The Birth Control Conversation We Need to Have: Helpful Tool or Hidden Problem?

Transcript

Today’s episode is a powerful one because we’re talking about something millions of women have taken, often for years, without ever being fully informed of the bigger picture. Oral birth control. Welcome to this week’s episode of hormones, metabolism and you. While the pill has benefits and has been normalized for decades, it’s important to ask whether women are being told the full story, especially as they age. And this episode, we discuss the risks and benefits of oral birth control, why it can become increasingly problematic for women over 40, and why those concerns deserve even more attention in women over 50. We also talk about the ways oral contraception may affect gut health and the body as a whole, and why even newer formulations with lower estradiol doses still carry side effects and potential risks when taking orally as a synthetic estrogen. This is not a fear based conversation. It’s an informed one. It’s about helping women better understand their options, ask better questions, and make better decisions with more clarity. We also talk about alternatives to oral contraception because for many women, the pill may not be the only option or the best option. Joining me for this conversation is Doctor Johnny Peat. He was on my podcast in 2024. He’s a board certified ob gyn who specializes in bioidentical hormone therapy and sexual health for men and women. It was one of my most downloaded episodes in 2024 when we talked about sex. He studied at UT Austin for undergrad, earned his medical degree from Texas A&M, and completed his residency at Scott and White Hospital.
He is the founder of Woodlands Gynecology and Esthetics and the Woodlands Medical Esthetics Institute practice, which he’s led since 2000. In addition to his private practice, Doctor Peat is a speaker for several esthetic and laser companies and serves on the medical faculty at Evexias Health Solutions with me. His mission is to help patients look better, feel better, and live better. And that passion comes through clearly in this conversation, if you’re a woman taking an oral birth control, thinking about contraception or navigating hormone health in your 40s and 50s, this episode is one you do not want to miss. It is a must listen to. Let’s get into it. Here’s my conversation with Doctor Johnny Peat. So I’m here with Doctor Johnny P. If you don’t listen to my podcast, I had him on a little over a year and a half ago. And we talked about sex actually, and it was one of my most downloaded episodes. He is an ob gyn in Texas. He does evexias training with me because a lot of the thyroid training. But as an ob gyn, I wanted to talk to him today about birth control because I have a lot of women in my practice who are in their 40s, some in their early 50s, who are still on birth control. And so lots of questions out there. Is it safe? Should they be on it? Tell us about birth control and women in their 40s and 50s.
So if you start out with the young folks, teenagers in their 20s and even into their 30s, birth control pill is a wonderful thing because there are some risks of taking the birth control pill. But in reality, if you’re talking about risks of blood clots in your legs or lungs, it’s actually more risky to be pregnant than it is to be on a birth control pill. So for young people who tolerate those things, well, a birth control pill is a great thing. But as you get older, the side effects of birth control pill become a little bit more intolerable. In other words, by going through your liver with first pass liver metabolism, it raises levels of things like sex hormone binding globulin, which is great for your acne, but it lowers your testosterone functional free testosterone so much that women don’t feel as good in their 30s and 40s on birth control pills. Whereas in your teens and 20s, it didn’t affect you that much, you could fight past it. But in 30s and 40s, women do have quite a few side effects of being on birth control pills. Now, the risks are a whole nother thing when you get a little bit older. Risks of blood clots in your legs or lungs is one thing. But as you get into your 40s and 50s, some women are still taking birth control pills in their 50s. There’s definitely a risk of stroke. And that is something that we see with taking oral synthetic progestins and estrogens.
They’re going to increase blood clotting. So I do not like to use birth control pills in women in their 40s that don’t need it for birth control. In other words, a lot of women might be taking the pill for controlling their bleeding or PMS or endometriosis or something of that nature. In reality, there’s a lot of other things we can do for those problems. I do not like using birth control pills in ladies in their 40s and 50s, unless they need it for birth control and can’t tolerate every other form of birth control. Long acting progestin IUDs are actually a really good option for those people that are past their 30s and 40s, and they need to have something that is long term. It’s effective. It also gets rid of your periods, has very little systemic effects. Some women may have systemic problems with the IUDs. Very rare, but 95% of women do really well with them. It’s a good form of birth control that’s still reversible, and it doesn’t impact your hormones the way that birth control pills impact your hormones as far as lowering your androgens. So it’s much easier to treat those folks if you’re using testosterone therapy per se. If they’re on a birth control pill, it’s very hard for them to feel the effects of the testosterone because of the birth control pill.
So what I’m hearing you say is in our 20s, if we need birth control for birth control. Okay, as we get into our 30s, the birth control that we’re taking for birth control may make our testosterone lower. So we’re going to develop symptoms of androgen deficiency. But once we get into our 40s, it is almost where the side effects are worse or the risks are worse than the benefits, because there are other birth controls that we can take in our 40s, and especially in our 50s, that don’t have those side effects.
Exactly. And now they even have some progestin IUDs that are much smaller that they recommend for folks who have not had children yet vaginally, because it’s very difficult to insert an IUD into the uterus if the cervix is stenotic or small. And if someone has never had kids before. So they make a smaller IUD that we actually have used in people in their early 20s who’ve never had children. You can use an IUD. It’s a lower dose of progestin, so they still have periods, but the periods are much lighter, but they don’t go completely away. Some of the good things about the longer acting IUDs now is that when I first was starting to use them, I think they were good for four years. Now they’re approved for seven years. So the same ones we put in five years ago, we don’t have to take out and replace. And I think at some point they may be approved for up to ten years. So a lot of times you can get through your entire 40s and your perimenopause all the way to menopause with one IUD placement. And it’s kind of nice in your 40s not to have periods anymore. That’s a good thing without having to have surgery and not worrying about birth control as well.
So if you’re a woman in your early 40s and you haven’t had a child and you get a progesterone only IUD, or you’re talking about the Liletta.
So Liletta and Mirena are the two that are approved for seven years. Now at this point, Skyla and Kyleena are the two different brands of the smaller IUDs. They don’t last as long, but they are physically smaller and can be inserted in patients who haven’t had kids yet.
But they may still have menstrual cycles.
Yes, they’re going to be lighter than they were before. They’re just not absent. So it’s nice with the Liletta and Mirena to not have to worry about periods. So you’re treating bleeding as well as covering birth control. And you’re not having a lot of systemic hormonal imbalances because of that. Every once in a while, we’ll have someone have some systemic signs from the IUD, whether it’s headaches or weight gain or whatever. But most of the time it’s a local effect of the progestin in and around the uterus, not so much systemic. And so those patients do really well with hormone therapy. If you’re using testosterone or something like that, because the IUD doesn’t really impact that. Whereas the birth control pill really does interfere with that type of therapy, which in a perimenopausal woman, testosterone therapy is really important. And if you’re on a birth control pill, you’re not going to get the benefits of that.
Yeah. And I think it’s also important for women to understand when you take birth control orally, especially in your 40s, and you’re going to be affecting your estrogen production also. And so estrogen is really important for women’s health. And so when you put them on these progesterone only IUDs, it’s not going to typically affect their hormones. Is that correct.
Yes that’s exactly correct. Okay. And that’s why I like transitioning folks in their 30s onto IUDs or a vasectomy or a tubal ligation work really well too. So those are great forms of birth control, right? But they are, of course, permanent, which is a different problem altogether. We like reversible things. So the long acting, reversible progestin IUDs are fantastic. I think they’re safe. And birth control pills as you get older, not so safe. We’re talking about an oral synthetic estrogen and an oral synthetic progestin. It’s not something that we like to do long term. That’s something that we use in younger people to prevent pregnancy.
And I think people also need to realize with birth control, oral synthetic birth control, I mean, you do have some gut dysbiosis that’s going to happen as well. So when you take someone’s estrogen and progesterone away, it’s going to affect their gut, which isn’t going to affect their T3 conversion, their thyroid, lots of different things. So another question that I have a lot of women ask me, they say, okay, well, if I take a progesterone only IUD in my 40s, then that doesn’t necessarily mean that I need oral progesterone. Like, I’m going to be fine. And I don’t find that’s always the case. Would you agree?
Yes. Not at all. So they’re going to get very little systemic progesterone from that. It’s going to be a local effect in the uterus. So if they need progesterone for mood and sleep and things like that, it has to be taken orally and more systemic. So we use bioidentical progesterone. And a lot of women that have IUDs in place, that progestin there does kind of get rid of the menstrual cycles, and it does treat endometriosis and keep it quiescent in the pelvis, but it’s not going to help you sleep. It’s not up here. It’s not going to help you sleep or affect your mood like progesterone does, which is super important in a perimenopausal women in their 40s, women really do benefit from having bleeding control with the IUD and progesterone for sleep and mood and then testosterone therapy. All of that is along with thyroid is very beneficial. The perimenopause is a tough place. Menopause is easy, right? Menopause is simple. You just replace what’s gone. But in perimenopause, there’s such wide fluctuations in estrogen and progesterone, in such irregularity and unpredictability that it’s nice to be able to use an IUD and not worry about bleeding and then be able to use progesterone orally for sleep and mood and thyroid for all the benefits in testosterone. If you’re not controlling bleeding with an IUD, then the perimenopause is a real problem. There’s a lot of irregular bleeding and issues that go on there, so we just try to get to menopause. Because menopause is easy. Perimenopause is this difficult bridge you have to cross before you finally get to menopause.
You get to the other side.
Yes. Yeah. No more fluctuation.
No more fluctuation. So yeah, so I have a lot of women who ask me, you know, in their 40s. Well, what, you know, they don’t want to do IVs, right? They’re like, well, IUD, I don’t want to do, but I need something for birth control. And so their go to is, is birth control. But I think it is important for people to realize if you do synthetic progestin, synthetic estrogen. You’re at a much higher risk of clots of lots of side effects. And so what do you tell women who, let’s say, a 45 year old comes to you and says, you know, I’m just not going to do an IUD, and I really want something for birth control. Then what do you tell those women?
Yeah. So there’s not a lot of really good options, things like Nexplanon and Depo-Provera. Those are for young people who can’t remember to take their pills. There’s too many side effects and issues. I don’t use those in women in their 40s getting a tubal ligation or really and truly a tubal removal is what people need nowadays. Salpingectomy or a vasectomy are going to be much better options than getting on a quote unquote birth control pill. Now there are some new birth control pills out. There’s a new one out called Nextstellis that has a different estrogen. For all the years since birth control pills have been created, they’ve always used ethinyl estradiol. So it’s not 17 beta estradiol like your ovaries made. It’s a synthetic different estrogen. So on a side note, if you’re doing a 17 beta estradiol test on a patient who’s on birth control, it’s going to be zero. Their estrogen level would be zero because ethinyl estradiol is a totally different compound than 17 beta estradiol. But there is a new birth control pill out that uses a different estrogen that is actually supposedly metabolized in the intestine before it gets to the liver.
For first pass metabolism, it’s called nextstellis. And I have been using it in some patients who have had really high Shbg from the birth control pills. We haven’t seen as high of Shbg elevation with this particular pill. And the claims from the company are that there is no increased risk of DVT and PE. I’ve looked at their data. It’s not wonderful, but it’s pretty good. So there is a new birth control pill that doesn’t have first pass liver metabolism of the estrogen. It’s still got first pass liver metabolism of the synthetic progestin. So it’s still a better option. So for some people I’ll transition into that pill as they get a little bit older. If you’re going to do testosterone therapy and their Shbg is 150 or 200 or through the roof, you really just have to keep going up on the testosterone until their free testosterone is to the point where they feel better. But you have to be willing to not be so concerned about a total testosterone level that looks too high.
And do you see in those women, they have more side effects of testosterone therapy because you’re pushing their testosterone levels higher?
Not really, because that’s really all a function of the free testosterone. If the testosterone is not really bioavailable, then it’s not going to cause a side effect. The side effects are more with the free. And if their Shbg is 150 or 200, these poor ladies are not going to feel any testosterone you give them until they hit 400 on their total. Yeah. And which, you know, that scares people to see a 400 on a total testosterone of a woman. But the reality of it is she’s not having acne. She’s not having hair growth. She’s not having any side effects. All of that is bound in the bloodstream to these proteins. And it’s not available to go into her cells. So sex hormone binding globulin is a big protein. Testosterone is a tiny little molecule and it sticks to it like flies on a bug zapper. They’re not coming off. It’s a covalent bond. In other words, it’s a permanent bond that testosterone sticks to Shbg and it’s going in your bloodstream, but it can’t get into your cells because it’s got this huge protein attached to it. So Shbg is powerful. It’s a powerful buffer that your body has, so you don’t get too much of anything. Well, unfortunately, when we do things like birth control pills, we create an abnormal environment in your bloodstream with too much of this protein and it binds up all your androgens. Great for complexion, not so good for sleep and mood and sexual function and all those kind of and energy, etc..
And it’s the same thing with oral estrogen. So so people that take oral estrogen, right? Estradiol, because that’s what we did for years. Those women have really high sex hormone binding globulins. And so it’s kind of a different patient. But once you have made it through the graces of perimenopause, if you’re into menopause, if you’re taking oral estradiol, a lot of people will have very high sex hormone binding globulins. And then those women are started on testosterone and say, well, this doesn’t work. I don’t feel any different. But it is the oral estrogen that you’re taking so similar. Although oral estrogen after menopause is a different, it’s sort of the same as birth control, just different phases, different doses.
Exactly. But still a synthetic, a synthetic. And it’s oral and it’s just for big pharma. The easiest way to get something to market is to put it in a pill, let someone take it. But it’s also not a natural way to do it. So if you do something transdermal, sublingual, subcutaneous, or like a pellet is subcutaneous or subcutaneous injection, you’re bypassing the GI tract, which is more natural because the hormones that your body makes don’t go through your GI tract. They go right into your bloodstream from whatever endocrine organ is making that your ovaries or your testicles or, or your adrenals. It goes directly into the bloodstream. It’s not metabolized by the liver first, and then whatever’s left over then goes into your bloodstream. But that’s a cheaper way for big pharma to get a product onto the market. Oral premarin or oral estradiol.
So I want to ask you one other thing. I have had several women that I’ve taken care of, and I think you have as well in their late 40s, early 50s, who have continued to take birth control or who come to you on birth control, have been on birth control for a while. And their question to me is like, well, is there really a risk of this? Is there really a risk of clotting? And so I want you to answer that.
Yeah. There’s no question an increased risk of blood clots in your legs or lungs. But then as we age, those risks become even more arterial instead of venous. In other words, risks of heart attack and stroke in your 40s on birth control pills is a real risk. It’s a real thing. And the older you get, the higher cardiovascular risk that you have. So if you’re taking a medication that makes that cardiovascular risk even higher, then you’re more likely to see a problem. I’ve seen some devastating strokes in ladies in their 40s, and the only medicine they’re on is a birth control pill. And they have no hypertension, no cardiovascular risk, nothing. Just taking a birth control pill. So if you don’t need it for birth control, don’t take a birth control pill. And as you get into your 40s and closer to menopause, you’ve got to transition into something safer. Correct. Yeah.
Yes, I agree. So either tubes removed progestin only IUD vasectomy. Yeah.
I mean, Handcuff your husband and drag him to the urologist and make him get sniffed.
Well, I mean, if you say, hey, it’s either no sex or you’re getting a vasectomy. I bet they’re going to be at the ER. Some proper motivation always works.
Motivation is always good, right? So I just wanted to bring you on and ask you about this, because I do have a lot of women who ask, you know, they’re concerned about can I take birth control? Can I not? If I can’t take birth control, what are my options? A lot of women get progesterone only IUDs, but are misled to thinking, oh, well, you don’t need oral progesterone because you have an IUD. And so then they suffer with mood and sleep issues. And so I just wanted people to hear from a gynecologist that I’m not necessarily crazy or mean when I’m not giving you birth control in your late 40s or early 50s.
Yeah, there are safer, better options. And so we have to be really concerned with every prescription we write in our office. The most seemingly benign prescriptions we write can hurt people. A simple prescription for Bactrim for a UTI can cause a serious, life threatening reaction. I mean.
Skin reaction.
Everything. And so we have to be careful. We write so many prescriptions and we don’t think about it enough. Is that okay? What are the potential problems that I could cause by doing this? And we dole out birth control pills like candy. And the reality of it is these are serious prescriptions that have serious side effects. And yes, their use is important for a lot of people. But we also we don’t just pass them out to everyone without thinking about the individual patients that we’re treating, and we could potentially harm them. So that’s our first goal is not to harm anyone. Correct? Right.
And I mean, I’ve had a whole section in my book, a whole chapter in my book about birth control and what it does to your gut. And so again, in your 20s, you know, sometimes it’s probably better to not have a 20 year old pregnant that doesn’t want to be versus having a bad gut. But I mean, you need to understand even in your 20s, like a birth or a, an IUD may be a better option for you, especially if you already have a dysregulated gut. Because when we start messing with people’s gut and the way their estrogen metabolizes and their T3 metabolizes and their insulin and their cortisol. I mean, they end up with all these other issues later. And, you know, there is a type of PCOS, a post pill, PCOS, where after people get off birth control, they have a lot of issues with PCOS and then infertility. So I think it’s just something you really need to ask questions about, be educated about, and make sure that you realize a lot of people think, I’m going to take birth control for ten years. I’m going to come off. I’m going to immediately get pregnant. Some people will, but a lot of people won’t. And so it’s just something that you need to understand.
That same patient in their 20s may be the same person, but they’re a different person when they’re in their 40s and 50s and they have a different set of risk factors and a different set of problems and concerns in their life. And so you can’t treat everyone the same and even the same person three decades later, you have to treat them differently. Correct? Right.
So the last time you were on my podcast, I don’t know if you remember, I asked you three questions. This is really fast. Oh, this is how we end. First thing that comes to your mind, don’t overthink it. What is one food that’s most beneficial and why.
I said it? I know what I said last time two avocados, avocado, avocado, guy. Love it. I would eat one every day If I had it available to me. Yeah. It’s fantastic.
I love avocados.
Yeah. They’re fantastic.
Why are they good for you?
Well, because they’ve got a good amount of fat in it that you don’t have to worry about. It’s not the bad fat. It’s not empty calories. It’s good calories. And then I think the glycemic index is pretty low on your avocado. You can eat a whole avocado and you’re not going to spike your sugar.
Antioxidants.
It’s really everything. It’s kind of everything.
And they taste good.
They do taste.
Good. Yummy.
Yeah.
What is one thing anyone listening to this podcast right now can do for their health? That’s 100% free.
Free. Okay. Free walking is free. That’s my kind of my first thing. Like if you don’t know what to do and you’re trying to get in shape and you don’t really know where to start, just leave your house and walk 20 minutes that way and turn around and walk 20 minutes back. And then you can think while you’re doing that and try to figure it out, but you’ll be getting healthier while you’re trying to figure out what to do for your health.
I completely agree and it helps with your stress. Yeah. Where’s your cortisol? So many great things. And the last question is, what is one thing you wish you would have known about your health 25 years ago that you would have done differently.
I wouldn’t have waited until I was 45 to fix my thyroid and my testosterone. I would have done that sooner. I would have started ten years earlier.
Why do you think so many men are resistant to starting testosterone in their mid 40s?
Well, men are wimps. I mean, they included taking testosterone in order for it to work requires something invasive, either a shot or a pellet. Creams don’t work for men. Period. So you got to do a needle. Men are wimps. They avoid needles, and they typically avoid needles until they get E.D.. Then they’ll do a needle. Like once you get to the serious crux of the matter, that’s when they finally come in. I started testosterone pellets and injections first, probably at age 43 or 44. I should have done it ten years sooner. Yeah. And thyroid. I should have fixed my thyroid ten years ago.
I completely agree. Well, thank you for coming on and telling everyone the truth about birth control. Yes, I’m always happy to talk to my favorite endocrinologist.
Thank you so much for joining me for today’s conversation. I hope this episode gave you a more thoughtful and balanced perspective on oral birth control. As we close, I really want to emphasize this. There are certainly times when birth control is warranted or needed. For some women, it may be an appropriate tool and an important part of care, but oral birth control should never be viewed as something to use lightly at any age. The risks and benefits need to be carefully weighed, openly discussed and considered in the context of the whole person. That means looking at your symptoms, your health history, your hormone health, your gut health, your goals, and your long term well-being. These are important decisions, and women deserve more than quick answers. They deserve real education, real partnership, and personalized care. If you’re looking for that kind of support and want to work with us directly, you can become a patient by visiting www.endocrine.com. We have a license in 46 states and do provide telehealth care. We also have a clinic in Oklahoma City. If you want to continue learning, I’d love you to join me on my next Gut Health Live webinar, where I teach more about how the gut impacts hormones and how these systems are deeply connected.
If this podcast has been helpful to you, please take a moment to follow the show and leave a review. It truly means a lot to me, and it helps more people discover this podcast and get access to answers and information like this that they truly need. Also, if you want to go deeper, you can find my new book, Fix Your Gut, Fix Your Hormones on Amazon. In the book, I give you a step by step plan to help you fix your gut and support each hormone your body makes. Chapter by chapter, I explain in detail information about birth control and how it affects your gut and other hormone production. I also explain how our microbiome and gut health became so disrupted in the first place, so you can better understand the root of what so many people are dealing with today. Thanks again for being here. I’m so grateful you listened and I will talk to you again soon.