you're having an IUD, is really important to say, “Hey, I'm concerned about this. I really like an IUD, but this is what's keeping me from thinking about it: the fear of what that insertional process will be like. What pain control options do you have for me?”

If your physician is very dismissive of your pain, that may not be the best place to be— and that's okay, too. You might want to get another opinion. I will say that even though it is not a common side effect, as a fertility doctor I've definitely seen patients who've had IUDs placed incorrectly or that result in scarring into their uterus.

Even though the IUD placement might be painful in everybody to some extent, I would never want to say that that would be a pain-free process. You are putting something inside the uterus. It's not going to be comfortable. It's going to have some cramping. Of course, we want it minimal and not terrible, but the pain should go away. It should be transient. Your uterus should adjust.

If you get an IUD placed and you have persistent pain from the IUD, that's a warning sign that potentially it is inserted incorrectly or didn't stay in the right position—because they can move around somewhat. I've had women who've got uterine birth defects and had no idea, and it wasn't until they had the IUD placed that it caused a lot of discomfort.

When we don't talk about pain, we don't know what's normal, and somebody will have pain for months and think, “This is just what everybody who has an IUD deals with.” So I do think it's important to say: cramping associated with insertion or the day you get it inserted can be normal. Of course, we want to minimize your pain during the process, but you should not have persistent pain after the fact. That is concerning for me as a fertility doctor, and you should bring that up to your doctor because they're going to want to investigate to see if it has moved or if it is in the right place.

Pathak: So let's talk about some of the other side effects that people may be concerned about. How should they talk to you about some of these? So let's start with concerns around weight gain and birth control. Within what range might you anticipate that your weight has changed because of your birth control regimen?

Crawford: If we look at studies, the only birth control that has actually been associated with an increase in weight gain is Depo-Provera, which is the birth control shot. This is a long-acting progesterone shot that you get every three months. This is such a high dose of progesterone that it will prevent you from ovulating. It has to be received at a three-month interval to prevent ovulation in a high enough number of people to be a contraceptive option.

While we're talking about it, I will say that one single injection of Depo-Provera can last for up to 18 months—meaning it could prevent ovulation for up to 18 months. So if you want to be pregnant anytime in the next two years, do not use the birth control shot, because that is obviously something we don't want to see happen to you.

Weight gain with that shouldn't be more than five pounds over the course of a year, but still, that's not an insignificant amount. And in some patients it is more. Other birth controls have been studied and not shown to consistently cause weight gain— although again, birth control is a blanket term. The mechanism of action for how these contraceptive options work is very different.

And one thing we're going to probably say over and over for the rest of the show is that the individualized response to changing your hormones has to be acknowledged. So where we would expect a non-hormonal option, like a vaginal gel or a copper IUD, to not impact your weight at all, we all have different responses to a change in our hormones—whereas one person might lose weight on one contraceptive option, somebody else might gain weight. So two things can be true at once. Meaning, studies don’t prove consistent weight gain for any birth control outside of Depo-Provera. But that doesn't mean that one individual user might not have some weight gain themselves.

Pathak: And then let's talk about one of the other risks you mentioned, which is the risk of deep vein thrombosis, stroke. Which medications or which birth control methods put you at highest risk, or where do you have that counseling with your patient? You mentioned migraine with aura. You mentioned having a history of DVT prior to birth control. What else should people be thinking about when it comes to risk of blood clot?

Crawford: Classically we're most worried about the combined oral contraceptive pill, known as “the pill.” Really what most people think about when they say the word birth control. The reason why is mostly due to the estrogen component in the pill, which is an ethinyl estradiol. This is very different structurally from the estrogen that your ovaries make, which is just called estradiol. So different, in fact, that ethinyl estradiol does not show up on an estradiol blood assay—meaning if you're on the birth control pill and I took an estrogen level, it'll read zero essentially.

It will fill estrogen receptors, so it is very effective at filling estrogen receptors in the brain and telling the brain that you don't need to send out FSH, so you're not going to ovulate. So it's a highly effective option because of the combined progesterone. So you have daily ethinyl estradiol and a daily type of progestin. You're also going to see a decrease in your bleeding, a decrease in cramps, a decrease in acne and androgen production.

But ethinyl estradiol does increase your clotting factors the most, and it also is metabolized through the liver, which is where all of your clotting factors are coming from. So you really get this increase that puts everybody at a slight increase in risk. For the average person, we're not very worried about it. Family or personal history—those are contraindications where we don’t want to use this, or we want to be very mindful.

Anybody who's on the combined birth control pill, when placed in a scenario that even in normal life would increase the clotting risk, we want to be very mindful of. Whether this is a long-haul flight overseas, whether this is prolonged immobilization, maybe after surgery. This is why you might hear somebody say, “Wear compression socks, get up and walk around the flight every hour, move your body.” Don’t elevate your legs. Don’t just stay totally sedentary—because you now have two hits. You might have the prolonged flight and the birth control that you're on, that is increasing that risk.

So the way I look at it is: we don't love people to be in the two-hit category. If you do have a personal history of a clot, it doesn't mean that it's a never. It is a really combined circumstance. But we really don't love the combined birth control pill for long-term contraceptive options for these people.

There is a lower risk with progestin-only options—not no risk, but lower. There's also a difference in the birth control pill and what we might think of as hormone replacement therapy—when we give somebody estrogen alone, or especially if we're giving estrogen maybe vaginally or some way where it is not metabolized through the liver.

So this is a complex discussion. Fear alone has led to many people who might benefit from hormones in some part to be really fearful of hormones in general. So I think that it's really important to know your own medical history and have a good discussion about what you're using it for. And I'll give an example—we often will give very short-term birth control to somebody in the context of fertility treatments. Maybe they're on it for a couple of weeks so we can synchronize their cycle. I'm much less worried about the thrombotic risk in that person than I am in somebody who is on combined oral contraceptives for a decade because they are preventing pregnancy.

Pathak: That's really, really helpful. I'd love to shift gears and talk around birth control and mood changes. So we know that a lot of mood disorders—whether it's depression, anxiety, bipolar disorder—can be impacted by hormonal change. And this is honestly a very individualized experience, and we have literature showing us this. Meaning, in some groups of people, it actually might improve their symptoms. So there are some cases with bipolar disorder where actually having stable hormones across the board actually minimizes their mood symptoms. There's other cases where, if you already have a mood disorder and then you're started on birth control, you might have an exacerbation of your depression—versus somebody who has no mental health history. Being on birth control has a much lower risk.

Crawford: So I always think this: your response to your hormones is real. There's been a lot of gaslighting, a lot of dismissiveness by medical professionals. You are the only one who cares the most about your health, and it doesn't mean that all birth control is bad if you're noticing mood changes. But certainly, you want to be able to bring that to the attention of your healthcare provider and have that taken seriously.

This is going to be easiest with you knowing the story, for lack of a better word—keeping a good symptom diary, understanding what has really changed, how long has it changed, and what is bothering you.

There definitely have been some people who’ve been worried about having a blunted mood on combined oral contraceptives. Like we said, that might be beneficial for somebody with bipolar, where mood swings are not helpful for them. So it's not a universal thing where if you have a mood disorder it's always bad. But anybody who has a predisposed mood disorder, I'm going to say, is going to be at a slightly higher risk of seeing a change. Whether that change is good or bad, it's going to be a very individualized response. Somebody who doesn't have a health history of a mood disorder is at a much lower risk, so we shouldn't have to worry about the birth control causing depression in the average person.

But again, if you're on the birth control and now you feel depressed, it is certainly something you want to bring to attention—because stopping the pill, if that alleviated your symptoms, is going to be a much simpler pathway than starting medication for depression and just adding to the list.

So it can happen. But across the board, yeah, I view it as the two-hit: if you have a history already, you are at a higher risk of seeing a change in your baseline mood.

Pathak: So in our discussion so far, we've been talking about the contraceptive capabilities of these various methods. So it's important to note that this does not protect from sexually transmitted infections, these methods.
So how do you talk to patients, counsel patients around combining methods if, you know, they're on something primarily because of a contraceptive need, to prevent pregnancy? But how do you also talk to them about needing to potentially think about protecting themselves from STIs as well?

Crawford: I think this comes from making sure that we as providers don't make assumptions about our patients or their life circumstance one way or another, but simply just stating the facts for them. Hey, the birth control pill is a great contraceptive option, which means it can help you prevent pregnancy if used correctly.
It's not gonna prevent you against sexually transmitted infection, so please make sure you and your partner are both tested and you know that you guys are in a monogamous relationship, or you're protecting yourself with other means like condom usage. So just not beating around the bush and being very direct about it.
I see a lot of people who really don't know that — they actually think that contraception is also protection from STIs.

Pathak: That's really helpful. So now I just kind of want to talk through a few scenarios, few types of patients that you might see, and recognizing that our entire discussion has been around how there's no blanket prescription that you're gonna provide.
So a lot of this is gonna be individualized, but how do you think through different life stages and how you're gonna counsel a patient? So for example, let's start with a teen. This is her first time talking to you about contraception. She's navigating acne, irregular cycles. What are some of the things and the choices that you're gonna be thinking about as your first best options?

Crawford: Anybody who is younger, who's also struggling with any hormonal symptoms — so both acne and irregular cycles can be tied to hormonal issues, which is not uncommon as our brain-ovary connection is not fully matured — can benefit from typically the birth control pill or combined oral contraceptive. You know, one of the mechanisms of action is to lower testosterone levels, so that can be very helpful for acne, which is very problematic for teens and their self-esteem.
But also for predictability with their irregular cycles. We certainly don't want people bleeding through their clothes at school or being caught unprepared. So you find a lot of younger women who are struggling with some of these symptoms can benefit from hormonal control, like the combined pill. One of my pet peeves is going to be, I'm already worried that a patient has PCOS, and so in my doctor brain I might say the pill is gonna help your symptoms — which is a true fact — but if I don't tell the patient I'm worried about PCOS or what it is, or do any investigation on if she might have it or set the stage for that, she might come to a real big surprise later on if she stops the pill and these symptoms return, not having that notice. Because we don't know if she'll be on the pill for one year or 15 years.
So I think that's one important thing just in general that we need to think about. That's a perfect treatment for this person, but it's always important to think about what could be the underlying cause. And she may not want to get it evaluated now, but just the knowledge that, hey, this might be something called PCOS.
This is what it is. I would recommend that when you come off the pill, you come back to me so we can talk about it. As simple as one sentence like that can go a long way in helping somebody have some autonomy over their health.

Pathak: Then let's talk about a younger woman who is balancing postpartum needs, breastfeeding, and comes to you talking about contraceptive options.

Crawford: Postpartum, you know, we're typically a fan of progestin-only options, and somebody who is breastfeeding — estrogen-based options can impact the production of milk. And this isn't across the board, but it's certainly the case at the very start of postpartum or when milk supply is not fully intact. So we want to talk about progestin-based options.
These can be pill-based options, although I will say the progestin-only pill is very specific in when you have to take it every single day. Postpartum is a very tough time as far as every single day — you're not sleeping well and you have a newborn — so there is a little bit of a higher failure rate in that time period sometimes.
This is when a progesterone-based IUD can be a great option between babies, so it's not gonna impact breastfeeding. The postpartum uterus is often a much easier place to insert a progesterone-based IUD. There's more options. There's also an arm-based implant. Obviously, we talked about the Depo-Provera shot, but I really think that the pill or the progestin IUD and progestin-based options are gonna be the ones we talk about the most.
I have had patients postpartum who are on the combined pill, and just knowing, again, it's about informed consent. Hey, this might decrease your milk production — if that's really important to you, pay attention to that so we can change.

Pathak: And then what about a perimenopausal woman? So facing shifts, this person has been on hormonal contraceptive for a long time, and now you're sort of concerned potentially about rising heart-related risks. What is your discussion like with this patient?

Crawford: I love the attention we've seen lately on perimenopause and menopause and helping women have better control over their reproductive health in this timeframe. Certainly, there is space for continuing a birth control pill. It definitely can help mitigate some of the bleeding symptoms that exist. We see a lot of women get transitioned over to hormone replacement therapy.
But this is not always a contraceptive option depending on how it is utilized. So this is a really important discussion. If you see a doctor who says, oh, let's switch you over and put you on HRT — which is typically daily estrogen, and then often some cyclic-based progesterone — if we're just cycling progesterone, you're not protected. The estrogen in HRT is typically not a high enough dose to always prevent ovulation.
You can be on a daily progestin if that is, in fact, the case. So that is one scenario where we want to make sure that if you don't want a pregnancy — you can still get pregnant in the perimenopause timeframe — we really want to make sure that if you see somebody and maybe your doctor says, let's switch you over, this might be a better cardiac option for you or a longer-term option, it's not that they're wrong, but we want to make sure that it is the right thing for your stage of life too. Because of course, a pregnancy in this timeframe is also a cardiometabolic risk.
So really having an informed discussion. Probably half my patients will actually want to stay on the birth control pill. Once we kind of talk through it, we want to make sure we're not smoking cigarettes, otherwise, you know, gaining weight — kind of that two-hit idea as well. But we do feel confident continuing the birth control pill in lower-risk patients as they get older.
Or is this somebody who we do want to transition over? This is a group where I love a progesterone-based IUD with some, you know, a daily estrogen patch if they are wanting some hormone replacement, but they really want to have good contraception also. There are a lot of different ways we can talk about how to get there, but making sure that your healthcare provider truly knows your goals and the stage of life that you're at is gonna be key.

Pathak: I want to give you another scenario. So someone who has been on birth control for a while and is now ready to pursue their fertility.
Can you talk through some of the different options that someone might be coming off of and what they can expect?

Crawford: Absolutely. So for most of the time — and I see this scenario every day — when you stop birth control, most birth control options are immediately out of your system or very soon thereafter. There's this myth online that you need to go buy a cleanse to get the birth control pill out of your system, and that is fake news.
But what we do know is that your period, your cycle, is a vital sign telling us your ovulatory status. And if you've been on the birth control pill, or you've had a progesterone IUD for a while, we've lost that vital sign and we've lost that insight into how your body is functioning. Due to this, I recommend that somebody who wants to get pregnant stops the birth control pill about three months before they want to start trying to conceive.
Of course, you could get pregnant immediately, so if that is not something you want, use another method — barrier method, like a condom. But this is going to give you at least a couple months to track your cycles and see if you do have regular cycles. And if you do not, go and see your doctor to get an evaluation to see if there could be some underlying cause. Since we have lost that vital sign, for a progesterone-based IUD, if you are not having periods — so some women still have cycles, they might be very light on a progestin IUD — but often we see amenorrhea or absence of a period, and this is because of the profound progesterone impact inside the uterus and that local reaction thinning the lining to such a degree that even if you are ovulating, you are no longer having any bleeding.
This can last a while, and so I recommend that a progesterone IUD is removed six months before you want to get pregnant so that the lining has time to not be completely suppressed by progesterone and start to build and grow back up. And if you don't have a return to your menses by that time period, definitely go see your doctor to get an evaluation for why, to see if there is something else going on.
In any circumstance, again — you stop a pill, you could get pregnant right away. Or if you remove an IUD, you could get pregnant right away. But we're wanting to identify issues before you're deep six months into trying and getting really frustrated. So again, that's gonna be three months for the combined birth control pill, six months if you have a progestin-based IUD or any method of contraception, I'll say, where you have no period at all. And then two years for the Depo-Provera shot.

Pathak: I'd love to end our discussion by pulling again on some of what you've already said, but I'd love your advice on language tools, things that patients can use to talk about their concerns — potential side effects that they might be having, whether it's low libido, breakthrough bleeding, mood swings, mood changes — to make sure that they're having this conversation with their healthcare provider in a way that they're not potentially being gaslit or their symptoms are being minimized. What are some of your recommendations?

Crawford: I find, shockingly sometimes, how hard it is for patients to explain in words what they are experiencing on a day-to-day basis. So I think it's really important to — before you sit down with your healthcare provider, the first thing they're gonna ask is, “What brought you in today?” or “How are you doing?” — and this is your open forum to describe what is happening, what is bothering you. You should prepare for that moment.
So take the time to think through what has been going on, write it down. Write down the timeline of symptoms. If you are being bothered by things, you know, track it and note which symptoms you're having. If it's just a conversation of goals, think about what goals are important to you or what questions you have, and write those down ahead of time.
Because very often, especially a contraceptive visit is a very short visit. So we want to make sure that you have your questions answered and that your doctor can only work with the information you give them. So we want you to be able to feel empowered to present that information the best.
I will say, I love bedsider.org as a resource to learn about different contraceptive options. So if you hear about a few different things, yet you want to learn a little bit more about them, or maybe that will help you learn what questions to ask. It's very patient-facing, friendly, and you can compare different options and see side effects or how long they last. And so taking a moment to maybe do your own research — but on a verified site — before you go see your physician might put you in a position to have a more fruitful discussion by saying, “Hey, I've researched this and I am really interested in these two choices. Can we talk about pros and cons of these?” That can help the discussion be a little bit more tangible and help you get the answers you want than a generic conversation about birth control, because there are so many different contraceptive choices.

Pathak: Finally, is there anything that you wish I had asked you that I haven't?

Crawford: I do want to say that birth control does not harm your future fertility. There is a fear that birth control is going to cause you to run out of eggs faster, or is gonna cause you to have irregular cycles. Again, any contraceptive option that is manipulating your cycles is simply causing you to lose that vital sign and you're going to have a return to whatever is your baseline when you stop that contraceptive option.
Women are born with all the eggs they're ever going to have, and every single month you lose a group of eggs. When you use a birth control, no matter the type, you're still losing those eggs that month. This still happens in pregnancy and breastfeeding as well.
The birth control pill, for example, works by telling the brain not to send out FSH, so you are not ovulating. All the eggs that were released that month simply die — not one is selected to ovulate — and the next month you have another group. So it does not save eggs for the future. It does not cause you to run out of eggs any faster.
No contraceptive option is going to change your fertile potential long-term or going to cause infertility. And I think that's an important myth to bring up so that people aren't fearful of that.

Pathak: That is great. Really, really important information. I want to thank you so much for this conversation. Really just such concrete information. So thank you again for your time.

Crawford: Happy to be here. Thank you for having me.

Pathak: My takeaways from this discussion are that misinformation is rampant, and it's up to us to exercise our discernment and seek out evidence backed by science rather than relying solely on viral social media posts.
Birth control doesn't harm future fertility. But if you're concerned about the timing of a future pregnancy, make sure to discuss that with your healthcare provider. And birth control does not equal protection from sexually transmitted infections. Consistent use of barrier methods, regular testing, and honest conversations with your sexual partners are also essential to reproductive health.
To find out more information about Dr Crawford, make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform.
If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected].
This is Dr Neha Pathak for the WebMD Health Discovered Podcast.