Episode 26: Why and How Birth Control Affects The Microbiome

Criticizing birth control is a tightrope walk. On one hand, birth control has been instrumental to women’s liberation, allowing them to control their fertility on their own terms. On the other hand, we’re now starting to learn that years (and sometimes decades) of hormonal birth control use can impact women’s health negatively.     

On this episode, Andrea talks with Dr. Jolene Brighten, a Functional Naturopathic Medical Doctor and nutritional biochemist with a focus in women’s endocrine health. She is recognized as a leading expert in Post-Birth Control Syndrome and the long-term side effects associated with hormonal contraceptives. She’s also the author of Beyond the Pill, A 30-Day Program to Balance Your Hormones, Reclaim Your Body, and Reverse the Dangerous Side Effects of the Birth Control Pill.   

This is an eye-opening conversation about how something women have been told is harmless actually has far-reaching implications on the microbiome, overall health and future fertility. Along with discussing common issues, Dr. Brighten explains why birth control impacts our microbial communities and gives tips for what to do to minimize symptoms if you’re not ready to stop taking birth control.    Toward the end of the discussion, they switch gears to talk about the microbiome during pregnancy, specifically as it concerns pathogenic strains, such as GBS.   

To learn more about Dr. Brighten, visit her website at drbrighten.com or follow her on Instagram @drjolenebrighten. 

   

On this show, you’ll learn: 

• The issues that birth control, like the pill, can cause in women (2:02)
• Why would birth control have an impact on our microbial communities? (5:36)
• Research on non-hormonal birth control and gut health (8:51)
• Do symptoms resolve once birth control dosage has stopped? (12:38)
• Ways to offset symptoms for those not ready to come off birth control (20:51)
• The impact of birth control use on future fertility (31:29)
• How to lessen the chances of GBS during birth (43:16)
• Recommendations for women wanting to stop birth control (49:16)

Transcript:

Andrea Wien:  Welcome to the Microbiome Report. This episode is powered by drmicrobiome.com, the website of Dr. Mahmoud Ghannoum. Dr. Ghannoum's new book, Total Gut Balance is now available for preorder for a December 24th release. Just search Total Gut Balance book, wherever you get your books to get your copy as soon as it drops. I'm your host, Andrea Wien, and today I'm talking to Dr. Jolene Brighten, a functional naturopathic medical doctor and nutritional biochemist with a focus on women's endocrine health. She's recognized as a leading expert in post birth control syndrome and the long term side effects associated with hormonal contraceptives. She's also the author of Beyond the Pill, a 30-day plan to support women on birth control, help them transition off and eliminate symptoms of post birth control syndrome. On this episode, I asked Dr. Brighten about the issues that women are rarely told about when it comes to birth control, including how birth control impacts gut health and the microbiome, whether non-hormonal options like the copper IUD still cause problems, and what women who aren't ready to come off the pill should do to offset the negative effects.

We also talk about the other side of the coin, what happens to our bodies during pregnancy and how does what we do while we are pregnant impact our future child's microbiome. Enjoy the show. Dr. Brighten, welcome to the Microbiome Report. This is a topic that I think is just starting to really be talked about, this whole birth control, hormonal birth control question and so many people haven't really heard a lot about it. We're excited to have you on and to be talking about the effect of hormonal birth control on the microbiome. Now, when we look at the options for birth control, there's not very many good ones, and it seems like the more we learn about hormonal birth control, the more bad news we really uncover. Can you talk about the issues that birth control like the pill can cause in women?

Dr. Jolene Brighten: Mm-hmm (affirmative). Well, it's an interesting thing that when we stand back and we look at how long birth control has been available to women and specifically the pill, that's what we started with, how little research we actually have on what does it look like for a woman to be on birth control for decades on end and never ovulate naturally herself. We are coming to understand that just like your natural hormones impact every single system in your body so do the synthetic ones in birth control. We see that there's a correlation between new onset of mood symptoms, so maybe that's anxiety, depression, and even younger women can be suicidal ideation. That is, they are at higher risk of committing suicide. We also see that the pills specifically causes nutrient deficiencies like B12, selenium, zinc, magnesium, folate, CoQ10, vitamin C, so there's a lot nutrients being impacted.

We also know that birth control is involved in terms of liver function and liver health and gallbladder function, which are very important in the digestive tract, but also very important for a lot of things. In research that has come out in recent years, we have for the first time really started to understand the impact on birth control on the microbiome, which part of that is because medicine for a long time dismissed all the critters that grew in our guts saying things like, at least this is the story when I was getting my nutrition degree, that these gut bugs are a bunch of freeloaders. Maybe they make a little bit of B12, little vitamin K, but other than that, they don't do much for you. There have been these stories that have played out in medicine and because doctors, and I'm a doctor too, have perpetuated some of these stories, we haven't dug deeper to understand what is going on.

There was a study that came out of Harvard showing that women on hormonal birth control with a family history of Crohn's disease were at a 300% increased risk of developing Crohn's disease after five years or more on the pill. That was very eye opening. When I saw that research, I went a little bit deeper to try to understand what could be going on, and I found case studies and reports and other studies showing this correlation between hormonal birth control and auto immune disease of the gut. Birth control also can result in a lower libido. We can see vaginal dryness, yeast infections in the vagina and a whole host of other symptoms. Really, we're not often told about when we are written that prescription of birth control, there might be discussion about clots or potentially cardiovascular risk, but really for the most part, women are given birth control and told that the side effects are so low, we don't really need to worry about them or discuss them.

Andrea Wien: That was certainly my experience. I was on hormonal birth control for probably upwards of 10 to 15 years, and a lot of the symptoms that I started having, even though I was on "the lowest dose", I had a Mirena IUD at one point, it was causing incredible fatigue. My gynecologist said, "It can't be your birth control." I said, "Well, literally I've isolated every other factor and it seems like this is the only one left." Sure enough, as soon as it was taken out, my health improved. When we think about what's actually going on in the gut, why would birth control have an impact on our microbial communities?

Dr. Jolene Brighten: You don't actually absorb it all. We know that with all medications, absorption can vary. The pills specifically, we take this and those metabolites and what's in the pill can end up in the large intestine interacting with those microbes. I have yet to see a research study that shows what happens with these good little critters and not so good little critters sometimes. I think most of your listeners are probably aware that it's very rare to have very extremely bad organisms living in your gut. For the most part, these good guys throw down against that. With that, I haven't seen research that's like you took birth control, you metabolized it, how do these microbes actually interact with these metabolites and what do they do with them? That's one of the issues there is that these hormones are coming in direct contact with microbes, which from an evolutionary biological perspective have never encountered these synthetic hormones.

We like to think birth control has been out for a few generations, therefore these gut bugs have evolved, right? No, that's not the way things work. We don't actually totally understand how is the microbiome impacted by hormonal birth control metabolites. Not just what you're being exposed to, but what your body actually ends up doing with it. What's interesting is that we see that the ecology of the gut, the mouth and the vagina gets shifted in such a way that yeast is actually allowed to overgrow. In dental research, we see overgrowth of yeast in the mouth, so candida as it's referred to, which could actually be the place that we're inoculating the gut with because we're swallowing that. I just swallowed probably three times just saying that. You're swallowing yeast, but we also see yeast overgrowth in the gut and it is well known in medicine that we also see yeast overgrowth in the vagina in some women using hormonal birth control.

As the microbiome research has evolved, we understand that what grows in your gut and what grows in your vagina, they like to share. The natural hormones help the health, the overall health of the beneficial flora, and so there may be something in these synthetic versions because even though I hear experts saying what is in birth control is exactly what your body makes, I'm like, did you never look at the biochemical structure because it's different. It's not the same. Also, US patent laws say you can't patent something that the human body makes itself, you have to alter that. These are medications that are patented, which means that they are different enough that someone can actually have a patent on this intellectual property. It may very well be that these synthetic hormones, they don't take care of these microbes like our natural hormones, which evolved with our microbiome do.

Andrea Wien: Have you seen any research on non-hormonal options for example, the copper IUD and how that might impact gut health?

Dr. Jolene Brighten: No, I have not and it is a big question that I have, right? Copper IUD, it's our only IUD, the Paragard specifically, that is non-hormonal and it's the one that women report the highest degree of satisfaction because odds of getting pregnant are really low. In addition to that, you don't have to think about it. You place it seven to 10 years later, you get it removed and if you didn't have painful heavy periods or endometriosis before getting it, you're probably going to love it. I have seen clinically, and there's lots of women to report it, that they had issues after getting the copper IUD placed, which is why I'm very cautious in that recommendation, and educating women that with any medical intervention that you have, you should absolutely be aware of where your normal is, so baseline labs, baseline tracking your data. Then if anything changes, that you follow up with your doctor. With the copper IUD, it's much like the same story about the progestin based IUDs like the Mirena, which is to say that what medicine said for a long time is the progestin stays localized. It never leaves the uterus, and even as my younger self, pre-medical school, I was like, that doesn't make sense.

Andrea Wien: I thought the same thing. I was like that doesn't make sense. It's part of the body. The bloodstream is going there. Yes, totally.

Dr. Jolene Brighten: It's not a vacuum container. I don't know whose uterus things go in and nothing comes out, but I haven't seen that. It doesn't make sense, and so much of what we get told and what gets dismissed doesn't even make sense physiologically and biologically. With the Mirena IUD and these progestin IUDs, we now understand they do go systemically and sometimes the flaws of the research is that they're not looking for metabolites. We know that some women with the progestin based IUDs will stop ovulating. What does that mean? That means it's eliciting an effect on her brain. That's how hormonal birth control works. It may seem that copper IUD is a much better option, however there have been studies that, although they still say the copper stays localized, they have also said in their conclusion, but we should be cautious because with women who have copper storage disease issues who have a propensity to store copper, we shouldn't recommend the copper IUD.

That says to me, they know something. There's something that's come up, but they don't have enough evidence, enough data to really make a statement in a big way about it. There is a possibility, and I have seen patients with copper IUD, their blood copper levels do go up. Now, why is this important when we talk about good flora? Copper is antimicrobial. It is antimicrobial. It kills some sperm, that's part of how it works too. It is very well that you could introduce a copper IUD and see disruption in vaginal flora or gut flora. We don't have research that has shown that yet. Now, this is where we've got to be really careful in medicine and in science not to say what we don't have any evidence of that, therefore it can't be possible, no. If we don't have any evidence, then we haven't asked the question and maybe because there's no funding for asking that question, but it doesn't mean that it doesn't exist, it's not real or what a patient is experiencing should just be dismissed because we don't quite have the research yet to understand what she's experiencing in her body.

Andrea Wien: Right. I think so many times I've heard this from so many different women, my friends, my clients that they say, "I'm having these symptoms, but my doctor keeps telling me that they're not possible." When we talk about this anxiety, depression, the nutrient deficiencies that could lead to a whole host of other issues, do these symptoms just resolve if the woman stops taking her birth control?

Dr. Jolene Brighten: Nutrient deficiencies will not resolve just by stopping birth control. With that, if a woman is on hormonal birth control now, if a woman is on any medication that I know leads to nutrient deficiencies, the ethical recommendation is to say, let's make sure your diet is dialed in so that you're replenishing those nutrient stores and let's consider also bringing on a supplement for that nutrient. If somebody is on statins, we supplement CoQ10, if someone's on buformin, we supplement with B12, if someone's on birth control, we often just dismiss that. We're like, whatever, it's birth control. It's a great thing, and yet it's one of the main medications that leads to a whole host of nutrient deficiencies and so well recognized. We actually saw one pharmaceutical company make a version of the pill that came with folic acid in it because that's one of the nutrients that's depleted.

We also in general recommend that anyone who is sexually active in their reproductive years begin a prenatal or a multivitamin so that we safeguard against neural tube defects. If a woman becomes pregnant, by the time she has a positive pregnancy test, you already needed that folate. Now, folate is being depleted by the pill specifically. I think you hit the nail on the head that doctors will say that's not possible. I was having a conversation with a researcher and she actually said to me, "I don't know why there's such a disconnect with doctors and science in that doctors think that everybody should respond in the same exact way to a medication. They should all have the same response, whereas science doesn't support that black or white outcome." Science doesn't support that at all. In fact, we see that there is the clinical trial and what that shows, but the general population often responds differently to medications. From my perspective, it's an opportunity.

It's an opportunity, we can be humble, we can be curious and we can investigate further so that we can do better in women's medicine. We can do better in our iterations of birth control, but so often, especially with the mood symptoms, that is something that since the introduction of hormonal birth control in the '60s, I mean really in the '50s when were going through trials, women have been complaining of depression, anxiety, mood swings, all of this with hormonal birth control. It exists in the package inserts. By the way, everybody listening, if you're on birth control, read your package insert because I have found so many times my patients have said to me, "My doctor said this was impossible, and then I pulled out the package insert and showed them that it was listed right there." That changed the conversation on this. With that, this has been listed in the package insert one of the name reasons women drop out of trials for birth control, hormonal specifically, is because of mood alterations.

It wasn't until 2016 that we saw this large Danish study come out showing this correlation. We're still at a correlation phase. We can't say causation. I don't know that we'll ever be able to say causation because it's really complex what's going on with the female brain, birth control, inflammation, nutrients. It's a lot going on. If you think about it, it's kind of crazy to me that in Scientific American this year Dr. Kissling who's a researcher actually made this statement that when we stand back... Keep this in mind, there's 100 million women that are estimated worldwide to be taking hormonal birth control. At this current time, we have researchers who are saying, we haven't done our due diligence with research. It was Dr. Elizabeth Kissling who said longterm menstrual suppression, so shutting down our periods with hormonal birth control is the largest uncontrolled medical experiment on women in history.

That's because we are lacking so much data in the long-term use. What does menstrual suppression mean? Well, when you're on birth control and it shuts down your brain ovarian communication and you stop ovulating, that bleed you have is a withdrawal bleed. You stop, you go into the pill pack, that's the placebo week, that's a withdrawal from a medication. The suppression of ovulation is menstrual suppression, that's suppression of the cycle. We don't totally know what happens, which is kind of mind blowing how many doctors and researchers and experts, so to speak, lined up in 2016 to dismiss that Danish study and to say this isn't true. This isn't real. It's not a causation study, and to see the outcry and the response of women because for the first time in history, we had a study over a million women validating what generations of women had said, and then to have experts come in and say, "Nope, it's still just all in your head."

Well, of course it's in my head. That's where birth control works and that's where neuro-transmitters are going on along with my gut, which I don't know how you feel, but I feel like the gut is going to be named the first brain. I think that's going to come in my lifetime because we understand. At this point, I'm like, these are some really smart people, but the fact that they can't go we know from gut research that anything that disrupts... NSAIDs, we now understand that nonsteroidal, antiinflammatory drugs lead to intestinal hyperpermeability, and what do you know? They might mess with your empathy as a human. We have this research that shows that in mice with sterile guts, if we inoculate them with lactobacillus rhamnosus, which is very high amounts in the vagina and inoculates a newborn baby, but this species helps with anxiety and actually cuts anxiety.

To think that you're on birth control, the pill specifically depleting nutrients, but birth control itself being able to mess with your microbiome mess with gut health and no one can say we know that if your gut ain't right, you're mood ain't right. Well, okay, but I'm taking a medication that may very well make my gut not right, can we just use a little bit? Well one, can we just be humble to say that we may have gotten it wrong? I think we did get it wrong in dismissing women's stories. Where does research come from? It really comes from a place of listening to what the patient says. They're really are best teachers and being curious about what they're saying, but we can really start to understand through all the ways that hormonal birth control impacts the body that it may very well be correlated with mood symptoms. No, I can't say causation, but if a woman starts birth control and says to me my mood completely tanked, I'm not going to say there's no research, I don't believe.

I'm going to say that's interesting. Let's do some lab testing. How do you feel about changing maybe a different pill formulation? I mean, I have patients who on one pill, they're like, "I feel like a crazy person." We switch formulations, they're like, "Oh, this is me again." Or they go to an IUD. It's something where I don't think we have to vilify birth control, I don't think we have to throw it out, but I do think we need to be believing women's stories and getting to a place where instead of dismissing women and saying the research isn't there, that we start asking those questions and we get more knowledge around why one woman will sometimes start hormonal birth control and feel like she's going to commit suicide, whereas another woman starts hormonal birth control and feels amazing and is like, "This is the best thing to ever happen to me." If we can understand why, we can screen patients better, we can counsel them better and we can have better outcomes in women's medicine.

Andrea Wien: I've been having this conversation with my sister. She is not ready to come off of birth control. She feels like it's a necessary part of her life. She doesn't have a better option than hormonal birth control. What about the women who aren't ready to come off, is there anything that they can do to offset this? You mentioned switching up the pill or going with a different form of hormonal birth control and finding one that works for you, but are there other thing besides that and maybe repletion of some of those nutrients that you mentioned?

Dr. Jolene Brighten: Totally, and that's a big reason why I wrote Beyond the Pill. People who find this conversation inconvenient or are operating from a place of fear around our access to birth control, one of the quickest ways they find to dismiss me and what I'm talking about is to say I'm anti birth control and anti-women. I think the most anti-woman thing we can do is not listen to women's stories and try to do better. It is something that in Beyond the Pill, I wanted women to have the information, so they know when to talk to their doctor, they know what lab testing to advocate for, but they also know how to care for their body if they choose birth control. I did the pill for 10 years. I'm a first generation college student, first woman in my family not to get pregnant before age 20. I mean, these are amazing things for my life.

People often ask me like, if you had to do it again, would you not take the pill? It's a really easy thing for my adult woman self to be like, yeah, I wouldn't do that, but let's be real. I was 17, and back then no one was going to give me an IUD because they were afraid of, if you didn't have a baby before, then you might fail the IUD. For me, the best option was the pill. I don't know that I would do it differently, but what I would have loved is someone to say, and at that time it wasn't Dr. Brighten, "Jolene, you shouldn't be driving through the fast food window every single day because that's not doing you any favors when it comes to your nutrients in your gut health." That's really what I set out to do in Beyond the Pill is to educate women, this is how you care for your body if you want to be on birth control. I don't live in your body, I don't live your life, I don't know the best decision for you.

Only you can decide that for you, and this is how we respect your decision and support you in that. Number one is yes, prenatal multivitamin want to have that on board so that we can replenish those nutrients stores, but also we want to be eating in a way that is going to replenish those nutrients stores. It's not just about nutrients, but it's also about what you are feeding your microbiome. When we're eating lots of varied plants, we are giving those critters that grow in our gut what they need to thrive. I'm very much a terrain person, which is to say that if the terrain is right in your gut, you're going to have the right stuff growing and things can happen that, certainly as humans, we have to intervene, we have to do things to reset that, but if you're not feeding them, then how can you expect them to grow? We want to be eating varied amounts of fiber, and so it's not just eat your vegetables, but also the things like burdock root that you might not think about eating.

Go eat some burdock root. Can you get some tiger nuts in, can you get different fibers coming in and that different kind of variety because yes nutrients, yes, supporting the microbiome, but also when we're eating in this way, we are supporting what our liver needs to do to naturally detoxify these hormones. Now, some people have read my book and misunderstood me in saying that your body cannot detox synthetic hormones unless you do a specific supplement cleanse. That's not true. Your liver is set up to do this, but it needs certain things like B vitamins, amino acids, inositol, cystine, selenium to be able to run these detox pathways. If you're taking the pills specifically, that's a high enough dose of hormones. Your liver first tries to detox it and then it still works to shut down brain ovarian communication.

As they talk about in the liver chapter, we really have to support our liver, and in this way that I'm talking about eating like lots of vegetables, high quality amino acids, high quality fats, that is also going to help with excretion of these hormones. We can have our liver do its job at its finest, but if we don't poop every day or we've got the wrong kind of critters growing in our gut, and I realize that I keep saying critters that your audience is probably way more hip to microbiome talk. Usually when I say microbiome or flora, the interviewer is always like, "What are you talking about?" I'm just like, "I'm going to say critters." As I say this, I'm like, "Now, I bet these people know what I'm talking about when I say it." In that they can make enzyme called beta-glucuronidase, which is not a bad thing, but it can be when it reconjugates estrogen and puts it back into circulation, and now we have a state of dealing with too much estrogen.

We also want to be eating these fibers, drinking water, moving our bodies, so that we poop every day. We pee often. Yes, you should be going to the bathroom multiple times a day so that we clear these hormones, so we mitigate what could happen, which is a buildup of these hormones in the system and the body struggling to remove them. When you know what birth control is doing to your body, then you can definitely take steps to support that. For instance, we know from the research they've tested women, they get their blood, their C-reactive protein specifically, which is a marker of inflammation. They put them on birth control, they retest and it's up. Birth control is inflammatory. With that in mind, we want to be mindful of the Omega-6 to Omega-3 fatty acid ratio in our diet. We want to include things like turmeric and ginger in our diet because those can help with inflammation.

We may even want to supplement with them an Omega-3 fatty acids just depending on what's going on for us in our personal history. If we understand that birth control can tank our moods and that's a possibility that, that might come up, then we can go see our doctor much sooner when those symptoms come up and have that conversation. Some people will right away be like, "I'll just take tryptophan." I talk about this in my book. Tryptophan metabolism is altered while you're on the pill, and so in that, you may make more neurotoxins in your brain. 5-HTP won't go beyond that pathway, but tryptophan can. You can actually make some things worse, which is where partnering and discussing with your doctor, getting the right lab testing, monitoring and making these individualized decisions can be so very powerful. Then of course, everybody eat your cruciferous vegetables.

If you are like, I can't eat broccoli because I get bloated or I pass gas, you've got something going on in your gut and we need to investigate that. Being on birth control can also be really hard on the gallbladder. Gallbladder is, I like to call it the designer purse of the liver, because it really flips the script because what have we gotten this narrative of medicine? I mean, how many times has medicine told us that organs are expendable, and then we find out they're not? Hi, tonsils, hi, appendix, and the gallbladder was one of those where it's like we can live without a gallbladder, but you might poop yourself. We've got to have real talks about that, and thank goodness we have access to surgery and medicine so that we don't die from an infected gallbladder, but it's definitely important to understand that birth control can impact your gallbladder.

Your gallbladder is going to secrete bile acid, and bile acid is great for absorbing fatty acids and absorbing specifically those fat soluble nutrients as well, however it's also anti-microbial. What does that mean? That means that what grows in your large intestine shouldn't be in your small intestine, and your gallbladder is part of keeping that in check. If your gallbladder is struggling and if your thyroid is struggling, and this is because of the effects of birth control, then we can see things like small intestinal bacterial overgrowth developing. I've had patients who are on their 12th round of Rifaximin coming in and they're like, "I can't clear SIBO and it's just impossible. I read everything on the internet that it's just impossible." I'm like, "Well, has anyone ever questioned your birth control?" No, and what I found is, especially I think male doctors sometimes don't want to question birth control because they see it as this tool, this women's rights, like it was part of women's liberation, and so nobody wants to be birth control was bad because we graduate college at higher rates, we make more money. We're CEOs of companies.

Birth control has totally been a tool, but that doesn't lend to being an objective scientist. I have had patients where they cannot clear their SIBO, they cannot get rid of the yeast overgrowth. Instead of doing the pill, they instead switch to an IUD and those problems start to resolve. I think it's just really important in what I'm saying is that it's not an all or nothing conversation. It isn't all hormones are bad or all synthetic hormones are good or that every woman should just take the pill and be happy and say thank you if it's not working for her, but it's much more nuanced individualized conversation that needs to happen. With this curiosity of I wonder what birth control might be doing, is birth control involved because it's really a disservice to women's health to put them on birth control for symptom management, never ask why and equally to ignore when symptoms do come up and never question could birth control be involved in this.

Andrea Wien: This episode is brought to you by drmicrobiome.com, the website of our resident scientist Dr. Mahmoud Ghannoum and his new book, Total Gut Balance: Fix Your Mycobiome Fast for Complete Digestive Wellness. Dr. Ghannoum has spent over 40 years studying our microbial communities and has now condensed his insights into an entertaining book that dives deep into the fungal colonies in your microbiome, why candida gets a bad rap and his advice for a diet plan complete with recipes that's happy for your gut based on years of clinical research. He also lays out a handy test to take, so you can find out where on the health meter your microbiome is at today. Then he gives you recommendations on how to better balance your gut in 24 hours with supplements, lifestyle and diet.

Total Gut Balance: Fix Your Mycobiome Fast for Complete Digestive Wellness is now available for preorder at Amazon and Barnes & Noble. Just simply search Total Gut Balance book to find it. The book will be shipped and released on December 24th. I want to switch gears a little bit and start talking about fertility and pregnancy. I just had a baby recently, and so I've been going through this whole process of seeing my midwife and talking about fertility and then giving birth. In discussions with my midwife, she said that so many of her patients are told that their fertility will just come right back after 10, 20 years on birth control or even shorter amounts of time and that's just not the case. Can you talk a little bit about the impact of birth control on fertility and how the microbiome impacts fertility?

Dr. Jolene Brighten: This one is so, so tricky because we don't have any research to show them that birth control does have a long-term impact on fertility, that is to say that it causes infertility. We don't have evidence of that. At the same time though, there's lots of clinicians who are like, I just don't see fertility immediately returning when women start birth control after decades of use. What might be going on? Well, one thing is age does matter. Why do we use birth control for, delaying pregnancy. We're seeing more and more women, going to college, having careers and deciding not to get pregnant until their 30s. There's this natural decline in CoQ10 production in the body that happens, but also the fact that birth control depletes CoQ10. Now, this is important because CoQ10 helps fuel our mitochondria, little powerhouses of ourselves that also keep our eggs safe and happy and healthy and mitochondria are concentrated in the ovaries, the brain, the heart.

It may very well be the age of when we come off, it may very well be these nutrients that had a role to play in terms of protection of your eggs. While you're on birth control, there's doctors out there, I've seen this where doctors say, birth control will preserve your fertility. No, you're still spending those... That's actually not entirely true just like it's not entirely true to say birth control caused my infertility because we can also look at why did you start birth control. Well, you may have started birth control for irregular periods that were due to PCOS, polycystic ovarian syndrome or due to thyroid disease. Both of those can lead to infertility and birth control masks those symptoms, and therefore you didn't get the diagnosis and you were delayed in diagnosis and appropriate treatment. Same thing is true with endometriosis, the younger you were put on birth control and the longer you're on it for painful periods, the higher the probability that you're going to be diagnosed with endometriosis, which is a leading cause of infertility.

It's something where women will call for birth control and say, I'm infertile, birth control caused this, when in fact birth control actually masked and downplayed the symptoms that you had, which were your body's way of telling you something's going on, and that was really never addressed because you had this withdrawal bleed and you didn't have the pain and you didn't have the cystic acne, so you didn't worry about going to your doctor. PCOS being cardio-metabolic issue is allowed to progress. Sometimes birth control is absolutely beneficial in the treatment of endometriosis, but it's only one tool in the many of tools that we need to use in that, and women need to have the discussion of what's going on. There's this non-proven, no scientific evidence, just a hypothesis that myself and other researchers have. Dr. Sarah Hill actually also writes about this in her book, which is This Is Your Brain on Birth Control talking about the mismatch of mates.

I talk about this in Beyond the Pill how we actually select for mates. This applies to men who are more genetically similar to us. When we got off birth control, there might be a mismatch between those genes of something going on. Do we know that for sure? No, I'm very forthcoming in what's a hypothesis of what has not been tested to play it out, but the interesting thing is, is that I'm not the only one saying these things, although I am pretty loud. That's part of being a mixed Latina, but in that people are always like, "You're the only one that I've ever heard say this." I'm like, "Oh no, make no mistake. There are other books, there are other research papers. There are lots of other people talking about this. It just depends on who's actually listening or aware that's coming through. Now, the microbiome is everything when it comes to baby making and ensuring baby's health and longevity, because as moms, we pass our mitochondrial lineage and our microbiome to baby, and this really is a great example of the humility that needs to exist in medicine.

I don't say this being like, "Oh, I'm the super humble, great holier than thou person." No, I am flawed, you guys. I am flawed just like everybody else. I used to say when this was the research we had that if baby was not born via vaginal delivery, so via C-section, we had to inoculate baby's sterile gut with mama's vaginal microbiome, so to speak by doing the gauze. We swab the area, put it in baby's mouth. Yes, that's still beneficial, but as it turns out, we were incorrect in saying baby's gut was sterile. In fact, these little critters, these microbes, they are coming through, they're crossing through. Also, there's the skin microbiome, which is yet to be really explored. It's like back when I was a kid, and the Amazon hadn't been explored and I'm like, "I can't bomber the whole planet's been explored." "Oh, but we have this skin microbiome. We haven't gone there yet."

This is something that we used to say like, you want to have a baby via vaginal delivery. If it's C-section, please swap the vagina, put it in baby's mouth because that's the only chance baby stands. As it turns out, community really matters, and other people handling your baby and their skin microbiome also helps inoculate baby. I say this to illustrate that we have one idea in science and in medicine when we all stated, and it's true at the time in terms of our understanding, and then new research comes out and we have to be nimble. We can't be the Titanic trying to course correct, we need to be the little speed boat of like, we got that wrong. Okay, let's learn. Let's do better from that. Now, it is very important still that mama gets her microbiome right, her gut health right because it's not just about those microbes, but it's also about pregnancy and postpartum breastfeeding being one of the most nutrient demanding periods of a woman's life, so you've got to have gut health intact if you're going to absorb it. We're what we eat if we absorb it, so you are what you absorb, which I write in my book.

I actually tried to find who was the first person who said that and so many people have said at this point, I'm not sure who said it, but it wasn't me first. You are what you absorb, and that's a really important thing to understand. We've got to have gut health on point with that, but we've also come to understand that within the uterus, the vagina itself, that ecology matters. There was a study that actually showed, and I want to be really careful with this because I think women are really quick to blame and shame themselves. Please don't do that. This is not your fault, but there was a study that showed that a fertilized egg, so this embryo will actually survey the health of basically where it's going to implant the uterus and it's looking for nutrients and it's also looking for inflammation. It's looking for this environmental signaling to tell it that it's safe, that this is a good time to implant. In this research, they said if that doesn't happen, it's likely that implantation will not occur, which me, as a woman who has had a miscarriage, I will say that medicine did not prepare me for really holding space for women who have had a miscarriage nor myself, and that isn't medicine's fault.

I just think until you've been through it, you really don't get how there are no amount of words in this world that bring any level of comfort. To understand that if the implantation doesn't occur, it might be more about the environment and an opportunity to really work with the environment of your body, which is also impacted by the environment that you live in than to judge and shame yourself because the first thing we do when we're infertile is be like, we're broken, something's wrong with us, which is also medicine does a pretty good job of being like, let's investigate the woman, what's your problem. It's like, there's 50% of the equation that is a man too. If you are struggling with fertility, make sure you're working with a doctor who also considers the male factor in that as well.

Andrea Wien: I think you bring up so many good points and I want to kind of shift gears a little bit and talk about once you are pregnant and the changes that happen in the gut microbiome and the vaginal canal. Do we know what changes are shifting around how our microbial communities are changing once we are pregnant?

Dr. Jolene Brighten: I'm going to be very honest. I wouldn't consider myself an expert in how the gut microbiome shifts during pregnancy, but what I will say is that those hormones absolutely do influence gut function overall. You just had a baby, so I'm sure you remember first trimester nausea. Good time.

Andrea Wien: Yes, not fun.

Dr. Jolene Brighten: Oh God, all bets are off in the first trimester. You just eat what you can eat because I remember I was so naïve. I was like, I'm going to be so great during my pregnancy. I'm going to be like green drinks and vegetables, and then the nausea hit and I was like, I never knew romaine lettuce smell, but it smells terrible. I mean, romaine lettuce doesn't smell now, but it did at the time. In that, when your progesterone levels go high, so that corpus luteum is like, we're pregnant, that's the structure of your ovaries left behind after ovulation. It pumps out all this progesterone before the placenta takes over, and that progesterone is going to relax the smooth muscle. It's going to relax your digestive track, so that's why women get pregnant and they're like, I'm bloated, I'm constipated, I'm nauseous. Sometimes there's a drop in hydrochloric acid as well, and especially if the thyroid is being stressed.

Thyroid hormone's really important for hydrochloric acid production, gut motility, gallbladder contraction, liver health. I mean, it does it all. It is important to understand too that your liver and your gut are main conversion sites of inactive T4 to active T3, so they really go hand in hand with that. I would imagine when things slow down and when you are bathing in now estriol, so more E3. We have estrone, estradiol, estriol. E2, highest in menstruating females, E1, that's more of post-menopausal and E3 is the estrogen of pregnancy. Those are going to be different hormones, different metabolites, and I would venture to guess that the microbiome is going to shift in that time and we are going to see changes that happen just by way of the interaction of the hormones and how the hormones are impacting those systems.

Andrea Wien: I'm hearing all this stuff about group B Strep, so GBS, and this was something that was huge for me when I was pregnant is doctors were talking about it, my other friends who were pregnant were concerned about it. Really, when I took a step back to think about it, to me, it's just an imbalanced microbiome, right? It's letting these more pathogenic strains take hold. What you were saying too before about the womb and the uterus being a sterile place, it's obviously not because we're learning now that GBS can actually infect the baby before it ever comes through the birth canal. That's why we're encouraged to get antibiotics during labor, but we have to get there at a certain time beforehand. Really when women are thinking about how to reduce their chances of having group B strep, I think so many of the things that you've talked about in terms of diet and things we talk about in the show all the time of how to increase the beneficial bacteria is something that could really be helpful in this case. I don't think many people are thinking about it in that way. Do you have any other tips for how to kind of lessen the chances of having some of those pathogenic strains during birth?

Dr. Jolene Brighten: Totally. What you do as part of your preconception care is really everything in this. That's really the starting place, so making sure you're tending to that microbiome before you get pregnant. In women that I have worked with who have had positive GBS in the past, we'll actually test their vagina and test their gut and see if we can find it because if we find it before they're pregnant, we're going to find it when they're pregnant. The interesting thing about group B strep, now we are always super cautious with babies, good job medicine. I do think we should be really cautious with babies, but the newer research is actually showing that group B strep isn't as much of a threat as we thought it was in the past. There was one study talking about how most colonized babies don't develop an infection. They actually have group B strep, but they don't actually develop the infection.

The CDC currently has on their website that the life threatening group B strep infection is about 1% to 2% of cases. Now, for me I'm like, I'm the mom, 1% is too high. 1% is really high, so I do think we should be cautious. I do think we should screen, but it is also really interesting to see the newer research coming out saying we might want to be rethinking how we're approaching group B strep. If I have a patient when she's pregnant, her OB/GYN or her midwife takes the lead on her case. I'm like, whoever catches that baby gets the final say in what's going on with your health because they have to be comfortable with what they're doing. Often, what will happen is that in these situations, I'm managing thyroid and the OB/GYN or the midwife is like, "I'd prefer you just continue to manage the thyroid. She started with you, please continue that." Things that we have done with women is actually having them take oral probiotics, doing vaginal probiotic rotations.

Again, everybody, what did I say? We are first checking with her OB/GYN or her midwife on this. I'm not going to just be like, go do all these things, no. Please talk with your birth provider as well because they need to know what's going on because when birth happens, all bets are off and we don't know how that's going to play out. We make all these birth plans. I think they're kind of cute because after I had a baby, I was like, that's not actually how it works, but in that, you need to be having this discussion with your doctor of like, I have a group B strep, I want to do this probiotic protocol and work with that, and then can we circle back and retest. My experience is that most doctors are going to be totally fine with that if we've still got a window of time. In addition to that, if you're saying you'll retest, they're going to be more comfortable with knowing that sometimes it works and sometimes it doesn't, and the choice that's made is using antibiotics.

If that's the choice you make, just like the choice of making a C-section if a woman's like, it's emergency, I need to have a C-section, you shouldn't feel ashamed of doing whatever it took to ensure the health of your baby and your health as well. There is no gold medal for whoever did it the most natural way. Who cares? We have modern medicine, leverage it as you need to. In that, sometimes patients do end up going the route of using antibiotics or they elect it out together. They're like, "I'm going to use antibiotics during my pregnancy." We then have a probiotic protocol for them as well to make sure as we know with antibiotics, it can decimate the microbiome of the vagina, of the gut. I mean, this is why when you take antibiotics and the doctor might talk to you about a yeast infection. There's all sort of things that we can do that if you do decide to go that route to actually use antibiotics that we are having you eat things like sauerkraut and maybe homemade yogurt.

I don't really think that the yogurt at the store is as good as we once upon a time believed to doing like a homemade yogurt, sauerkraut, having kombucha. It really does depend on the kombucha. If your kombucha tastes like straight up sugar, not the best decision. Things like kimchi, if you can tolerate these fermented foods can be really beneficial. Again, eating that fiber rich foods, taking your prenatal, which is going to give you vitamin D ,zinc, vitamin C, the type of vitamin A that's safe in pregnancy, which is going to support a healthy immune system which is living in your gut, which can help keep those less favorable bacteria and other organisms in check. Then also looking at things like what are your stress levels. Stress is not good for the gut, stress is not good for the immune system. Making sure that you're employing these lifestyle practices as well, these things that I'm talking about, get them dialed in if for nothing else so that you survive motherhood in those initial months because it really can be surviving with the lack of tribe that we have these days, but also so that you're as healthy as possible so you can be that mom you've always dreamt of being.

Andrea Wien: Absolutely. I'm about three months postpartum right now, and I can't attest to that enough and just having that support system has been really amazing.

Dr. Jolene Brighten: I need to send you my first book.

Andrea Wien: Oh, I would love that.

Dr. Jolene Brighten: Did I send that to you? Yeah, my first book's on postpartum health.

Andrea Wien: That's great. I would love to. I've also been following a lot of Lily Nichols' work who does a lot with pregnancy diet, and then now she's getting into the postpartum. She just had a baby herself, so she's also an excellent resource, but I would love to read that. Just to circle back quickly on one last question, let's say a woman is listening to this. She's ready to come off of her birth control. Maybe she wants to get pregnant, maybe she's just concerned about some of these side effects that are happening. Is this something that we're slowly phasing out, is it a cold turkey approach? How do you recommend women start to dial back?

Dr. Jolene Brighten: Birth control is an all or nothing. Hormonal birth control is all or nothing because I have had women right knee and they're like, "Well, I decided to take half my pill and then quarter my pill, and now I'm having hot flashes, night sweats, acne." I'm like, "That's because your body doesn't know what the heck is going on right now." It's an all or nothing medication and you will get pregnant if you're rolling the dice with that. It's got to be the dose. If it's the pill, it's got to be that dose. If it's depo shot, you're going to wait for that to wear off after about 90 days, phase out of your body, be eliminated. If it's an IUD, you have to see a doctor, have that removed, same with an implant. If it's the NuvaRing, you just take it out when you're done with it. With the pill, you can finish it. With my patients, I say when you get to the end of the pill pack, you're supposed to have that withdrawal bleed, go ahead and discontinue it because if you can discontinue in the middle, you're going to have a double period potentially and nobody wants to bleed twice in one month, nobody does. That's a consideration.

The very first thing when you're going to stop birth control is you need to have a backup method and talk to your doctor about that because they can help find you what's right for you. Even if you want to have a baby, you want to spend the time preparing your body, at least six months. The egg you become pregnant with goes through a 90-day maturation window, so 90 days it's maturing. That's at least three months that you have to be on a prenatal and taking care of everything. As we say in my practice, mom is both the seed and the soil. It's not just about the race to get the best egg and get pregnant as soon as possible, it's about having the best soil as well to gestate and cultivate that small human. Think about this as moms, we get one shot of housing that human and giving them the best chance at this life. Now, don't feel ashamed or guilty if you're like, I didn't know this.

I just admitted in this interview several things that we didn't know in medicine. You don't know what you don't know, but when you learn, you can always do better, and so have that backup method. In Beyond the Pill, I take you through a couple considerations. One being if you are on birth control, if you start it for symptom management, you probably want to spend a good three months prepping your body before you come off. If you have something like endometriosis, you need to partner with the doctor to be successful in that transition, same with polycystic ovarian syndrome. If you can start supporting your body now through nutrition and dietary considerations as you step up to the plate, as I call it, but also making sure that your lifestyle is dialed in, you'll be so much more successful in making that transition.

Andrea Wien: Dr. Brighten, thank you so much for all of this amazing wisdom. I know so many people are hearing a lot of this for the first time. If they want to learn more about you, you've mentioned your books, can you tell us again what the titles are and then where to find more information on you?

Dr. Jolene Brighten: Yeah. For postpartum health, you can check out Healing Your Body Naturally After Childbirth: The New Mom's Guide to Navigating the Fourth Trimester. Then there is Beyond the Pill, which is a comprehensive women's hormone guide that gives you what to do instead of birth control, what to do if you're on it and how to transition off successfully. Then you can always come play with me on Instagram @drjolenebrighten. That's where I hang out the most. Then if you go to drbrighten.com, that's D-R-B-R-I-G-H-T-E-N.com, that is what women call the Google of women's medicine because there is so much information on there that helps you make the best decision for yourself, helps you get the information you need, so you have a more productive conversation with your doctor and understand not just the natural ways to heal, but also the other conventional alternatives. I also have to apologize because I have a contractor remodeling my kitchen who decided to start drilling as we're speaking right now.

Andrea Wien: Well, that was perfect timing. I thought it was a motorcycle. Either way, that's totally fine.

Dr. Jolene Brighten: Okay. I'm like, I'm trying to get through this little spiel and I'm like, I just need to call out what's happening right now.

Andrea Wien: No worries. Well, we will certainly link to all of that in the show notes at biohmblog.com under the podcast category for anyone who wants to check that out. We so appreciate the time today. Thank you very much for coming on the show and we hope to talk to you soon.

Dr. Jolene Brighten: Thanks so much for having me and thank you so much for everything that you do to support women in this world.

Andrea Wien: Thank you. Thanks so much for listening. Don't forget to check out Dr. G's book, Total Gut Balance, which includes microbiome friendly recipes that can help you get back on track if you've been taking hormonal birth control. Until the next time, I'm Andrea Wien.

 

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