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    122: This Is Your Brain On Birth Control w/ Sarah E. Hill

    Your brain on birth control can have some pretty undesirable side effects on your body. That’s why, when you’re considering going on the birth control pill, you need to research the current evidence out there, weigh up the pros and cons, and make an educated decision.Sarah E. Hill, author of This is Your Brain on Birth Control, joins me to talk about what actually happens to our bodies when we’re on the pill.

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    Sarah is a psychologist who specialized in studying women’s health and the birth control pill, in particular, after she noticed some changes to her body when she came off it. The biggest thing she discovered was that being on the pill actually damped her personality traits - coming off it allowed her actual likes, loves, quirks, and dislikes to shine through again.

    Sarah explains what role cortisol has in our bodies. We’re often scared into thinking cortisol is such a negative hormone, but actually it has a lot of positive actions. When we’re taking the birth control pill, however, it’s almost like our body doesn’t respond to the cortisol triggers and forgets to have normal, positive responses to situations.

    The birth control pill can be linked to a lot of the health problems and issues our society is currently experiencing, such as post-partum depression, teenage anxiety, and autoimmune diseases. Though Sarah warns against a blanket statement that all birth control pills impact all women in these areas; how our bodies react is really down to our individual brains and physiology.

    Sarah also talks about how being on the birth control pill can actually impact what type of partner we choose. Research has shown that if you choose a partner that you’re attracted to while on the pill, you’re more likely to stay together if you come off it, as opposed to choosing a mate you’re not attracted to but has other redeeming qualities. But overall, women who are on the pill are less likely to get divorced than women with naturally occurring cycles.

    Are you on the birth control pill? Have you had any of the health issues we’ve talked about on this show? Do you feel like your personality traits are less your own while on the pill?

     

    In This Episode:

    • Why the birth control pill can dampen your personality traits
    • How the birth control pill blunts our body’s cortisol response
    • What the link between the birth control pill and post-partum depression is
    • How being on the birth control pill impacts choosing our mates
    • What the relationship between the birth control pill and autoimmune diseases is
    • How your brain and individual physiology impacts the way your body reacts to being on the birth control pill
    • Why you should monitor a teenager’s anxiety levels if they choose to start using the birth control pill

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    Quotes:

    “Cortisol is part of how our body is embedding those meaningful events into our memories and making us feel good.” (15:31)

    “Women who chose their partners when they were on the Pill were less likely to get divorced later than women who chose their partners while naturally cycling.” (29:18)

    “There’s a million different factors that are going to influence the way that the pill plays out in your individual body’s landscape. So knowing what to look out for, keeping a journal, and knowing what the domains of influence are can really help women start conversations with their doctors to troubleshoot their options.” (43:18)

     

    Links

    Buy This is Your Brain on Birth Control

    Find Sarah E. Hill Online

    Find Sarah E. Hill onFacebook |Instagram |Twitter |LinkedIn

     

    Transcript

    Sarah:
    The experience of being the person we are, and the way that we experience the world, is driven by these chemical processes going on in our bodies. And when it comes to our experience of who we are, the two key things are neurotransmitters and our hormones.

    Sarah:
    And those create the experience of our personality and everything else about us. That's a signaling software. I mean, that's what our brain uses to communicate. And you can't change your hormones and not change who the person is.

    Dr. Anna:
    Well hello, everyone, and welcome to Couch Talk. I'm super excited about our guest. Today we're going to talk with Dr. Sarah Hill about the birth control issue, and hormonal changes as we age, as well as the consequences of the birth control pill, to better inform you, whether you've been on the pill, never on it or are trying to have this discussion with maybe your daughter.

    Dr. Anna:
    Now, you know I have four daughters, so we've had birth control pills, discussions for a number of years, as they are now ages 11 to age 31. This has been a topic that's come up, birth control for acne, birth control for period regularity, birth control for PMS. And fortunately, my girls have been on board to naturally regulate some of the side effects and symptoms through the healthy, healthy diet, healthy choices, supplements, and just more of a natural route and understanding that this is the body's normal changes, as well as a couple, have been on birth control pills for a period of time when they'd needed to.

    Dr. Anna:
    So this is a discussion that we should be having to have this open conversation, and know our risks. Now I'm a gynecologist, I've prescribed thousands of prescriptions of birth control, and I didn't know all the risks, all the consequences that are going to be brought up today with Dr. Sarah Hill.

    Dr. Anna:
    So I am thrilled to bring this to you, and I am just back from a three-week trip with my daughters. I actually homeschooled my 11-year-old while we were away, for three weeks, traveling Switzerland, then Italy, and Holland and Poland. I gave a couple of lectures, actually, three lectures to a medical conference in Poland, and a lecture in Switzerland to an amazing group of ladies. So it has been a journey.

    Dr. Anna:
    And guess what? All around the world, women, and men are having the same issues with hormonal issues, the hormonal fluctuations, the transition of perimenopause and menopause, and suffering.

    Dr. Anna:
    The sooner we can correct our hormones, that those times and transition years, and where we're using the birth control pill, or when we're looking to increase our fertility in our forties, what we need to know, what are the risks and are the benefits? And also, one big issue that I've had as a gynecologist, is when clients would come in, to me, on birth control pills at 52, 54 years old, just because they needed to modify their periods or regulate their periods, during the crazy transition time.

    Dr. Anna:
    And there's other things we can do. There are really other things we can do. And irregular periods, PMS, these are symptoms of an underlying physiologic issue. Well, let's get started with our guest, and this is Dr. Sarah Hill. I want to share a little bit about her. She is, truly has an amazing history. She is a Ph.D. from the University of Texas, in Austin, and she earned that in 2006, in the emerging field of evolutionary psychology.

    Dr. Anna:
    She has quickly become a leading expert in health and relationships. Dr. Hill has published dozens of papers on topics such as eating, sexual behavior, inflammation, and romantic relationships. In her new book, This Is Your Brain on Birth Control, Dr. Hill has turned her expertise to uncovering what we know and don't know about the impact of birth control pill on the brain.

    Dr. Anna:
    So again, This Is Your Brain on Birth Control. It is available now, and it is a good read, and eye-opening, plus the science, the little-told science behind this wildly, widely prescribed medication.

    Dr. Anna:
    We need to know the ins and out of this, so here we go. Well, hello, Sarah. Great to have you with us, and my audience today, to talk about this very important topic. How are you doing?

    Sarah:
    I'm doing well, thanks for having me.

    Dr. Anna:
    Now where is home for you?

    Sarah:
    Home is Colleyville, Texas. We're in the suburbs of the Dallas-Fort Worth area.

    Dr. Anna:
    And you did graduate school at Austin, Texas, one of my favorite cities.

    Sarah:
    I love Austin. Yeah, that was actually my first real-time in Texas, was Austin, and it's one of the coolest cities in the US for sure.

    Dr. Anna:
    And now you have two girls at home. Or two children.

    Sarah:
    I do. I have two children. I've got one daughter and one son, so I'm living the best, I'm living my best life.

    Dr. Anna:
    Well, and I like how one of the chapters you put in the book is A Letter to My Daughter, the letter to my daughter about birth control. And so, we're going to definitely hit on that today. We're going to hit on the cortisol topic that you've brought up.

    Dr. Anna:
    At first, I want you to tell why you're so passionate. I mean, it's a lot of work to write a book. It's a lot of work, a lot of time, a lot of sacrifices. And what made you write this book?

    Sarah:
    Yeah. So I was on the birth control pill for more than a decade of my life, and while I was on the pill, I was getting my Ph.D., I was in college, and I'd spent my career, including my time in graduate school, and now my career as a psychologist, I'm studying women, and studying health and studying relationships, and even studying the effects of hormones on what women's brains are doing, and how it influences women's behavior, and how they think and they feel.

    Sarah:
    So I'm studying all of this stuff over here, and then I'm on the pill over here, and I never connected the idea that my birth control pills, which are influencing my sex hormones, would be influencing any of these things that I had been studying, for my career. And then I went off of it.

    Sarah:
    And when I went off of the birth control pill, I felt like I woke up. It was about three months afterward, and I was noticing that in the last little while, I had started going to the gym again, and I was concerned with my appearance, in a way.

    Sarah:
    It just felt, I felt feminine, I felt sexy. I was in tune with my femininity. I was cooking again, and listening to music, and I was interested in sex again, and thinking about sex. These were all things I thought I had matured out of when I was in college.

    Sarah:
    I thought, "Oh wow, I'm more mature now. And I don't have that much time to be thinking. I'm studying, I'm not going to be thinking about sex, or what I'm going to do with my hair today, or listening to, downloading new music."

    Sarah:
    But all of those things, that person that I was before, kind of came back. And I realized, I think, that my birth control pills might've been dampening my experience as a human. And I thought it was too crazy to be true.

    Sarah:
    But then, as I began to learn more, I went into the research literature. Because, as a research psychologist, I have access to these databases that have all the papers, all the science, the scientific research papers, on the way that the pill influences the brain, and the way that it influences women's behaviors and cognition, and all these other things.

    Sarah:
    I have downloaded every paper that had been published that had the keywords, "oral contraceptives," or "hormonal contraceptives," and so on and so forth, and really learned everything that had been done on the birth control pill and the brain. And it was then that I had this, I mean, it was really an epiphany that of course, my hormonal birth control was going to be influencing what my brain was doing. And it's, even though I knew as a scientist, that there are hormone receptors, sex hormone receptors, all over the place in the brain, I mean, everywhere, it never, never occurred to me that my pill would change when my brain was doing.

    Sarah:
    And so, it was this epiphany, and then I wanted to put all of the information that I had learned, that I didn't know. And again, given my field of research, I really should, it should have occurred to me, this information should have occurred to me. And so, I should have at least thought to look it up. But this information hasn't been available to women up until now.

    Sarah:
    I wanted to get this information, put it in one place, make it really easy to understand, and then give this information to women. So that way, when they are making decisions about themselves, or about their daughters, or just talking with their daughters and their girlfriends and their sisters, and their doctors, about the birth control pill, they can have a better idea of the impact that it has on psychological functioning.

    Sarah:
    I mean, it also, I think, will give women a language to describe their experiences. Because I think that, when we talk to women about the way that hormones influence them, and this is definitely true with the pill, it's true of other things, like menopause, and other things, where, when women, they don't have a language to explain.

    Sarah:
    Like, I feel, not like myself. I feel cloudy. And so, giving women an experience to read about their experiences, and describing the psychological processes that might be contributing to this, for a lot of women, is neat, very edifying, and sort of giving them, finally, a language to explain these things that women have been talking about with their girlfriends forever.

    Dr. Anna:
    Yeah. And I think that's exactly true, is that also, the symptoms that we're experiencing aren't in our head. You make a great case for how our hormones run our bodies, and run our behaviors. So physiology drives behavior. So it runs to reason that dampening, not just the ovarian, we think, "Okay, we're just shutting down the ovaries."

    Dr. Anna:
    But we're also shutting down the uterus. And we're decreasing this normal ebb and flow of hormones, and feedback loops to the brain, by shutting this really important, great energetic process down. We're shutting down this great energetic process.

    Dr. Anna:
    So one of the things you talk about in the book, making that connection of how the birth control pills dampens the cortisol response. Let's talk about that, too, because that's that whole, living life in color, versus dull.

    Sarah:
    Yeah. And this is something that, for me, was one of the big differences I noticed when I was off of the, when I went off the pill, is that I just felt, I felt more vibrant. Life just felt more three-dimensional, and textured and rich.

    Sarah:
    Part of the reason for this is undoubtedly, some of the differences, that we see between pill taking and naturally cycling women, in terms of their HPA-axis response. So the HPA-axis that hypothalamic pituitary adrenal axis, which is terrible. And I will never say that again, but it's your brain's communication pathway, that leads to the release of the stress hormone, cortisol.

    Sarah:
    Cortisol, it has kind of a bad reputation, because people think, "Oh, cortisol's bad. Cortisol causes stress, blah dah dah." But cortisol isn't what causes stress, unlike life. Life is what causes stress, and cortisol's actually part of the way that our body helps cope with stress. And that includes bad stress.

    Sarah:
    So things like being stuck in traffic, or having to give a presentation in front of a group of people, but also good stress. Sometimes, some of the most potent elicitors of cortisol release in the body are things like falling in love, and Christmas morning in children causes a big surge in cortisol. And it's part of, it's the way that our body responds to things in the environment that are meaningful.

    Sarah:
    It's basically saying, "Here's something meaningful, and something exciting might happen, or something terrible may happen," as are you getting your body ready to deal with whatever possibly could happen next. And so, experiencing this big surge in cortisol, when important things are happening, allows us to be able to pay attention to whatever it is that's causing the stress response, whether it's this new romantic partner that we're falling in love with, or whether it's the wildebeest stampede that we're trying to get away from.

    Sarah:
    And it flags those things as being really important. It helps, it increases perceptual vigilance, and it helps to filter things into our long term memory. And it does a bunch of other things that contribute to managing a stress response. And what they find with women on the birth control pill, is that they don't have this big surge in cortisol response, in response to stressful situations.

    Sarah:
    So when women are feeling, they usually do this by doing a public speaking paradigm, where they have women giving a speech, and then they measure their cortisol after they do this. And there's usually a big dynamic increase in levels because your body's getting ready to, it's responding to the stress, and getting, mobilizing the body's resources to deal with the stressor. Now, but pill-taking women don't have that. They have this blunted cortisol response.

    Sarah:
    And this is something that we usually only see in the context of chronic stress, so usually we don't see this, a lack of cortisol response, unless somebody has PTSD, they've experienced trauma or prolonged exposure to extreme stress. So this tells us a few things. It tells us one, there, it might, there's probably something going on with the pill. And we don't yet know what it is, from the research that's leading to the stress system, the stress response system becoming completely overwhelmed.

    Sarah:
    Because when this happens, in the context of trauma, the body actually shuts the stress response off. And that seems what's happening with pill-taking women is, there's a lot of different signaling pathways, and I'm not going to get into them, because it will just bore everybody to tears. But there's a lot of different steps in the signaling pathway between the brain and cortisol release, each of which is being tuned down by the body. They're all in.

    Sarah:
    That's usually the only type of thing that you see when the body is just shutting down the stress response. So it's not just a problem with not being, cortisol not being released. It's like, the whole signaling pathway is, each step is showing evidence of being shut down intentionally.

    Sarah:
    There's been research now, looking at differences in brain scans, of women who are on the pill versus off of the pill, and the brains of women who are on the pill look like the brains of people who've had trauma, unexplored, call that, "language." That's this idea that something in the pill is causing the stress response to become overwhelmed, and then shutting down the stress response.

    Sarah:
    Now this might sound like, "Wow, it's amazing to have the stress response turned off." But that, to circle back to the idea of this vibrancy, and this lack of dimension in experiences, cortisol, one of the ways that we can think about what it does is, that it helps us absorb our environment.

    Sarah:
    When really good things are happening, we're falling in love, it's Christmas morning. It's like, cortisol is part of how our body is embedding those events, those meaningful events into our memories, and making us feel it's life. And even stressful things, like, not necessarily traffic, we're giving an important presentation, or something, a stressful deadline at work.

    Sarah:
    I mean, these are part of what makes life meaningful. It's these, it's like, little blips in activity that, we're having to manage. And cortisol helps put those and flag those things and put them into our memory.

    Sarah:
    And not having that dynamic surge in our cortisol in response to stress may, to start with, it probably decreases women's ability to cope with stress, which can lead to depression and anxiety. And there's some evidence linking pill use to both of those things, but also just even feelings, like a loss of vibrancy, because you're not, your brain isn't grabbing onto the meaningful things in your environment. And it might make your life feel more one-dimensional and flat.

    Dr. Anna:
    This is really interesting, and you've given me a lot of food for thought. For one thing. I had to tell you a funny story, though. Because when I public speak, that is exactly what happens. My cortisol shoots way up. I'm certain because I was wearing a 24 hour, 14-day blood sugar monitor and fasting, I got up to speed for a conference of a thousand people, and my blood glucose fasting went up to 150.

    Sarah:
    Yeah! Yeah, I know.

    Dr. Anna:
    [crosstalk 00:16:55] I know. That's the power of it!

    Sarah:
    Yeah, I know. And that's such a big because that's what cort does. That's another one of the things that it does, is it dumps sugar into your bloodstream. So another possibility, and then, and I don't mean to interrupt you, but it's just that because it seems like something's going on. And again, this is not well-characterized yet, where pill-taking women are having a surge in stress hormone signaling, at least initially when they're on the pill before the stress system shuts itself down.

    Sarah:
    All of that dumping of sugar into the blood could potentially increase women's risk of diabetes, and pre-diabetes, and hyperglycemia, and some other things. And so, this is not something that I really spend a whole lot of time speculating on in the book, just because I'm not, I'm a psychologist, and so, it's outside my domain of expertise. And I tried to really do a good job of not doing that. But yeah, that's a possibility, a real possibility.

    Dr. Anna:
    Well, and then the good thing about it, right, that's spiking cortisol, because we're on. We're on, we're higher performing at that point. And then our brain needs that extra glucose. So that's in a really good adaptive response. So I imagine what it would be if that would be dulled.

    Dr. Anna:
    The other thing is wondering too, about this blunting of cortisol with a birth control pill, if it is also blunting oxytocin. Well, I imagine it is, because when we ovulate in the corpus luteum, we're going to secrete some oxytocin with that. So in that delicate balance between oxytocin and cortisol, so then that dullness, that lack of oxytocin, among that blunted cortisol, maybe that's part of the story, too.

    Sarah:
    Right. So, and here's another piece with the oxytocin thing that I found, and I read about and I was like... But with this, they did a study with pill takers and non-pill takers, and they gave them intranasal oxytocin. Normally, when you do that, you give somebody an intranasal oxytocin, and you show them photographs of their romantic partner, their brain lights up like a Christmas tree.

    Sarah:
    It's like, "Oh, there is my love of my life." And you get all of these, warm and fuzzy, and your brain is doing all of the happy things, and your reward pathways are lighting up. And if you look at a complete stranger, the same thing doesn't happen. And so, it's just this idea that oxytocin sort of primes the brain to respond in a rewarding way to the face of those who are in our groups, and that sort of thing, and people we love.

    Sarah:
    And what they found was with pill takers, and this is even with administering oxytocin, which suggested it's not just the levels of oxytocin, but the signaling pathway? They gave the women intranasal oxytocin, they show them photographs of their romantic partners, and strangers, and... nothing. It was really, a lot like-

    Dr. Anna:
    It's shocking.

    Sarah:
    It's shocking. Yeah, and I almost said alarming. I don't want to alarm, because I don't think is a-

    Dr. Anna:
    I know, but I'm just thinking right now, I've written thousands of birth control prescriptions in my 30 years or so, 25 years as a gynecologist. Thousands of birth control prescriptions and I didn't know these consent issues, that really, we need to be aware of, we want informed consent.

    Dr. Anna:
    Every one of us, we're going to make a decision. I always choose my vices. I know their advice, but I'm choosing it, right?

    Sarah:
    Right, exactly!

    Dr. Anna:
    They say you have to be able to choose what works for us at this time. So that informed consent, if you didn't... And this research isn't new.

    Sarah:
    I think that once the research gets more advanced, and we know more about what individual formulations of these different types of progestins, and what receptors are binding to, and the more we know about all this, I don't necessarily know that every single pill is doing this. It's just because normally, when they do this research, it's like, "These women are on the pill. These women are not on the pill."

    Sarah:
    But we need more research to know whether or not this happens with everything. And especially where I thought you were going to go with that, I mean, it is an important thing is, I'm sure that a lot of the pill prescriptions that you writing were to new mothers. Because when you first have a baby, and even if you're nursing, usually, I was on a progestin-only pill, when I was breastfeeding.

    Sarah:
    If you're not nursing, a lot of times, they'll just put you on a combination pill. And if this signaling pathway with oxytocin is getting messed with, it's like, I think that could be contributing to the rising numbers of women with postpartum depression, because they're not bonding with their children.

    Sarah:
    Because if there's something being messed up with the signaling pathway with oxytocin, and they're not in there holding their infant, and looking at it, and just feeling this is a little stranger, instead of getting that reward pathway going like it usually does, I mean, that's really provocative. And it's potentially really important. And this is really important research. Nobody has done this right?

    Sarah:
    They've done research showing that oxytocin signaling problems are associated with postpartum risks, and others is research showing that the pill when you're looking at your romantic partner, it doesn't seem like your brain is flagging that as somebody important anymore when you're on the pill.

    Sarah:
    So the idea that that might be going on with women's babies is really, really important. And I think it could end up, we're putting some effort into this research. It could really change the way that we approach postpartum fertility regulation.

    Dr. Anna:
    That is huge. And definitely, I've been a proponent of the Paragard, the non-hormonal IUD, but also recognizing that if that's interrupting the oxytocin signaling pathways, bonding, breastfeeding, those are issues, and from a childhood perspective, adult social behaviors. So if they're not having that, a deeper connection, and bonding. And I'm not saying that's the case, but how interesting. How interesting.

    Dr. Anna:
    I think of rising rates of autism, and I think, "Okay, well, what we're given the mom is going to the baby too." And that's affecting our oxytocin signaling pathways, too, in autism.

    Dr. Anna:
    So the other thing too is progestin versus progesterone. And I do want to make a point here, is that often, for postpartum depression, when I became more aware of bioidentical progesterone, I would use bioidentical progesterone as a... They're, essentially they're anti-depressant, while breastfeeding or otherwise, because it helped them get a good night's sleep.

    Dr. Anna:
    It helped them feel better, they felt more awake and alert. So there's a difference between the progesterone and the progestins. What have you found in your research?

    Sarah:
    Well, so the birth control pills that are available, and all those are all progestins. There's not any sort of a bioidentical that's used, and each one is manufactured from a different, it's actually synthesized from a totally different chemical.

    Sarah:
    And in almost all of the cases when the first, the progestins are divided up into four different generations, on just, based on when they appeared on the market place. And so, there's the first generation, which was the original, the OP, the original progestin. And now we're up to fourth generation progestin.

    Sarah:
    They're all still in use, and each one's so, a little bit different. The first three generations are all made out of [inaudible 00:23:56], rather than starting with a progesterone molecule, they start with the testosterone molecule. And then tinker with its chemical structure in ways that allows it to stimulate the progesterone receptors in the brain, and throughout the body, but it also sometimes also stimulates other receptors.

    Sarah:
    It stimulates testosterone receptors, which is why some women get things like breakouts, and hair in places that they don't want hair, when they're on the pill, because their testosterone receptors are also being stimulated. The cortisol issue, maybe, my guess is, what's happening, based on some, I read some research in a chemistry journal, which I don't recommend to anybody to do.

    Sarah:
    Because it was like, my eyes were crossing, and I had to call in reinforcements, just to make sure I was understanding, like, "Do I understand what's happening here?" And my chemist friend was, "Yes, you're doing a very good job. But there's some research showing that some of these progestins have some binding affinity for cortisol receptors."

    Sarah:
    And that they stay on there, but then it doesn't seem like they have a good binding affinity, and I don't know what that means, but I mean, I know what it means mechanistically. I don't know what that means physiologically. Like, What does it mean when it stimulates the receptor and then stops simulating the receptor?

    Sarah:
    This is one of the battle cries, the things that I keep repeating in the book, unfortunately, is, "Oh, we need more research on this. Here's what we know, and here's what we don't know." But on some of these progestins, I think might be, also stimulating cortisol receptors. And I think that might be why we're getting this overwhelming of the stress response that's causing it to shut down.

    Sarah:
    Because these things are tinkered from something else. They're sort of, I call them Franken hormones. Because they're created from these other things, and sort of made to be something else. The only one that is not made out of testosterone is, it's one of the fourth generation progestins, and it's made out of a diuretic, actually, that's manipulated, I can't pronounce the word-

    Dr. Anna:
    Spironolactone. Is it from spironolactone?

    Sarah:
    Yeah. I was like, yeah, I've written it down a hundred times, I can't pronounce it. So one of the fourth generation progestins is made out of a modified, a chemically altered version of that. And so, each one of these is, I mean, they're all Franken hormones.

    Sarah:
    And so they're all going to do things besides stimulate progesterone receptors. And that is why I think we got such a, I mean, that's part of the reason that we get so many unusual and surprising side effects that we get with the birth control pill.

    Dr. Anna:
    That's a great point. And then, too, how birth control pills affect our choice in mates. And we talk about the blunting effect of birth control pill on the surge in oxytocin, or the receptivity to our mate when seeing that photograph. But how does being on birth control help us choose our mate?

    Sarah:
    Right. So there's been about, for about 30 years now, researchers have been demonstrating, women's sex hormones play an important role in terms of who they're attracted to, and even just their sexual responsiveness, how attuned they are to men, and how attuned they are are to sexual communication, and how attuned they are to sex, and how much they want to have sex.

    Sarah:
    And what this research all finds is that the sex hormone estrogen is really, drives the bus, in terms of it motivates our interest in sex, and desire for sex, and how much we're thinking about men.

    Sarah:
    It also increases the priority that women place on, sort of, what we'll call sexiness cues in men, so traits that have historically been linked with the sex hormone testosterone in men. Things like a chiseled jaw, and a nice brow ridge, and broad shoulders, deep voices, swagger, these kinds of things that are associated with testosterone.

    Sarah:
    Women, when the sex hormone estrogen is high, or when fertility is high across the cycle, women tend to really place an emphasis on these kinds of sexy qualities. And so researchers, more recently then were interested in what happens on the pill because when you're on the pill, it keeps women's own levels of estrogen very low. And the ratio of artificial estrogen to synthetic progestin is such that progestin is the overwhelming hormone.

    Sarah:
    So it's like women, it's trying to mimic in the brain, and it's trying to pretend it's progesterone, a progesterone dominant state. So that way the brain doesn't start the cascade that begins the maturation of the egg, and ovulation and the whole thing. Levels of estrogen are low.

    Sarah:
    And in terms of the artificial hormone, she's taking, it's a perpetually progestin dominant state. So we should expect that it's possible, that given that estrogen is what fuels women's interest in sex, women's interest in men, and the priority that they place on sexiness, that women when they're on the pill, might actually choose partners that have fewer of these markers of testosterone.

    Sarah:
    So they might choose partners who have less masculine faces. And they might choose partners, they might emphasize qualities other than sexiness, and sexual appeal, in their choice of partners, when compared to naturally cycling women.

    Dr. Anna:
    Now this sounds like a good thing, so was it? [crosstalk 00:29:04] I'm just curious about divorce rates now, and...

    Sarah:
    Right. Yeah, but no, and actually, it's really interesting because the research that has been done, looking at the divorce rate, divorce is less frequent among women. It was in this large sample of women, they found that women who chose their partners when they were on the pill were less likely to be divorced, to get divorced later, than women who chose their partners while naturally cycling.

    Sarah:
    What was also interesting is that when the women who chose their partners on the pill did get divorced, they were, eight times out of 10, they were the ones who initiated it. Which is also consistent with this idea that maybe, if you're on the pill, and you choose your partner, and then you go off the pill, and all of a sudden you're prioritizing these cues, for sexiness and sexual appeal, and these things that really weren't important to you before, that that potentially could cause problems in their relationship.

    Sarah:
    And I've heard that now from a number of women anecdotally, who have told me their story, about, "I went into this, and now it sounds like the craziest thing you've ever heard, but I went off the birth control pill, and I'm not attracted to my boyfriend anymore." And this sort of thing, and I've heard anecdotally, and now there's some research evidence also suggesting, that if women choose their romantic partners when they're on the birth control pill, and then they go off of the birth control pill, that it does, or it can influence their relationship satisfaction and sexual satisfaction in their marriage.

    Sarah:
    What the research finds is whether that change is positive or negative, it depends on how attractive their partner is. And so, women who chose their partners when they were on the pill, if they go off of the pill and they're partnered with somebody who's attractive, they actually report being more sexually attracted to their partner.

    Sarah:
    They report being more sexually satisfied, and they report more relationship satisfaction than they did prior. Now with women who chose as partners, less attractive men, when they go off the pill, you find the opposite. So they actually, these women report having lower relationship and sexual satisfaction after they go off the pill.

    Sarah:
    Again, the idea here is that, when you're on the pill, and just might cause you to prioritize a certain, one set of qualities, instead of another set of qualities. And there's research showing that women who chose their partners on the pill are more satisfied with their partner's financial provisioning ability, and their partner's intelligence. And it's probably because those are the kinds of things that they're prioritizing when they're no longer also really in tune with these sexiness qualities.

    Sarah:
    And women who choose their partners when they were on the pill report being more satisfied with most of the sexual aspects of their relationships. And so, whether this is a good thing or a bad thing, it was really up to an individual woman and her life goals.

    Sarah:
    Because again, this is information to have, not to get alarmed about, but rather, just to take into consideration. What do you want for your life? What are your goals, and how can you use this information to best strategize your birth control, and even mating strategies?

    Dr. Anna:
    Well, and this is where it comes again to, physiology drives behavior. And talking about this makes me think of a conversation I had with, in another podcast, with Alison Armstrong who is studying male and female. And one thing she says is, she said, "The guy you're attracted to, and you can't be yourself with, because you're trying to be, you're being someone else with, because you're so attracted to him, and you just want to theirs completely? Avoid that situation."

    Dr. Anna:
    She said, "Avoid that situation, choose all, make sure you know your non-negotiables, and all these other things. Don't just completely, if you're feeling head over heels, don't let that sway you in a choice for a life mate." So that's, that's interesting, too, to think about it from, "Oh, so if we're looking for, what we're looking for, what feeds our attractiveness, and then that attraction and that balance, for quality of life and longevity in a marriage, but making..." It's interesting, I'm really am fascinated by this topic and this subject, and also how the birth control pill influences that.

    Dr. Anna:
    Another thing I see, often, I actually lecture to hormone docs all the time about this issue is that hormone replacement, so other than the birth control pill, does blunt certain things. And I believe in a healthy menopausal transition. I don't believe in completely shutting it down. Just like when we start our periods. Using the birth control pill to shut that process down puts us at tremendous risk, moving forward.

    Dr. Anna:
    And this, the menopausal transition, so blending it, whether we're doing it with the birth control pill, which is something that really irritates me, especially women who have had their tubes tied, or their husband has a vasectomy, and they're on the birth control pill to manage menopause. I mean, we've got better ways. Read my book, The Hormone Fix. So we've got better ways, but also, just prescribing more and more testosterone.

    Dr. Anna:
    There's more and more testosterone clinics, but what I've seen are higher and higher divorce rates. Physiology drives behavior, men and women, like, increased number of affairs, increased dopamine, dopamine seeking behaviors as well. Testosterone and dopamine go hand in hand.

    Dr. Anna:
    So dopamine creates that, as you know, that excitement. That that's, that boost, that charge, that addictive, "I want more." Okay, so we're adding that, if we're doing that, it's just really important to know. And as physicians or as consumers, if we are getting testosterone, and I do use some testosterone replacement, but I'm, less not more type of philosophy, and also counseling... If you're starting to act in ways that you would not normally act, either it's anger, or you're thinking about, the delivery man, or whatever it is...

    Dr. Anna:
    And you know, "Hey, I would normally not do this," and or I'm dating and going too fast, too far too fast, you're like, "Hey, well, maybe there's something here with the physiology affecting my behavior, or this exogenous hormone affecting my behavior." And that's a powerful, this is a powerful area of study.

    Sarah:
    Yeah, no, I think it is. And I think that it's like we forget, this is the one thing I talk about in my book. Because it's so hard for our brain to keep in mind that, and it's this thing, that you keep saying, about physiology drives behavior, that the experience of being the person we are, and the way that we experience the world, is driven by these chemical processes going on in our bodies.

    Sarah:
    And when it comes to our experience of who we are, the two key things are neurotransmitters and our hormones, and those that create the experience of our personality and everything else about us. That's a signaling software. I mean, that's what our brain uses to communicate. And you can't change your hormones, and not change who the person is. And I think it's a blind spot that a lot of us have.

    Sarah:
    I think that we lapse into Cartesian dualism, or we think about the mind, this mind/body split. Even those of us who study the brain... Because it doesn't feel, that's not what it feels like to be a human, with restaurant preferences, and somebody who has likes and dislikes, and a sense of humor that doesn't feel like chemicals and electricity.

    Sarah:
    We forget that. So then we do things, like, yeah, we take hormonal contraceptives or these other things, and we forget that it's not just going to influence us from the neck down, it's going to influence what our brain is creating as reality.

    Dr. Anna:
    Hmm. That is powerful. I'm going to jump back, because when you were talking about, how birth control pill blends that cortisol response. And now there's the three-month pill. I mean that's been out, since, gosh, decades. But I don't recommend it either. But what, I'm just wondering, and the increased risk of autoimmune disease with birth control users, right? And so here we're suppressing this cortisol response.

    Dr. Anna:
    So that's our body. Cortisol is naturally, we need it to respond to inflammation and stress. So we need it to support our immune system. It's an, it's crucial to a healthy immune system. Well, again, we don't know, but I wonder if that's not part of the reason, the autoimmune disease.

    Sarah:
    I absolutely think it is. I mean it, to me, it seems unquestionable. I mean, [inaudible 00:37:34] quarterly is, in a sort of, in fine-tuning the volume up and down, in terms of the inflammatory response. And then to have that not functioning properly, it seems unlikely to me that it doesn't play a role, in terms of autoimmunity. I'm pretty certain that it must.

    Sarah:
    The other piece of that is, and I don't know mechanistically if this operates through the activities of cortisol, but we know that progesterone, progesterone is also, also has a role, in terms of regulating immunological responses, because of all of the workarounds that the body needs for pregnancy. And it could also be the case that keeping women in a progestin dominant sort of hormonal state, for as long as they do, never letting progesterone be low, could also be contributing to that in some way.

    Sarah:
    And I don't know if it's like a, through a rebound effect, right, where once women are... Or, once women are naturally cycling, that their immune system just goes crazy. Or if it's something that goes on, like during the process of having this daily, dose of progestin at the time. But I think that the progestins are probably also playing a role.

    Sarah:
    Again, I don't know, I'm not a physician. And I don't study physiology. I study all the stuff that happens up here. I don't know mechanistically if the link between progesterone and the immune system operates through the activities of cortisol, I'm not sure. I don't think it does. I think it operates on inflammatory activity itself.

    Sarah:
    I think that that there's receptors on the white blood cells for progesterone is my guess. But I, I'm just not 100% percent positive on that. But I think that the combination of keeping women in a progestin dominant state constantly, plus having dysregulated cortisol, I mean, it creates the perfect storm, in a lot of ways, for leading to changes in inflammatory activity.

    Dr. Anna:
    I'm going to add one more disruptor to this. Because I agree with what you're saying is just, and when we're on birth control pills, and we were married, we're not using a condom, but our body has to mount an immune attack to the sperm that enters, the leftover sperm that's millions and millions, if not billions of sperm, that don't fertilize the egg. Our body has to mount an immune attack to that, as well as the viruses and bacteria and parasites, et cetera, that our vagina can be exposed to.

    Dr. Anna:
    And we talk now about the autoimmune disease being a function of [inaudible 00:40:01], these outside immunogens, essentially. I don't know how to say this any other way, but help me here, but these outside immunogens that affect our immune system that our body's having to deal with.

    Sarah:
    Yeah, exactly. And so, that's another thing that, so, the more sex women are having... That's really interesting. I wouldn't have even thought about that.

    Dr. Anna:
    It's interesting. Actually we were just in the Netherlands, and in the Hague, this area of the Netherlands, they have this seven-story building that's called Corpus. And you actually go through Corpus. This is the body, you go through the body, and I can tell you where we entered, but at least we didn't go out that way.

    Dr. Anna:
    So we entered in it, and it was so funny. And so we go through the body. And we again, all enter the womb, and they do this great video representation of sperm meeting the egg, and the left, like some sperm dying amongst the uterine, or the Fallopian tube, the cilia within the Fallopian tubes, and [inaudible 00:41:05].

    Dr. Anna:
    I'm thinking to myself, "Millions and millions going there, millions of millions of DNA particles, mitochondria and other, whatever else is coming there. Bacteria, parasites, yeast, viruses, our body, as women, has to deal with that." What are we going to tell our daughters?

    Sarah:
    Right. Yeah, no, exactly. Exactly.

    Dr. Anna:
    But it's fascinating from a medical perspective, because I'm seeing this and I'm talking about it, and I'm very interested in this. So it goes back to protecting ourselves, knowing, having informed consent, and knowing the consequences of our choices.

    Sarah:
    Yeah, no, absolutely.

    Dr. Anna:
    No judgment, right? No judgment.

    Sarah:
    Right. No, exactly. I mean, it's just about having as much information as possible when you're making decisions. Because each one of us, it's, just because you know that something might do something that's "undesirable," or it actually is undesirable, a lot of us make those choices anyway. We just know what we're doing. We know what we're getting into.

    Sarah:
    I probably drink too many cups of coffee every day, and I know that it's not good for me, and I do it. I do it anyway.

    Dr. Anna:
    We choose our vices. That's what I say.

    Sarah:
    You couldn't, no, and that means, and we choose our vices. And pregnancy for prevention, and fertility regulation, is such an important thing for women. I mean, it's been so critical, in terms of allowing us to achieve financial independence, and being able to reach our educational goals, and to just, to even to be able to just dream big.

    Sarah:
    And so, for a lot of women, the tradeoffs are so going to make sense. But they should have all the information. And it will also allow them, if they do decide to be on the pill, at this point in their life... But maybe not that point, or to do this, and not that, to know what to look out for.

    Sarah:
    Because not every woman, and I'm sure you saw this in your practice constantly, nobody responds the same way to the same thing. And it's because the way that these things influence our brain, and everything else, is going to depend on what your level of hormones was like before you started it, the number of receptors you have for each of these different types of hormones, a bunch of things that probably depend on some sort of physiological chemistry that just makes you a little different than everybody else.

    Sarah:
    Your immune system, dah dah dah, this and that, the way that your liver processes things, I mean there's a million different factors that are going to influence the way that all of this plays out in an individual's, body's landscape. And so, knowing what to look out for, keeping a journal, knowing what the domains of influence are, I think, can really help women start conversations with their doctors that are, "This isn't working. Here's what's happening. Let's try this." And really troubleshoot their options, so that way, if women do choose to be on hormonal contraceptives, they can find one that allows them to feel maximally at home in their own bodies.

    Dr. Anna:
    Absolutely. So what do you counsel these young girls, or counsel your daughter?

    Sarah:
    The last chapter of the book is called A Letter to my Daughter. And I do, I have a daughter, and she's 12, and she's so embarrassed that I wrote a book about sex!

    Sarah:
    My best friend is actually, she also is a psychologist, and she studies women's sex hormones and decisions, and she also has a daughter. And so we talk about this all the time on this. This chapter is actually, it's a love letter, in some ways, to these discussions with my best friend, and to our daughters, who we're thinking about, and what do you do?

    Sarah:
    And to my daughter, and as I do in this chapter, I really layout what some of the risks and drawbacks are. And here are some of the big issues you should take into consideration when you're making these decisions. One of the considerations I talk about is age, and how old are you, because there's not a lot of research yet on what the pill does to the brain when it's still developing.

    Sarah:
    We know that the brain is still developing until women are in their twenties. It's like, most of the heavy lifting is done by the time a woman is 19, or so. But when a woman's brain and women are going through puberty, the brain undergoes a number of really important structural changes that allow us to be grownups. And sex hormones are the head contractor in that remodeling project.

    Sarah:
    And so, we don't know, does taking hormonal contraceptives when the brain is still being put together, does that influence how it's organized? I mean, that's something that wouldn't go away once a woman stops the pill. And so, it's just something to keep in mind and to be aware of.

    Sarah:
    Again, it's not something to necessarily get alarmed about, but just to keep in mind. Because also during these ages, these young girls are the ones who would have the most problems if they got pregnant.

    Sarah:
    So it's really, you know what I mean, it's a balancing act. And so, one thing I would consider is age. I would consider history of depressive illness, because, especially in 15- to 19-year-olds now, there's been a lot of evidence that's beginning to accumulate, that young brains don't seem, they seem to be the ones most at risk for anxiety and depression when it comes to using the birth control pill.

    Sarah:
    So there's something about the brain while it's still developing, that seems to be really sensitive to whatever it is that's, the hormonal profile that's created by the pill. And so, just keeping an eye on that, and being very careful with that. Yeah, these are some of the big issues, and just keeping track of who you are, where you are in life, and what your life goals are.

    Sarah:
    And then, try to use the information in the book about the ways that the pill can sort of change what the brain is doing, to make the decisions about at what times in your life does it make sense, and at what times in life you might have to do something different.

    Dr. Anna:
    Yeah, that's a great point. And I encourage everyone to read that chapter, whether it's for your daughter or your granddaughter, someone you're mentoring, it's good to have the words in the conversation and the information to give informed consent. Because your doctor does not know this. Likely your doctor does not know this.

    Dr. Anna:
    I did not know all of this. And so, this is important. This is groundbreaking information. As women, we have to look, okay, we want to optimize our body, so we have normal transition and again, many of us are put on birth control pill, not for birth control.

    Dr. Anna:
    So that's where we really have to put our foot down and say, okay, well, what's the cause of these symptoms? And let me address that. Sarah, I want to thank you so much. People can get your book at, Sarah, with an H. So, S-A-R-A-H-E, hill.com/book, and anywhere books are sold. So tell them also, your Instagram, and how to connect with you.

    Sarah:
    As noted, my book is available anywhere that you can buy books, and you can see more about me at sarahehill.com. And you can follow me on social at @sarahehillphd. And that's my handle on Instagram, Twitter, Facebook. You can find me everywhere. So I look forward to connecting.

    Sarah:
    But yeah, I mean, really, if I can just say one final thing, and that is that the book is about, is giving women information, and is about starting conversations. And really having women finally have a language, to be able to explain what's going on with them, to [inaudible 00:48:10] that to themselves, to their daughters, to their doctors, to their granddaughters, and really allow us to be able to better understand ourselves. And that way we can make better, more informed decisions about our health.

    Dr. Anna:
    Excellent, thank you and show the picture. Show the book.

    Sarah:
    Oh, yeah!

    Dr. Anna:
    Yeah, I just have the digital copy. So yeah, beautiful, this Is Your Brain on Birth Control. So you all recognize this, and Sarah, thank you so much for sharing your wisdom and sharing your time with us today. It's been a real honor to have you as a guest on Couch Talk.

    Dr. Anna:
    So I know this podcast has resonated with so many of our listeners, and I encourage our listeners today to comment, share, and certainly connect with Sarah on her Instagram, and also connect with me on Instagram and let me know, post a picture of yourself with the book, and let me know how you like it. So thank you, guys.

    Sarah:
    Yeah, thank you. And thank you so much for having me.

    Dr. Anna:
    My pleasure. Keep up the good work. Awesome. 

    Dr. Anna Cabeca

    Dr. Anna Cabeca

    Dr. Anna is a Triple Board Certified OB/GYN, Anti-Aging Medicine expert, and author of the best selling book, The Hormone Fix.

    Dr. Anna helps women heal the 9 most dreadful symptoms of menopause with natural, safe solutions. Follow her for content on hormonal imbalances, vaginal dryness, menopause (and more) that are medically backed, and created to empower women — not just treat them.