Dr. Sarah E. Hill [00:00:00]:

I encourage women, like if they're able to naturally cycle to do it and to produce those sex hormones. And this is particularly true for younger women, just because, you know, our brain is still developing up until the time that we're in our early twenty s, and our HPG axis, which is the hypothalamic pituitary gonadal axis, which is just the communication pathway between our brain and our ovaries is still maturing during this time up until we're in our you know, until we're about 20. Suppressing that and shutting it all down with hormonal birth control prevents that development from going on.

Georgie Kovacs [00:00:39]:

Welcome to Fempower Health, Georgie. Here. In today's episode, I interview Dr. Sarah Hill, who is the author of this is Your Brain on Birth Control? And we are uncovering the science behind birth control and how it may shape our lives. Now, we couldn't help but get a little bit nerdy on the science up front so that you have proper background on the potential impacts. And we do focus on hormonal birth control, but we can't escape the fact that all birth control has had a change in our lives, especially giving us the opportunity to excel in the world because we are able to make choices now, like going back to school, which now women outnumber men. We also discussed the impact of the over the counter birth control that recently was approved by the FDA, as well as the effects of the Roe v. Wade overturn. Now, I do want to share one quick thing that we didn't get to in the episode because we did have so many things to discuss. Just wanted you to consider this quote as you listen to the episode women, just by virtue of being the choosier sex, have the ability to inspire men to do amazing things. And it shouldn't spoil it for us that these things are ultimately motivated by sex. And this is proven in the research. In one of the studies, she cited men who believed that women's standards were high outperformed those who believed that women's standards were low. So when you combine this with the fact that men are now achieving less than ever before in history, it creates a situation in which women are finding that they have to cut some pretty crappy deals if they want to get married. I'm definitely curious on your thoughts about that quote, but let's dive into the episode because I do think it's such an important conversation and hopefully some of this introduction will help give you some food for thought as you listen. So enjoy and definitely share with me your thoughts. Email me at info at Fempower Health. Sarah, it's so nice to have you on the Fempower Health Podcast. I've been following you for quite a long time with your amazing book. And so before we dive into talking about birth control, because this is such a great time in the world to be revisiting this topic, why don't you give us your introduction and then we can dive right in?

Dr. Sarah E. Hill [00:03:05]:

Sure. So I am Sarah Hill. I'm a psychology professor and a researcher, and I've spent most of my career studying women's health and hormones and sexual behavior.

Georgie Kovacs [00:03:18]:

Tell us a bit about your book as well.

Dr. Sarah E. Hill [00:03:21]:

Yeah, I guess the thing I left off my intro was the most relevant piece to our conversation, and that is also that I'm the author of this Is Your Brain on Birth Control, which was a project that began I've been working as a research psychologist for a number of years now, over a decade. And this book was actually the result of me as a scientist who'd been studying women and women's psychology for a really long time, going off of hormonal birth control. And so I hadn't really had that much attention paid specifically to that issue, like the way that the birth control pill affects the brain. And then when I went off of it, I felt so fundamentally different that I began to sort of pivot my research to begin to really explore what do we know and what do we don't know yet about the effects of hormonal birth control on the brain. And so I spent a number of years researching everything that is written in the book, and that is what we're going to be chatting about today.

Georgie Kovacs [00:04:30]:

I saw you On The Business of Birth Control, and it was great because I saw many previous podcast guests in that documentary. And again, even since that documentary was published, so much has changed in the world. I had shared with you some of the questions, like about Roe v. Wade, the over the counter birth control pill and all that. And I still want to discuss it, but I still think it's important to talk about the research in your book, because I still feel like that data is so important to have the rest of the conversation. I thought I'd start with a couple of quotes in the book. So you said as of this writing, and your book was, I think, 2018 published, is that correct? 2019, as of this writing. The full extent to which the artificial hormones in birth control pill influence every other cell in the body that has hormone receptors for progesterone and estrogen, it isn't all that well understood, and we have been far too cavalier with our hormones. And I can't help thinking that we would be a lot more careful with ourselves if we understood how we work and why we work that way. You need to know how your brain works. You need to know how your hormones influence your brain, and you need to know how all that changes on the pill. They're from two separate sections, but I felt they had to do with each other, I guess. What do we know today? And then we can dive into some specifics. So where do you feel like our knowledge is now based on the studies you published there and anything new that may have come up around. And I know that's a very big question, but where do you want to start with these impacts that people don't really think about but need to know about? With the pill, right?

Dr. Sarah E. Hill [00:06:30]:

Well, I think that the important place to start is just in understanding the role of hormones in our brain. And it's like we tend to like, with the birth control pill or anything, really. When we're talking about hormones, we tend to talk about hormones like there's something that are happening to us, right? Like, oh, my hormones are doing this and my hormones are doing that. Or if we take hormonal birth control, we think about the effects that it has on our ovaries in terms of pregnancy protection. But we don't really spend any time thinking about the fact that our hormones, in addition to doing the things that they do in terms of regulating the menstrual cycle also play a really profound role in shaping our reality. And the reason for this is that our brain has hormone receptors all over the place in it. This makes a lot of sense evolutionarily because it's like we've inherited this brain that's wired for reproduction. And what that means is that it's going to be sensitive to our waxing and waning sex hormones. And so we know from decades of research that hormones affect the immune system. So when our hormones change, our immune system sort of shifts from one type of inflammatory state to another type of a state. We know that when our hormones change across the cycle that you get changes in sexual desire and sexual behavior. We know that the stress response changes. We know that our ability to learn and remember things changes. I mean, we just have hormone receptors all over the place in the brain. And our brain has been designed this way intentionally to sort of shift our behavior in functional ways depending on whether or not conception is possible, which is what's going on in the Follicular phase of the cycle, especially during what we call the periovulatory window, which is about five days prior to ovulation and then within 24 hours of Ovulation. So this is usually days like nine to 14 in the cycle. And during this time, it's like our brain and our behavior is all coordinated toward activities that promote sex because sex can lead to conception. And again, we've inherited this brain that has been really good at reproduction. And then during the second phase of the cycle when progesterone is the dominant sex hormone, that is the time when it's possible that a fertilized egg might be implanting itself into our uterine lining. And so our body is doing a totally different set of activities. And instead of being motivated toward doing things like going out and attracting men and having sex, we're more motivated toward sort of hunkering down and increasing our calorie intake and doing other things to prepare for the possibility of pregnancy. And so we have this brain that's super sensitive to fluctuating sex hormones and again, in ways that make absolute sense evolutionarily. But what that means is that when you change that profile of sex hormones by taking a hormonal contraceptive pill, in addition to causing all of the changes that we cause to prevent ovulation, so that way you don't conceive. You're also affecting all those hormone receptors in your brain that have been designed to be really sensitive to sex hormones. And what this means is that when we take hormonal birth control, we're changing women's brains. And that means that we're changing the way that women think and feel and experience the world. And it's just been within the last 15 years or so that researchers have really begun to ask that question specifically. And that is who do women become when they go on hormonal birth control? How does it change the way that we experience the world relative to what we see in naturally cycling women? And so I spend the book really kind of going over some of those things.

Georgie Kovacs [00:10:33]:

I love in the book that this is not birth control is the worst thing ever. And I'm going to write this book and I'm going to scare everyone. It is an incredibly balanced book. You're just presenting the research. You certainly share some of the horror stories that have happened, but it's not like a scare tactic. It's just this happened to this person. And you even show that that same exact prescription had a different effect on a different person. And I think in the back, I know in the back you have a table of all the different types of birth controls and the makeup of each of those. And so I really do appreciate that and the data is incredibly helpful. But before we dive into the research, I do want to just do a high level of types of birth control because there's hormonal non hormonal. We now have the over the counter. You have sexy, which is the on demand birth control, which some argue may impact the vaginal microbiome even though it's working in that way. So nothing is perfect. But I just want to clarify from all those different buckets how people should view this conversation. Is it solely hormonal birth control and do we want to specify when some of the topics apply to the others? So I'd love to kind of clarify that.

Dr. Sarah E. Hill [00:11:52]:

Right. Really great question. Generally when I'm talking about and a lot of times I'll just as shorthand use the pill, but I'm talking specifically about hormonal birth control and I do mean all forms of hormonal birth control. And so this means I could be talking about hormonal birth control pills, I could be talking about the hormonal birth control shot. I could be talking about the vaginal ring subdermal implant and even the hormonal IUD although the research with that is super messy for reasons that we can talk about if you want to, but it gives a tiny bit into the weeds. But the mechanism of action for all of these different types of birth control are the same. And the big sort of action agent in each of these types of hormonal contraceptives is progestin. And that's a synthetic progesterone. And what these progestins do is they stimulate the progesterone receptors in the brain. And when these receptors are being stimulated, it prevents the brain from telling the ovaries to start producing, to start maturing egg follicles. And so because the brain is not sending that message to the ovaries, that's why we don't ovulate. And so the primary mechanism of action in all hormonal birth control products is this progestin. Because again, stimulating progesterone receptors in the brain prevents that communication between the brain and the ovaries that ultimately leads to ovulation. And so it doesn't really matter, and I say it doesn't matter how it gets into our body, like whether it's a patch or whether it's a shot, but it does and it doesn't. So on the whole, the effects are generally the same sort of across modalities, but there are some differences. So just to give an example, when we look at depression risk, we tend to find that the risk of depression is greatest for types of hormonal birth control that only contain a progestin. And so for a combination hormonal birth control pill, for example, that contains both a progestin and synthetic estrogen, those have a lower risk of depression relative to the progestin only products. But on the whole, we generally see that there's an elevated risk of depression and anxiety among users of hormonal birth control across the board. It's just that there are some sort of small differences based on the specific.

Georgie Kovacs [00:14:29]:

Type of product progestin and progesterone. So we know that progesterone helps with our mood. Yet in this case we're saying the progestin can have impacts on depression and anxiety. And I know Dr. Jerry Lynn Pryor and Dr. Lara Brighton specifically have lots of conversations with me about this. And I think Dr. Pryor actually corrected someone in a paper that was published who called it progesterone and it was not. So yes, help us with the data that you've seen around that because I think sometimes people think they're the same and may misread it. But when I saw that in your book, I highlighted and I'm like, we have to talk about this.

Dr. Sarah E. Hill [00:15:16]:

Yeah, no, this is an important point. And there are some of these things where people get hung up on like, oh, a period that you get on the birth control pill isn't a real period. And I don't know that that makes a big difference. You're bleeding and it's like whether you have an endometrial lining or whatever. But this is one of these persnickety little differences that actually matters. And it matters in a really significant way. And that's because when your body is metabolizing progesterone, which is this endogenous product that our body creates after an egg has been released, the egg follicle releases this hormone that has incredible positive effects on our mental health, and it increases neuroplasticity. They've done really great studies looking at it as being therapeutic in the case of brain injury and in the case of things like PTSD, it's this really nice hormone. And it promotes mental health in all of these ways because when it's being metabolized by the body, it releases a neurosteroid called Alipregnalone, which is a potent stimulator of GABA receptors in our brain. And GABA is our primary inhibitory neurotransmitter that our brain uses to kind of calm itself down. So in the brain, we've got excitatory neurotransmitters, which make our brains start firing really rapidly. And then we have inhibitory neurotransmitters that kind of slow down the rate at which our neurons are firing. It kind of dials us down. And GABA is the primary inhibitory neurotransmitter that we have. And when our GABA receptors are stimulated in the brain, it makes us feel calm, cool, collected, and relaxed. It allows us to sort of regulate our emotional states and regulate our stress response. And so because of this, women who are naturally cycling and releasing progesterone and are regularly exposed to this really positive psychological effect of this hormone, it can be a very positive thing. Progestins don't do the same thing. And the reason for this is progestins aren't actually synthesized from progesterone. Almost all progestins that are commercially available and that are being used in hormonal birth control are being synthesized from either testosterone or spiralectolone, which is a diuretic. And neither one of these things, when they're being metabolized in the body, leads to the release of Alipregnalone. And so what we see is that women who are users of hormonal birth control, they have substantially lower levels of Alipregnalone across the cycle relative to what's observed in naturally cycling women. And we don't yet exactly know all of the effects that the downstream effects that this can have. But there's a lot of hints, like when we look at, for example, the greater risk of developing anxiety and depressive disorders in hormonal birth control pill users. That's something that is consistent with the idea of having lower levels of allopregna alone, decreased resiliency to things like PTSD, which is also something that's beginning to sort of creep up in the literature as a potential correlate of hormonal birth control pill use. This is also something that we might expect to see as a result of reduced levels of Alipregna alone. And so it's really important to distinguish between these two things because Alipregna alone and progesterone is really a mental health superhero. And then progestins aren't. And not only are they not in terms of not providing those really nice neuroprotective sort of calming effects on the brain that progesterone does, but also we know that they don't have great binding specificity in terms of only binding to progesterone receptors in the brain and other parts of the body. So, for example, the progestins that are synthesized from testosterone, we know that a number of them will also stimulate testosterone receptors. And so you're getting mixed messages from these artificial hormones. You're getting progesterone and you're also getting testosterone. And there's also evidence that some generations of synthetic progestin, in addition to stimulating progesterone receptors, will stimulate cortisol receptors, which sends a stress signal to our brain. And so these obviously aren't a perfect match for a progesterone. And it's these differences that are likely responsible for many of these unintended effects of hormonal birth control that we see.

Georgie Kovacs [00:20:17]:

So you also said that ovulation, not your period, is the main event of the menstrual cycle. And you had mentioned earlier in this conversation about what the hormonal birth control does to that. So one response I have heard people give to this ovulation because I've heard people saying, you don't ever need to have your period. It doesn't really matter. I've heard people say, yes, you do. Ovulation is main event. Ovulation is the definition of health, and knowing what's happening is important. If you're on the pill, it could hide and mask some issues that you may have. And then some have said, well, when you're pregnant, you don't ovulate. So clearly it's fine. So I've heard all these very interesting perspectives. And since you've done so much research, I would love to hear from a scientific perspective your views on all of these different things I hear from various perspectives.

Dr. Sarah E. Hill [00:21:18]:

Well, let me just say that it's a complicated answer. So I'm going to do my best on this and I'll just say that, yes, ovulation, in addition to being this thing that we learned about in health class in terms of being the sort of first moment when we're sort of putting forth this opportunity to create life, it's also how our body produces sex hormones. So when our egg follicles are being stimulated and we're getting ready to sort of choose a dominant follicle, and then this egg begins to mature, all of that leads to the release of estrogen. And estrogen is a hormone that makes most women feel really good. It's associated with increased energy levels. It's associated with increased sexual desire. It's associated with increased resiliency to stress. It's just something that generally makes women feel pretty good. And then, of course, once the egg is released, that empty egg follicle starts releasing progesterone, which, again, we've talked about all these great mental health benefits that progesterone has. And so when we inhibit ovulation, we're inhibiting this naturally occurring waxing and waning of these two hormones, which is something that we are built for. We spent most of our evolutionary history naturally cycling and pregnant. And those are both high hormonal states. So the ovulatory event itself is a high hormone event where you get this big peak in estrogen that occurs right before ovulation. And then you get a second peak in estrogen and this big surge in progesterone in the second half of the cycle. And that's something that is sort of like a natural part of our history as a species. But so too is pregnancy, because throughout most of our evolutionary history, we didn't have reliable birth control, and women also spent a lot of time pregnant. And being pregnant means that you're not ovulating, but it's a high hormone event. So your levels of sex hormones, both estrogen and progesterone, are substantially higher when you're pregnant relative to when you're not pregnant. And so when we do take synthetic hormones that suppress ovulation and just replace it with these relatively low levels of synthetic hormones, it actually creates this state that is actually quite different than what our sort of quote unquote natural biological states would be. And one thing I oftentimes have women ask me about is, like, whether the super low dose hormonal birth control pill is going to be better and more natural because it has really low levels of these synthetic hormones. And on the one level, when you look at the side effect profiles of that type of pill, it does look pretty good. I mean, in terms of it, women tend to feel less terrible than they do on some of the other formulations. But that state is actually not I mean, that's not a normal hormonal state for women to have really low levels of sex hormone. We are very hormonal creatures. We release high levels of sex hormones across the cycle when we're naturally cycling. We release high levels of hormones when we're pregnant and lactating. And that's sort of what we're optimized for. And so when you take away all of those hormones, it can make women feel pretty funky and not quite like themselves. And it's because that's not quite what we're used to biologically.

Georgie Kovacs [00:25:04]:

So it sounds like it's still better to ovulate and have this norm, because that but we don't necessarily so we don't necessarily have scientific data to say that this is literally the worst thing ever because of all of these aspects, we more have data that seems to indicate this is not optimal. Is that a fair?

Dr. Sarah E. Hill [00:25:25]:

Yeah, because I do think it's really important to not women. For most women, going on hormonal birth control is something that's completely safe and they don't need to worry about some terrible health outcome. But that being said, it is not a normal hormonal state for women to be in to have their sex hormones suppressed. And so, yes, I think that a better way for most women, and I'm going to say most women, because some women really feel so much better on the pill and they're so miserable when they're cycling, that I think it's a godsend for them, in addition to women who just need pregnancy protection and have no better choices. But for women, all else being equal. Yeah, we are wired for ovulation and for the waxing and waning of these sex hormones. And so I encourage women, if they're able to naturally cycle, to do it and to produce those sex hormones. And this is particularly true for younger women, just because our brain is still developing up until the time that we're in our early twenty s, and our HPG axis, which is the hypothalamic pituitary gonadal axis, which is just the communication pathway between our brain and our Ovaries is still maturing during this time up until we're about 20. And suppressing that and shutting it all down with Hormonal birth control prevents that development from going on. And nobody's really studying what the long term effects of that are, but I can't imagine that there aren't any.

Georgie Kovacs [00:27:21]:

I would agree.

Dr. Sarah E. Hill [00:27:22]:

And we also don't know whether taking hormonal birth control before your brain is done developing, whether that affects brain development. But there's some evidence that seems to suggest that it might be linked with an increased risk of developing major depressive disorder across the lifetime even after you discontinue it. And so especially for young women, like if you're 19 or younger and can avoid being on hormonal birth control, then I say absolutely yes, that's a clear choice. It's when women get older and their brains are done developing that, then I say, well, I still think that this is the best option. But if you do go on hormonal birth control, if you go off of it, everything's going to return back to normal within a couple of months.

Georgie Kovacs [00:28:08]:

Great clarification. So on to the fun with the studies. So I asked you, tell me which ones are your favorite.

Dr. Sarah E. Hill [00:28:17]:

Yeah. So in terms of what the pill does and some of the things that really surprised me by far the first one that just absolutely struck me was the research that finds that being on hormonal birth control might impact who we're attracted to. Because it's like, what it's like the idea of got a warning label on your birth may cause dizziness and insomnia and influence partner choice. But when you get into the literature, I mean, it makes absolute sense because there's been research now for it's almost going on three decades now, just linking women's levels of estrogen across the cycle and then their preference for sort of sexy qualities in men. So things like having a masculine face and like a deep male voice and being socially dominant. Research finds that when women are at points in the cycle when estrogen is high, that they really kind of gravitate toward these sexy types of qualities. And then when they're in the luteal phase of the cycle after ovulation has occurred and conception is no longer possible, then women are more drawn toward the good dad kinds of qualities. Right? And again, when we think about what these hormones are signaling, like conception, conception, conception, women are like sexy, sexy good genes, but then when they're in this other phase of the cycle. It's more like, oh, is he going to be a good dad? Is he going to provide? Research has been showing this now for years that women have these changing sort of it's not like these vast changes just sort of nudges us a little bit one way or the other based on our hormonal states. And it was only very recently that researchers then asked the question, well, what happens when you're on the Pill? And all that shut down and you never are in a state when estrogen is the dominant hormone and you're constantly being kept in this state of hormonal deja vu where you have synthetic progesterone or a progestin as the dominant hormone and then levels of estrogen being low. And so they ask, do these women, do women on the pill or on hormonal birth control, do they exhibit less of a preference for sexiness in their partners? And do they more gravitate toward qualities that are associated with provisioning and being a good dad? And that's exactly what they found. They've found it in different studies. Now, we just did a study that we're going to have out for review pretty soon where we looked at whether women chose their partners when they were on birth control or off birth control and then once they're off birth control, then looking at the frequency of sexual behavior within these relationships. And we find that women who chose their partners when they were on the pill have sex with their partners less than women who chose them when they were off the Pill. Another one that I found really provocative was the research on the stress response, just because it shocked me into sort of reality of how big of a difference it is when you change women's sex hormones in this way. And so what this research finds is women who are using hormonal birth control rather than having a cortisol response to stress like the rest of us do when we're feeling stressed out that they have a blunted cortisol response. To stress, meaning that their bodies aren't releasing the stress hormone cortisol, which on the one hand, at first, when you hear that, it's like sweet. That's great. I get out of jail free card and you don't have to go through all the messiness of feeling stressed. But that's not actually how it works. Even though cortisol gets a bad reputation just because in the context of chronic stress, cortisol is bad because constant exposure to cortisol is no good for anybody. It'll cause your body to completely fall apart because essentially what cortisol does is it redistributes all of the body's energy away from all of the regular things that bodies do like generate new cells and fuel the immune response in case we come into contact with pathogens and learn and remember things. And it takes all of that energy and redirects it toward dealing with a stressor right. And. So if you have chronic exposure to cortisol, your body falls apart, because that's the only thing that you're doing is your body's. All guns ablazing toward the stressor. But cortisol is actually very positive in a short term context. So, like most people who don't experience chronic stress, who just live normal lives and then have big stressful things that happen, the release of cortisol is actually very positive. And it's how our body helps to resolve stress. It's how we cope with stress. It helps us learn and remember things that are associated with whatever the stressful event is. It helps direct our attention toward the source of the stressor. It dumps fat and sugar into our bloodstream so we can make a quick getaway if we need to. So cortisol isn't really a bad guy in the context of short term stress. It's actually a good guy. It's how we deal with stress. And generally, when people get stressed out, they release this hormone because it's really adaptive to do that. And the only people that we see who have this blunted cortisol response to stress tend to be people who have experienced chronic stress, like people who've had trauma or people who've been in a warfare context and have PTSD. And the reason that they don't get a cortisol response to stress is their body has shut the stress response down completely just because of the overactivation of the stress response. And what we see in women who use hormonal birth control is that they respond to stress, like somebody with PTSD or like somebody who experienced trauma, and they don't have this dynamic change in cortisol in response to the stressor the way that other healthy, functioning adults do. And this is something that's really alarming, because, again, cortisol, even though it gets kind of a bad reputation, it's how we regulate stress. And what we tend to see is that those who have a blunted cortisol response to stress aren't dealing with stress very well. And it's associated with all kinds of psychological problems, including things like anxiety, depression. It's associated with PTSD. It's associated with reduced resiliency to stress in general. And so when I first learned that women who are using hormonal birth control had this blunted cortisol response, it was that the reason I found it so provocative is one that's just kind of provocative in its own right. But it really underscored the fact that the effects of this pill extend far beyond our ovaries, because the sex stuff in some ways makes sense, right? It's like sex hormones, sex yeah, that makes sense. But when I first learned that, and it was like, sex hormones, stress, that was when it sort of dawned on me. Like, duh, of course sex hormones affect everything in the body. And so the idea that it would affect the stress hormones shouldn't be surprising, but it was. And that was really what opened my eyes to the idea that there's probably a lot more to the birth control pill than meets the eye.

Georgie Kovacs [00:36:06]:

Now, interestingly, I remember reading in the book that even with your first point about the relationships, it's not a black and white. If you are on the pill when you meet your spouse and then go off of it to try to have your children, that suddenly you're going to lose attraction. So it's not an always type of a thing, but it is an interesting trend. So I guess any thoughts around how someone should take that data? I think taking it with a grain of salt may not be a fair way to describe it, but I honestly wouldn't even know how to describe it.

Dr. Sarah E. Hill [00:36:42]:

Women are so different from one another, right? Every woman has different numbers of hormone receptors. They're differently sensitive to hormones. They metabolize hormones differently. I mean, there's just huge differences between individual women and how we respond to things. And one of the examples I give in the book on this is with a particular type of hormonal birth control. And I think you were referring to this. I had a friend who went on it, and she had a psychotic episode, and it really did a number on her. I was on the same one. I loved it. It was great. And so it was just two people and who would have known? You'd never know it looking at either one of us that she'll respond in a great way and she will not respond in a great way. But everybody metabolizes things differently. And so because of that, the way that we respond to it is different. And then you take that and then you add to it the fact that there's almost 100 different formulations of hormonal birth control that are out there, meaning that there's like 100 different hormonal messages that you get from an individual prescription, and you get all this heterogeneity, right? And so we don't know who's going to respond what way to what. Hormonal birth control. And so what all of this research is that I present in the book is that here are some things that we know are associated with hormonal birth control. Pill use or hormonal birth control use, right? And these are things to be aware of that are a possibility, but not anything to be because they usually aren't the majority case. It's not the majority case where in the majority of cases, women do not choose a partner when they're on the pill and then go off it and think, oh my God, what did I do? What did I do? But some women do. Some women, even I've talked to women now who is like it kind of nudged them out of their primary sexual orientation where they were, like, a little bit bisexual and all of a sudden they're incredibly heterosexual or they were a little bit gay and then now they're totally bisexual or it nudges them this way or that way. Does that mean that most women are going to have that experience? No, it just means that hormones are absolutely messy. I mean, there are receptors for hormones all over the place. Hormones affect everything ranging from our gender identity to our sexual orientation, to our stress response, to the way that we learn a memory. I could go on and on and on. For some women, when you flip those switches by changing the hormones with the hormonal birth control that they're on, it'll nudge them sort of in and out of these different states, and it's was useful to know about what's possible. So that way you can monitor yourself and then decide how you feel and whether you prefer the way that you feel when you're on it, if you prefer the way that you feel when you're off of it, and if you prefer the way that you feel when you're not on what you're currently taking, knowing that there's 100 different formulations out there. If you feel like you need to be on hormonal birth control, the thing that I recommend in the book is go talk to your doctor and try something different, because you got a lot of choices out there and you're probably not going to respond the same way to every single thing that you take. But it sucks because all of us as women and it's this way in medicine, across the board, I'm sure that you are as aware of this as anybody. It's like we're constantly being experimented on because nobody really studies us. And so it's like, well, this didn't work for me, or I feel weird on this. And it's like, we'll try this and it's like nobody can tell you beforehand what's going to happen. And instead you have to be a white lab rat, essentially just being testing on yourself and seeing what's working and what's not working. And so I wrote this book to just let women know, like, here's what we know are some things that can happen. This is what science tells us. You can be on the lookout for any of this stuff, and then you can sort of proceed and make the best informed choices for your health. Because it's like you said, it's not like a certainty that somebody's going to respond in any given way. Again, it's not about alarming women or it's just about like, here's what we know now. You know, look after yourself and then make whatever decision is right for you. Because I don't know what's right for you, but you know what's right exactly.

Georgie Kovacs [00:41:24]:

And I like the other tip that you have, which is when you start a new pill to let someone know, someone that's close to you, because I agree. I remember when I was on fertility treatments, I think people were like, oh, my God, you're so stressed and you're this and that. And I was like, no, I'm not. No, I'm not. And so I agree. When you're in it. You don't notice it, but everyone around you does. So I think that's a really great tip. So I want to share one of my favorite studies and then let's dive into what's happening these days. So Dr. Miller and his team of researchers wanted to explore whether men find women more desirable at high fertility. And they wanted to study this in a naturalistic.

Dr. Sarah E. Hill [00:42:05]:

So this was the infamous strip club study where they went and they went to a gentleman's club and they worked with all of the dancers who worked there. And as you would expect, some of them were on hormonal birth control and some of them were not. And they just simply had them keep a diary of their tip earnings every day that they were working a shift over the course of two months. So over the course of approximately two cycles, they wrote down when they got their period. So they were asked, did you get your period today? So that way they were able to track where they were in their cycle. Like, are they at a conceptive or high fertility phase in the cycle when conception is possible or are they outside that window? And they were able to look at that. And then also the differences between naturally cycling women and then pill taking women in terms of their tip earnings. And they did this as a way to sort of naturally quantify men's interest in women based on cycle phase, based on hormones and what they found. And, you know, the dollar amount, because I don't remember it, but the naturally cycling women experienced a big surge in tip earnings that corresponded to their levels of estrogen across the cycle. And essentially what you see is that right near ovulation. So in what we call the periovulatory window, which is about that like five days prior to ovulation, and then on the day of ovulation that their tip earnings soared and they did really well. And then they started to fall when estrogen levels fall in the cycle. And so you get this really big change with the pill takers, who again, their fertility is being suppressed and estrogen levels are kept really low. What you see is that they have relatively invariant levels of tip earnings. It doesn't have these dramatic swings like the naturally cycling women's do. And they don't end up earning as much money overall as the naturally cycling women because they're missing out on this free, all natural sexiness boost that we get from nature. Right?

Georgie Kovacs [00:44:14]:

Near mean, that one made me chuckle. So since your book was written, Roe v. Wade was overturned and I'm so curious because this is a topic you're known for, I'm sure you have some interesting discussions with a lot of people. So I'd be curious what kind of interesting discussions you've had. That would be something we should highlight in this conversation. And I don't know if it would also have to do with the opill going on the market and getting approved by the FDA and that being an over the counter birth control. So it might be all one big conversation, but those are two massive things that have happened since your book was published and they all happen to be in less than twelve months. In the less than past twelve months. So let's talk about this.

Dr. Sarah E. Hill [00:45:04]:

Yes. So the first thing talking about Roe v. Wade, I think obviously this has created this state where fertility regulation for women has become even more of a salient issue than it was beforehand because we don't have an off ramp anymore. It used to be that if women ended up unexpectedly pregnant, there was still an off ramp in terms of being able to get a safe, legal abortion if that was the route that a woman chose. And now we don't have that off ramp anymore. It's not guaranteed anyway. So there's a lot of women who no longer have access. And this has made this issue of fertility regulation and finding safe, effective, affordable contraception a much more salient issue for women. And I think because of this, this has made the birth control conversation a lot more important because it's like women are really needing to understand what their options are and being able to know what to look out for and how to troubleshoot if they're on something that they don't like. I think that in a lot of ways, the Roe v. Wade situation has made education on hormones and hormonal birth control and all of these things even more important just because more women are having to make the hard choice of do I want to go on hormonal birth control even though I don't want to, just because the cost of an unintended pregnancy for women is so high. Because one of the things I talk about in my book is the ability to safely and regulate our fertility as women is like our number one rights issue. I mean, it is the biggest predictor of our ability to achieve financial and economic independence for men. Political independence for men is the ability to pick when we have children. And not being able to feel certain of that is a scary place. And I think that with the Roe v. Wade thing here's what my hope is with this. My hope is hormonal birth control isn't perfect for all these reasons that we've talked about. Right. I think that it's much better for women, all else being equal, to have their naturally occurring hormonal states. It's like what we are wired for. And I talked through in my book about the different types of side effects that are possible. We need better options. We need more options. If you don't do hormonal birth control and you're in a sexual relationship and you're fertile so you're not postmenopausal, you don't have a ton of options that are available to you to be able to be really certain that you're not going to end up pregnant. And so what my hope is that this political change is going to lead to greater investment in alternative strategies for regulating fertility that don't require women to totally change who they are. Which is what you do when you change a woman's hormones, right? That's my hope there because I talk to people about what are the range of effects that are possible from hormonal birth control and then we talk about, well, what are the alternatives? It's like, okay, well, you have the copper IUD, which is great because that doesn't have hormones but it is painful and it makes women's periods more painful. So it's not ideal. You have the fertility awareness method, which I love in theory. I don't love it for a 16 year old girl because most 16 year olds don't have a super regular cycles because they're HPG axes. They're still figuring themselves out and stuff like fexi in that it's like what? I think 85% effective, which is okay if you're in a really consensual relationship with somebody and you end up pregnant and it's not that big of a deal. But 85% doesn't feel very good to me in a post row era and so it's like we don't have a lot of great options. And so I am hoping that this makes people pissed off enough where we really start putting pressure on the people in R and D and contraception to start coming up with some better options. Because I think that the drug companies and everything have not been investing in birth control because it's like, well, it's good enough, right?

Georgie Kovacs [00:49:37]:

And it's crazy because I can't remember is it 35 billion or $65 billion industry? And just imagine the innovation, especially with this post Roe v. Wade era. Do you think, or have you seen that because Roe v. Wade has created such media attention and so many more are talking about it. Do you think that an interesting thing that will happen is more women will want to go on birth control I e. The ones that may be in communities where they tend to look be more in the I need men to support me type of community right? Because they have no other way out of their challenging life.

Dr. Sarah E. Hill [00:50:28]:

Yeah. So that's an interesting question. I don't know. I guess ultimately I don't know the answer. But I do think that the opill, which we didn't talk about and I'll give you my thoughts on that, too, but that was made available after the Roe v. Wade thing. And I think that it was like, okay, so we have sort of put our foot on the throat of women by removing this off ramp that we had if things didn't go right. And so we need to sort of make things a little bit better somehow by increasing access to birth control, which on the one hand I think is good, right? So I think that there are some good things that can come out of this, even though, on the whole, I don't think that it was good. I think that the Opill having that available and I've got such mixed feelings about this, I'll say, on the whole, I think it's good, right? Because I think that increased access, again, the biggest key that we have as women in our ability to take care of ourselves and be financially, politically independent from men is the ability to regulate our fertility. And so increasing access to that magic key is like, in my view, it's a good thing. But I will say that it scares me a little bit when we couple it with the fact that we have no sex education. Women are taught nothing about their brains and the way that their brains work and the way that hormonal birth control can potentially affect them psychologically and physically. And it scares me to think about teenage girls whose brains are not developing done developing yet, and whose risk, for example, of death by suicide goes up 600% when they're using hormonal birth control during adolescence. The biggest offenders when it comes to mental health problems with hormonal birth control are progesterone only contraceptives like the ones that are made available. Now, the idea of young girls who are asymmetrically shoulder the heightened risk of depression, anxiety and even suicidal behavior from using hormonal birth control, that they're using it and nobody knows about it, really terrifies me and I hate it. And I don't think that the answer is let's not make it available, because I don't think that's the answer. I'm thrilled that it's available. The answer is that we need to really be educating people about this. Because if a girl knows, here's a potential side effect of this, and she can talk to her best friend or her partner or whoever, if she doesn't want to talk to her parents and say, can you look after me and just let me know? Because, I mean, it was like you said, when we're going through a depression or anxiety, it's like our brain doesn't say, oh, I'm experiencing depression or anxiety. We just feel like, oh, my God, my life is so bad, things are so terrible. And it's like we don't have an because we're experiencing as real. It feels like us. And so I think it's so important to have people looking after us, especially these teen girls who are the ones who are most at risk of developing these kinds of side effects. And so I worry about that. I do. I worry about that. And so I'm hoping that with this sort of availability of this, that this also, that we start putting pressure on. I don't even know who to put pressure on about educating the public about this and making sure that everybody knows what they should be looking out for, so that way we can care for those that we love, right?

Georgie Kovacs [00:54:26]:

The research continues and I really appreciate the fair and balanced perspective because again, I've had guests with so many varying viewpoints and I was really wanting to connect with you to have that data driven perspective. Not that my other guests weren't, but I definitely saw some strong opinions with certain discussions. And so I really appreciate this additional data point for people to consider. Anything else that we should take away from this fabulous conversation?

Dr. Sarah E. Hill [00:54:57]:

No, I think that when it comes to hormonal birth control, I think that the big takeaway is because the effects are so idiosyncratic and varied and individualized that the best thing that women can do is really educate themselves. On hormones, the role of hormones in the brain and their body, what the range of effects are that are possible from using hormonal birth control and then being able to make decisions about what makes sense for them, given their individual life goals and circumstances. Because what the right answer is going to be is going to differ from woman to woman, and it's also going to differ within woman depending on different life phases that they're in. And so I think that this is really and again, I present the book as a way of providing information and not about making decisions for somebody. And so I like to think that it's a really useful guidebook in this way where it provides that information without providing any sort of I don't have a stake in the outcome, right?

Georgie Kovacs [00:56:00]:

No, absolutely. And you made it fun to read as well. I loved your little quotes. I learned a lot from those too, but thank you. And how do you want people to reach out to you and stay in touch?

Dr. Sarah E. Hill [00:56:11]:

Good. They can follow me on social. I'm @SarahEHillPhD. And so that's Sarah with an H. Sarah E. Hill. Ph.D. on all social handles. And you can also find me online @sarah.com.

Georgie Kovacs [00:56:26]:

Awesome. I'll put everything in the show notes. Thank you so much for making time. Really appreciate this.

Dr. Sarah E. Hill [00:56:31]:

Yeah, thanks for having me.