Dhru Purohit Show - Birth Control Deep Dive: How it Changes Your Brain, Its Link to Autoimmune Conditions, and Why We Need Better Options with Sarah Hill Ph.D

Episode Date: February 10, 2025

This episode is brought to you by Cozy Earth, LMNT, and Lumebox. There’s no denying that birth control has given women greater freedom and control over their fertility. However, many young girls and women have been on birth control for decades without fully understanding the long-term effects of hormone-altering medication. Today’s guest shares her research on birth control and provides key insights into its potential impact on long-term health and wellness. Today on The Dhru Purohit Show, Dhru sits down with Dr. Sarah Hill to discuss the impact of birth control on women’s health and brain function. Dr. Hill shares her personal journey with birth control and how it led her to research this topic. She reveals what her findings say about the long-term effects of birth control on the brain and explores alternative options for women. She also explains why informed consent should include comprehensive education on birth control’s potential impacts. Dr. Hill discusses her hopes for the future of women’s health and highlights the research still needed to provide women with accessible, well-informed options for managing their health and fertility. Dr. Sarah Hill earned her PhD in evolutionary psychology from the University of Texas at Austin, where she studied under Dr. David Buss. She is currently a researcher and professor at TCU, the lead research advisor at 28, and a recognized thought leader in women’s hormones and sexual psychology. Her groundbreaking research has led to nearly 100 research publications. She is also the author of This Is Your Brain on Birth Control, which sheds critical new light on the psychological impact of women’s sex hormones and the birth control pill. Her upcoming book, The Period Brain, is set for release in September. In this episode, Dhru and Dr. Hill dive into: What Dr. Hill noticed after stopping birth control (00:25) The long-term impact of taking birth control (4:08) The benefits of birth control for women’s rights (12:20) The lack of fully informed consent in birth control decisions (16:06) Using birth control as a prescription for period problems (21:06) What happens to your brain on birth control (27:18) How birth control influences partner choice (38:15) The possible link between autoimmunity and birth control (44:15) Recommendations for young women considering birth control (51:15) Alternatives to birth control (54:15) The research we still need on birth control (59:25) Dr. Hill’s hope for more options for women (1:05:15) Also mentioned in this episode: Dr. Hill’s book This Is Your Brain on Birth Control: The Surprising Science of Women, Hormones, and the Law of Unintended Consequences For more on Dr. Hill, follow her on Instagram, Facebook, X/Twitter, LinkedIn, and her Website. This episode is brought to you by Cozy Earth, LMNT, and Lumebox. Right now, get 40% off your Cozy Earth sheets. Just head over to cozyearth.com/dhru and use code DHRUP. Right now, LMNT is offering my listeners a free sample pack with any purchase. Head over to drinkLMNT.com/dhru today. For 48 hours, from February 13th through 15th, Lumebox is offering my community $284 off their FDA-registered portable Red Light device!  That's over 45% off! Go to thelumebox.com/dhru and get your Red Light device. Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Sarah Hill, you have a pretty wild story. Around the time your youngest child was around two years old, you stopped taking hormonal birth control. And at that point in time, for what I understand, you had been on the pill for about 10, 11 years. And when you stopped taking it, you noticed some pretty shocking changes. I'm going to hand it over to you. Can you pick up the story from there? Yeah, I really had no idea that birth control was having any sort of an effect on me until I discontinued it. And because I was on it for, as you noted, besides the period I spent pregnant and lactating, I was on it pretty much nonstop for about 10 to 12 years. And while I was on it, I felt fine. You know, I didn't have any major mental health breakdown or anything else that

you sometimes hear that happens to women. But when I went off of it, I realized that I was different. And I realized this because when I went off it about. three months after the fact, I noticed that I had more energy. And I was interested in sex a lot more than I used to be. And I was like noticing attractive men. And I was cooking. And I was downloading new music on at that point. It was like, and it was like when iPods were still a thing. I was like downloading new music on my iPod. And I was cooking. And it was like doing all these things that just were pleasurable in doing them to an extent that I hadn't in a while, and I just felt more vividly alive. And I was like, like, what is this? What is this? And I'm like, I wonder if this is

because I went off of the birth control pill. And, you know, I thought, well, maybe, but, you know, that sounds crazy. And so I kind of filed it away in the way that women do, you know, it's like we have something that happens to us. And then we assume that it must be all in our head since we've been conditioned to believe that that's true from doctors from the time that were pretty small. But then flash forward about it was about a year later. And I was in a research talk where a researcher was talking about how the birth control pill leads women to have a blunted cortisol response to stress. And it was at that moment that I was like, oh, duh, hormones affect everything. It was like hormones are part of what our brain uses to create the experience of who we are.

So our brains affect our hormones affect our personalities. And our hormones affect other hormones like cortisol. And hormones affect sexual desire. And they affect who are attracted to. And they affect our energy levels. And like, of course I felt different when I went off the pill. I was a different version of myself when I was on it. And so it was at that moment that I had this really embarrassing epiphany.

And I say that it's embarrassing. because I've been studying women. You know, I've spent my career as a research psychologist, studying women, and studying the effects of different biological influences, including hormones on motivational systems and the way that our brains work. And I never put two and two together with the fact that I was changing my hormones with the pill. And then I felt so different. And so I had this embarrassing epiphany where I'm like, oh, my gosh, duh, you know, changing your hormones.

It's going to change who you are. And it was then that I went into the research literature and really started to dive in to try to better understand who do women become on the birth control pill. And that was what led me to write my book. So we're going to unpack all that. And we're going to jump around a little bit. But I want to start off with a topic that I know is something that you are very fascinating about. And I've seen people interview you and your own community and your Instagram comments. a lot of women in my age group that are listening to my podcast who are in let's say like the 40 to 60 age group

many of them are wondering that they started birth control early in their adolescence and they're wondering has that had any sort of lasting impact on their personality on their brain and maybe even some of the chronic conditions that they're dealing with what do you know about that topic. What I know is far too little. And the reason I know far too little is because longitudinal research, looking at the impact of taking hormonal birth control early on in life, and then staying on it for long periods of time, is just not something that's being studied very much. And in fact, the number of studies looking at this particular question is teeny tiny. Anything that I can tell you about this is going to be based on a very limited amount of research.

Here's what we do know. We know that when women take hormonal birth control as adults, and I'm going to define an adult as being somebody who's about 20 or older, we know that the effects of hormonal birth control use are more or less, you know, sort of now you see it, now you don't. Right. So while you're on it, you have the effects, you go off of it. And then within, you know, and sometimes it can be several months. So if you've been on it, say, for example, 10 years, it might be a couple of months before your horse. hormone receptors are kind of back to where they were because our hormone receptors change in response to hormone levels in the body. And so it might take a couple of months for the body to kind of figure out what's going on again with the cycle. But given that the brain has been done developing by the time a woman started, chances are things should be relatively kind of quote unquote back to normal within some period of time. And like I said, for many women, it's within a month or two.

For some women, it can be longer. It can even be a year or so until their body's kind of. figure out what's going on, but those effects should reverse and kind of go back to normal or go back to baseline. For women who take it during adolescence, so when their brain is not done developing yet, we don't know. There's only been, and I use the word handful to mean only maybe five or six studies. Think about that for a minute. Five or six studies. And this isn't all of science, you know, it's like in the whole body of all the science of the world, there's only about five six studies that have really looked at what is the impact of hormonal birth control use while the

brain is still developing on different types of outcomes over time. And there's just no way that it doesn't affect development. We know that hormones play a really key role in the pubertal transition and, you know, all of the growth and development that goes on during that sex hormone surge that you get during puberty and all of that that goes on through your late teens, early 20s. And so there's every reason to suspect that taking hormonal birth control could have a lasting impact on girls as they develop. And there's some evidence that suggests that taking hormonal birth control during adolescence. So again, during this period when your brain is still developing, that this can lead to a heightened risk of major depressive disorder across your lifetime.

So even after you've gone off of birth control. But in terms of looking at other types of outcomes and even other types of age ranges, there's very little that's known. And so, a lot of women ask, you know, is it possible that taking hormonal birth control, especially if they were taking it during adolescence, is that related to my autoimmune disease? Or is that related to my sexual dysfunction? Or is that related to my dysregulation and my stress response? And the answer to that is we don't know. You know, it's maybe because we just don't. You know, people really haven't taken birth control seriously. And when I say that, I just mean that it's like you take it for this one specific cause, you know, which is usually suppressing your suppressing ovulation. So that way

you prevent pregnancy. But ultimately, hormones have their fingers in the pot, you know, of almost all the systems in the body. And so it causes systemic effects. And nobody really spent a whole lot of time thinking about that. You know, and they started putting girls on it for everything ranging from, you know, irregular periods to acne. And the result is that there are a lot of women with a lot of questions about what has this done to me? You know, and we don't really have a good answer. Like, we don't know. You know, I do know that if you go on it as an adult, that you should go back to normal later,

but we don't even know that for 100% certain. because the amount of research that's been done on all of these topics has been very minimal. And again, I think it's because people really just haven't taken the issue very seriously. They haven't taken the issue very seriously. And there's also this component where in many of your interviews, you have to share a disclaimer on your end that, you know, you are not against the women's rights movement, right? So let's get that disclaimer out of the way. And tell us why you have to talk about it, right? All right, here's a little secret.

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and political independence from men. And, you know, all of these, like, it's been so important to women and the forwarding of women's ability to, you know, take care of themselves. And I think that because of that, women are very protective of the pill and I don't blame them. I mean, it's like contraception for women is a big deal. And this is particularly true in our current political climate where, you know, if you have an unexpected pregnancy, it can really be catastrophic. Because there are a few things that are better predictors of bad outcomes for women than unexpected pregnancy, especially in your formative years. like teenage pregnancy is the biggest risk factor for being in poverty as an adult that's ever

been measured, you know, and so keeping girls unpreignant is like a really big deal. And so I think that women are understandably very protective of any type of contraception or, you know, access to these tools that are going to allow us to be able to regulate our fertility. And, you know, these conversations are nonetheless important because even though, you know, the hormonal birth control and birth control in general is such an important tool for women's ability to do everything that they want to do and make plans and achieve education and make, you know, build careers, it's not perfect. And I think that, you know, as a society, we are finally moving into a place where most people,

not all people, if you look at the, you know, Instagram comments, you'll see, you'll see that there's not, not everybody is in this place, but I think many people are in the place where we're able to recognize both the importance of birth control, right? And how, how important it is to protect women's rights to access to this really important tool, but also being able at the same time to recognize that it's not perfect and being really open and honest and having those conversations about the potential tradeoffs that you're making when you go on hormonal birth control. And so that way each woman has all the information that she needs to be able to make a decision about whether or not this is something that makes sense for her at this point in her life. And so, you know,

we have to recognize the importance of maintaining women's access to birth control while also at the same time saying it's not perfect. I think what I've noticed is where a lot of women who start to take care of their health, they're in their 30s, maybe they've already had kids or they, you know, They want to have kids in the future. And they're sort of unwinding and they're paying attention to different sources of media coming across, you know, your podcast interviews across the spectrum of all different types of podcasts you've been on. There's this internal feeling that people have. Again, this is just something that I've noticed that, man, is there some sort of big cover up going on? Because if it really is about the tradeoffs, why didn't anybody sit me down?

You know, this is the women that I'm hearing saying this and tell me that there was. a higher likelihood of as an adolescent taking birth control, taking the pill, that I could have anxiety, you know, that I could have some lifelong changes that were in my brain, that I could be suffering with low libido. Doesn't mean that it happens with everybody, but how come nobody mentioned that to me? So is there some big conspiracy? Is there some big farmer conspiracy? Or what led to many women feeling like I didn't have informed consent? So I'll say this. I don't think that there is a big pharma conspiracy. Do I think that the drug companies do a really good job of promoting research that makes it look like birth control has absolutely no side effects? Yeah,

100% they do. I mean, it's like when you look at who funds many of these studies that find no side effects, it's usually the drug companies. So I've no doubt that there is a hand that's being played by the drug companies in terms of contributing to this. but I don't think that there's a widespread conspiracy. Instead, what I think it is largely is the result of the fact that, you know, science and, you know, and this includes medical science, tends to have what we call in science as the silo problem. And this is this tendency for different bands of research to just live within their own little research fiefdom and then never to get outside of that fiefdom. So, for example, neuroscience lives in one sense.

silo, right? And so people who study the brain and study behavior, all of our research is published in these journals and we read each other's journals and we talk about each other's research. But we don't look at the research in the other silos, right? So we don't look at the research in, let's say, cardiac health, right? We don't look at the research in cognition. We don't look at the research in development, right? It's like we look at this research over here in neuroscience. Metaphor science is the same way. So within the field, you know, within the field, you know, field of medicine, people who study medicine and clinical practice, they tend to look at medical research journals. And most medical research, when they're looking at the effects of pharmaceutical

drugs, are interested in two questions. Safety, is it going to kill you? And then efficacy, does it work? Right. And these are obviously incredibly important questions when we're talking about drugs. Right. We want to make sure that every drug that we take is safe and that it works. But there's a lot more to it than that. You know, it's like the psychological effects of a medication are a big deal. And that tends to be in the field of neuroscience. You know, neuroscientists study this stuff and psychologists study this stuff. And so that research is published over here in these journals that most doctors have no familiarity with.

Because the fact of the matter is, you know, medicine as a practice was something that was developed, you know, long before people realize. that there was no mind-body split. You know, it used to be thought that, you know, the body lived over here, right, and followed these sets of rules, and that the mind was this, you know, product of the soul and lived over and had these other sets of rules. And because of that, medicine has never really been integrated with psychological experiences. And this is why you have a lot of medications that have psychological side effects, but that's all you get, right, is this will cause psychological side effects. It's like, what the hell does that mean? You know, it's like, That could be a personality change.

That could be that you have no conscience anymore, which I've heard happens to some people on some antidepressants. I mean, it could be a whole range of effects. And so what you get in your little birth control pamphlet is because people just put this down as a side effect is, you know, any range of things, including, you know, lack of libido and things like, you know, inability to regulate your emotional responses or inability to cope with stress. All of those are just put into a thing, like sexual side effects.

mood. You know, and so sometimes, sometimes women are told about that. Sometimes they're not. And when they are told about it, it's usually in a very blanket way, like, oh, this might affect mood. But like, what does that mean? And so they're not really told about this whole, you know, rich body of other research because their doctors aren't reading it, right? And it's not because their doctors are terrible people who don't care. It's just that this is the way that things have been done in science since science has been, you know, something that people did. And, and, um, and, um, and, The result is that many women, when they're making decisions about going on birth control, don't have all of the information.

Like, they don't actually understand the trade-offs that they're going to be made. And again, you know, I do think that the drug companies are very intentional in trying to make sure that all of the messaging around birth control is about the positive things that it does, which it does a lot of really positive things. I mean, people go on it for a reason. It prevents pregnancy. It can clear up your skin. And it makes it where you don't have to worry about period problems, right?

because it suppresses your HPG axis. But there's a lot of things that go along with that, you know, that don't make those tradeoffs necessarily something that most women or, you know, even many women want to make. A lot of women that are right around the age of my wife, so many stories, you know, mid to late 30s, they were put on birth control for period problems. Is that still as common of a practice today from your understanding? And is that also something that, you know, again,

And doctors are just trying to do right by their patient, find them a solution. You have such a little time with the patient that's there. But then there's this whole other educational component about how does lifestyle working out or mood, et cetera, how do all those things impact super problematic period? So how common is that today? And what would you like to see change or not change in that category? Are you looking for one of the most effective ways to naturally boost cellular and mitochondrial health, let's talk about red light therapy.

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This deal is available for only 48 hours. Yeah, so, I mean, I think it is still incredibly common. So I have an 18-year-old daughter, and it's very much in her cohort. It's still very common for her peers to have been on birth control now for years. And they go on it for reasons like they have problematic periods. And I do think that many doctors will give this to their female patients without understanding the impact that giving girls hormones during periods of brain development have. Like I think that most doctors, if you walk them through the following questions and you said, do hormones, like tell me about the rule of sex hormones and brain development. They would be able to repeat everything I know, you know, probably with even better precision than I can repeat it, right, about the fact that, yes, sex hormones play a really important role in brain development. And then you ask them, what does birth control do? And then they would explain that. And then having them put that all together, I think they'd be like, oh my gosh, like, I hadn't really thought of that. that because, you know, they're not really, it's not something we think about. Like I said, I studied

women's hormones in the way that they affect motivational states and I was on the pill for 10 years and never thought about it. It's just like we have such a disconnect with these things. And I think a lot of doctors are having that disconnect. And so I think the doctors do think that they're doing a big service to their female patients by removing their period problems. You know, the pill is really good at removing period problems. It, you know, it makes you not have a period. by suppressing your HPG access, and then you take that sugar pill and you get a little bleed just to let you know that everything's okay and that you're not pregnant. And it makes that part of your, you know, sort of menstrual experience very positive because you tend to have fewer cramps. Your periods aren't heavy because

they aren't real periods. They're just a little withdrawal bleed. And so I think a lot of doctors do this because, you know, it helps their patients and it is an easy answer. And I think that, you know, I think the medical community has become a little bit jaded. And I don't know if this is because of the public or if it's, you know, because of how they're being educated in medical school. But I think that there is a tendency for many physicians to believe that people don't have the stomach for lifestyle interventions, right? And that people just aren't going to do it. And I think that their view of like what people are willing to do is pretty cynical. You know, it's this idea that people don't want to change their diet and people don't want to

take steps to improve their physical activity or don't want to take steps to get better sleep. And that the only thing that people are looking for is a quick fix and looking for, you know, a medical solution, even if it comes with a long list of side effects. And so I think that, like I said, I think that many doctors believe that what they're doing is what their patients want. But it's not necessary, right? Because as you noted, there's a number of different ways that you can deal with menstrual issues that are natural and don't require suppressing your own hormone production and suppressing your cycles and, you know, can fix many of the problems that women deal with like PCOS and endometriosis. Let's come back to the beginning of the interview where you were talking about your journey and your story and you were explaining all these changes that you started to notice that were pretty shocking to yourself that you were interested. more in cooking and you're paying attention to, you know, different type of features in men or

even attractive men that you weren't looking at previously. Your preference in music was changing. So the book is called This is Your Brain on Birth Control. So tell us a little bit about what's actually going on in the brain when you are on birth control and then when you're off birth control. Why would somebody notice these and many other changes? To talk about what the brain does on the birth control pill, I think that we first, need to talk about what the brain does off of it. And for a naturally cycling woman, each month is characterized by a waxing and waning of two primary sex hormones. Right. The first is estrogen. And that is the hormone, like on the first day of your cycle, levels of both hormones,

estrogen and progesterone are very low. And the first day of your cycle is the day that you get your period. And on that day, both levels of hormones are low. as you move into the early part of the cycle, so say around day five, estrogen levels start to increase. And they increase in response to the fact that your egg follicles are being stimulated because when hormone levels are low, the brain tells the ovaries to start stimulating new egg follicles because it needs to ovulate. And so the brain is stimulating the ovaries. The ovaries are releasing estrogen and estrogen levels begin to climb. And then as a dominant follicle takes over, So if all these egg follicles that are being stimulated, one becomes the one that's allowed to fully develop and is going to be released.

That follicle begins to develop really rapidly and the other ones wilt away. And when that one begins this period of rapid development, it leads to a big surge in estrogen. So estrogen levels really start to take off right around day nine of the cycle and they stay really high until the point of ovulation, which if we're talking about a 28-day cycle, occurs around day 14. So ovulation generally happens about two weeks after the first day of your period, right? And so period prior to that time, estrogen levels are rising. And estrogen is a hormone that is related to things like sexual desire, sexual attraction, sexual behavior. It is associated with increased energy levels. You eat less. You move more. We're more sensitive to things like scent-based cues to things like testosterone levels. We notice men's testosterone levels in men's voices and faces and behaviors to a greater extent than we do outside of this period. And the reason for all of these changes in response to estrogen is that its release coincides with a period in the cycle when sex can lead to conception. Because sex can lead to conception for about five days prior to ovulation and then up until 24 hours after ovulation has occurred. And during this period of time, estrogen levels are very high.

and estrogen level shipped the body into a state that's optimized for conception. So essentially, it is getting your whole body to conspire, to look, feel, right? It's sexiest, right? And we're also, like, most able to discriminate among potential partners at this point. And so you get this, you know, increased sexual desire. Women feel sexier. They dress sexier. They move sexier. They smell sexier. So it's like women have all of these experiences that make them feel really good. They have more energy. And they're also more attuned to men. They notice men more often.

They're more easily distracted by the presence of men. They prefer the scent of men who have higher levels of testosterone at this point. They prefer testosterone markers in men's faces at this time. And so it's like anything male they are into, right? And the more male, the better in some ways. Right. And so what you see is you get this big shift in, you know, sort of gearing the whole body and brain together of sort of being focused on things related to conception. Then after ovulation occurs, the empty egg follicle that used to have that egg that was just released actually turns into a temporary endocrine structure.

It's called the corpus luteum. And it starts releasing women's other primary sex hormone, which is progesterone. And progesterone causes the body to shift gears away from being all about sex and sex and sex, and instead being all about implantation and pregnancy. And so its release actually coincides with a decrease in sexual desire, right? And an increase in fatigue, an increase in food intake. Women are hungrier. They're sleepier.

And they have lower sexual desire than they do earlier on in the cycle. And it's because the body is shifting. shifting its energy away from conception toward the idea of preparing for pregnancy, right? And this means doing things to try to prevent germs from getting into the body, which is why women's sexual desire decreases, is preventing inflammatory activity in the cervical area. Women are tired, you know, sleepy and hungry because they're conserving energy for the possibility of pregnancy. And in each cycle is sort of characterized by the waxing and waning of these hormones. You go through this period of time when you're optimized for sex and conception, and then you shift into this period of time where you're

optimized for pregnancy and implantation. And so, you know, for a naturally cycling woman, this is what life is like. You kind of go through these periods and you experience these, you know, hormonal ships where you're about sex and then you're about sleepiness and, you know, and so on and so forth. And the, you know, lather rinse repeat. And for women who are on hormonal birth control, the pill actually mimics that second half of the cycle, right? And so the synthetics that are in a hormonal birth control pill or any type of hormonal birth control contain a relatively high level of synthetic progesterone, which is called a progestin. Okay, and this progestin sends a signal to the brain that makes it believe that it just ovulated. And because of that, it's not going to stimulate the ovaries,

right? And this is how we prevent pregnancy is because your brain is getting a message that says, we just ovulated, no need to stimulate the ovaries. And so the ovaries never get stimulated, an egg never develops, and then it never gets released. But the negative part of this is that when you're getting this daily hormonal message of a high level of progestin and then relatively low levels of estrogen, is it prevents women from experiencing this range of, you know, effects that women experience as a naturally cycling woman. And for a lot of naturally cycling women, the time in their cycle that they feel the best is during that estrogenic phase of the cycle, right? When you're feeling sexy and, you know, you're geared up for sex and you feel good about yourself and you've got a lot of energy and you don't need to eat a lot of food even because you're just so busy and happy.

And instead, you're stuck in the state of being kind of hungry and kind of tired and kind of, you know, moody and kind of sexually meh. and that leads, I mean, when you experience that for long periods of time, it doesn't necessarily feel good. And on top of that, so that's like, you know, sort of the first level of the answer is that one of the reasons that we feel different on the pill is because we're not ovulating, right? And when we're not ovulating and we're not experiencing that sort of beautiful time in the cycle when estrogen is the one driving the ship, that leads us to not experience like this drive for pleasure. you know, like wanting, you know, beautiful things and beautiful men and beautiful food and, you know, and have our senses stimulated with music and other things that, you know, kind of feel good and activate those same senses and sexual desire and we don't feel as sexy. I remember not as tied into, like, sort of dialed into all of that.

So that's like one thing that happens when you're on the pill. But then the other thing and the other sort of set of changes that happen in response is that these, synthetic progesterone molecules that are out there aren't derived from actual progesterone, and they're mostly synthesized from testosterone, and they have some really funky molecular properties that make them not have good binding affinity or specificity for progesterone receptors. And so what that means is these funky little molecules, yes, they stimulate progesterone receptors, at least enough to a degree to suppress ovulation, right? So they're activating progesterone receptors in the brain, which is making the brain believe that it's just ovulated and that it doesn't

need to stimulate the egg there, the ovaries. But it also seems to stimulate things like testosterone receptors. And sometimes it also seems to stimulate glucocorticoid receptors, which can put you in a state of feeling like you're in chronic stress. And so it has all these other funky properties that make it behave in ways that we don't fully understand yet, but are likely responsible for some of the side effects that we see in women. So, for example, some women on some formulations of hormonal birth control that tend to stimulate a lot of androgen receptors or testosterone receptors, they tend to have problems with breakouts or weight gain as a result of the fact that their testosterone receptors are being stimulated, and these are things that are known to be related to

testosterone levels in women. Or we also know that sometimes, you know, women will have this experience where they feel extremely psychologically just, you know, in despair when they start hormonal birth control. And this potentially can be the result of some of this thing that, some of the things that go on with these progestin stimulating the glucocorticoid receptors, where women, you know, if you're stimulating these receptors that normally pick up stress hormone and they're being stimulated for no reason, that can make women feel like life is terrible and they don't know why, and that can really put them in a state of despair. And this may be related to some of the mental health side effects that we know are very common in hormonal birth control, right?

And so when we consider the fact that hormonal birth control both suppresses, you know, ovulation and then suppresses our release of estrogen, which is related to a lot of these things that women love to feel, And then also as being replete, you know, we get this, instead of progesterone, we get this funky progestin that not only stimulates progesterone receptors, but other types of receptors in the brain and body that can potentially lead to feelings of despair and distress. This, you know, potentially can impact, like I said, these mental health-related issues. You can have a whole lot of things that are going on from hormonal birth control, a lot of which have absolutely nothing to do with pregnancy prevention. Have you seen some of these viral articles and videos where women have said

things like being on the pill made me marry the wrong person? Yeah. Is it already true to that? Yeah. Well, there can be. So like let me just start this by saying that this doesn't happen to most people. Okay. So like if you're listening to this, you don't need to like absolutely freak out. But this does happened and I have absolutely no doubt. I have zero doubt that the birth control pill in the cases where this happened played a role in what unfolded. And so here's the story that I hear from women. I hear the story of I was on hormonal birth control. I chose my partner when I was on hormonal birth control. I went off of hormonal birth control and I'm not attracted to my partner anymore. And this can happen because when you're on hormonal birth control, it decreases the amount of

effort that your brain is investing in some of the areas that our brain uses to assess partner preferences, right? And so this includes things like testosterone levels, but also things like genetic complementarity, right? And some of these things are things that are communicated via assent. Some of these things are communicated via personality, right? Like, so is somebody kind of socially dominant or are they passive? These are things that are communicated. The facial features, so things like facial masculinity and so on. And, you know, many times when women choose partners when they're on the pill and then they go off the pill, it's really not that big of a deal, right? Because when we think about the way that hormones influence the brain, it nudges you, right? It doesn't

shove you, right? It nudges you. It nudges your preferences this way and nudges your preferences that way. right but sometimes if you chose somebody who is just on the threshold of what is considered attractive, right? And you get nudged a little bit that way, then it lights out, you know, and you're not attracted to that person anymore. And that does happen sometimes. You also get cases where women will choose their partners when they're on the pill. They go off the pill and then they're super attracted to their partner. And they're like, oh my gosh. Like, wow, I had no idea what I had. You know, know, and then they go off of it, and because all of a sudden they're getting that nice estrogen surge, you know, which increases how sexy women feel and it increases their, you know, their attunement to men and their, you know, and their attunement to sex and they become more sexually motivated. And now they have this partner that has these qualities that they would have wanted when they were, you know, cycling anyway. They're super attracted to their partner.

So you get it the other way as well, right? So sometimes when you go off the pill, you become more attracted to your partner. sometimes when you go off the pill you become less attracted to your partner and sometimes when you go off the pill it's not a noticeable difference right and it's all about these little nudges right if you're in the middle right in terms of what you're attracted to and who you chose you're probably not going to notice that much of a difference if you're on one of these two sides of the continuum right it can kind of nudge you out of attraction to your partner or nudge you into being really attracted to them in a way that you weren't when you were using hormonal birth control how this is going to affect any one individual woman is going to depend on the hormones in her birth control. It's going to depend on what her hormones were like when she's not on birth control, right? And it's going to depend on who she chose as partner. There's a whole lot of variables that go into play, which is why I say don't, you know, don't freak out if you chose your partner on the pill. If you go off of it, you know, there's a chance that nothing will happen or there's even a chance that you might become more attracted to

them. But yes, for some women, it does lead them to feel like now this is just this just isn't working anymore. And in those cases, it's, I mean, that's a really heartbreaking thing to have to contend with, you know, which is why I tell women, if you don't need to be on the pill and you're looking for a partner, I would stay off of it just because it's safer that way, you know, and then if you decide that you met somebody and you're interested in them and you want to have a sexual relationship and the way that you want to manage your fertility is using hormonal birth control, Godspeed. You know, I just, I do think that if you have a choice, all else being equal, I think that it's probably better and safer to choose your partner

while you're naturally cycling just to prevent this from happening. Because even though this doesn't happen often, it does happen. I've also even heard from women who, and this is also really fascinating, who have little nudges in their sexual preferences when they're on hormonal birth control or not. and so where they will have spent their life thinking that they were bisexual and then they go off the pill and they realize that they are either completely straight or they're totally lesbian, right? Or they thought that they were a lesbian and then they go on the pill and then all of a sudden they're bisexual. I mean, it's or the reverse, right, where they thought they were lesbian and then they go out

the pill and now they're bisexual. And so it's hormonal nudges, you know, because they impact so many different cells in the body and in the brain. It's like they have all these little nudging effects on all these different systems. And sometimes these things, again, is for these people who are kind of on the border, you know, who are like, you know, because I wouldn't expect that like the most obligatorily obligatory lesbian, you know, who's just like, like, you know, has never even imagined the idea of sex. I can't imagine that somebody like that would go on or off the pill and then all of a sudden become, you know, decide their heterosexual because that's just not the way that hormones work. Right. But

Instead, it's these little tiny nudges. And for people who are kind of on one end of a continuum or another, it can nudge you into a different category. And which, again, it's really fascinating both in terms of understanding the impact of hormone of birth control, but then also just giving us new insight into the role of sex hormones in determining things like attraction and even sexual orientation. You had a great interview with Tammy Peterson. I kind of talked about it a little bit earlier.

and one of the topics that came up inside of there, we already know that women are the vast majority of autoimmune conditions that are out there right now, diagnoses that are there. I think it's upwards of 80% is women. On top of that, we've had experts on our podcast like Dr. Lisa Mascone, who's studying the changing brain of women as they age, and its role in things like Alzheimer's, women are two times more likely. You know, there is this tendency to want to see,

did something that I do, or was something that I exposed to earlier, have any impact on the condition that I'm going through right now. If there are individuals that are thinking, hey, did my autoimmunity, which generally a lot of autoimmune conditions start for women when they're younger in a particular age range, if you take things like MS, I think the classic sort of age range for that is that, you know, younger women that are in their like 20s when they first start to have in their later 20s when these conditions have. And people thinking about being on birth control around that time period.

For anybody who's looking for, hey, I know there's not a lot of research that's on this, but I'm trying to even see, are there connections? What should I be thinking about? What should I be exploring? Is there anything that you would want to share with those individuals? There's absolutely a possible connection between hormonal birth control use and the development of autoimmune disease. And in some cases, there is some research evidence that suggests that it can increase the risk

of certain types of autoimmune disease. And just to give you an example of this, I believe it's either Crohn's disease or divertriculitis, but it's one of these autoimmune diseases that's related to hormonal birth control use, and it's related to the gut. And there's evidence linking usage of hormonal birth control with that. And I think there's a couple of other ones at this point as well.

And there's every reason to suspect that this might be the case that using the pill or using some other form of hormonal birth control will influence this just because we have research evidence now showing that one hormonal birth control use is linked with changes in the cortisol response to stress. And cortisol, in what this research generally finds, is that women who are using hormonal birth control tend to have a blunted cortisol response to stress, meaning that they don't release as much cortisol in response to a stressor, which sounds like a great thing because everybody thinks that cortisol is a bad guy, but it's actually a terrible thing because we release cortisol in response to stress for a reason, and it's because

it helps our body cope with stress. And one of the things that it does is it decreases inflammation because another thing that happens to us in response to stress is our inflammatory response goes nuts. And it does this because stress historically has been a context that can lead to danger and the possibility of injury. And so when we're stressed out, in addition to releasing stress hormones, our body also starts to release inflammatory activity, getting the immune system ready for a battle, right, just in case you end up getting injured. And so cortisol actually can turn the volume up and down on inflammatory activity in the body. And so having a blunted cortisol response to stress can lead to exaggerated inflammatory activity in response to stress, right? And exaggerated inflammatory activity is one of the hallmarks of autoimmune disease.

Right. And another piece of evidence linking the possibility of the development of autoimmunity and hormonal birth control use is research that comes from my own research laboratory. And this, we did a study specifically looking at the differences in inflammatory release in response to stress between women who are using hormonal birth control and then women who are naturally cycling. And what we found is that in response to stress, and so we bring women in into the research lab and then we stress them out. We make them give a public speech, like an impromptu speech about their dream job. And then we make them do backwards math equations. We make them count backwards from steps of 13 from like 1,124. And they have to count backward in steps of 13. And any time that they mess up, they have to start over again. And so it's this really stressful research paradigm. And then we take their blood and we looked at the release of different types of inflammatory markers or pro-inflammatory cytokines for the science nerds who like to listen to this. And what we find is that for women who are using hormonal birth control, they have a different

inflammatory response to stress relative to women who are using or women who are naturally cycling. And in particular, what we find is that the stress response for women who are using hormonal birth control, and we looked at just women using combination hormonal birth control pills. and their response to stress was characterized by the release of a cytokine called TNF alpha. And whereas women using hormonal birth control, it was more dominated by IL-S. It's an IL-6, it's interleukin-6. And this is noteworthy because A, so IL-6, this inflammatory cytokine that tended to really get released in higher levels in naturally cycling women, it's both pro-inflammatory, but it's also anti-inflammatory in the body.

So it has these pleatropic effects that are sort of nice where it's like your body's preparing for inflammation, but it's like, you know, it's this kind of soft inflammatory response. TNF alpha, which was the inflammatory response or the sort of cytokine signature of women who are using hormonal birth control, it's a little bit more gnarly. It's a more inflammatory inflatillary, like uniformly, unilaterally inflammatory, inflammatory response to stress. And not only that, it is one of the sort of hallmark cytokines that's known to be indicted in the development of autoimmune disease. So we know that exaggerated release of this particular type of inflammation is something that's linked to the development of autoimmune disease. And it is what we see is characterizing the inflammatory response to stressful situations and women using hormone. birth control. And so we think that this is potentially something that could ultimately lead to the development of autoimmunity in women who use hormonal birth control. And that is that their stress response,

their inflammatory response to stress is different and characterized by different cytokine release or different types of inflammation in response to the stressful situation, which then in turn, when you have that repeated over time, because of course we're all exposed to stress multiple times a day, you know, and then of course over the course of the lifespan then can lead to the development of autoimmune disease. You know, autoimmune is so multifactorial. And obviously there's a bunch of different diseases within that category of autoimmune. But for the person that's listening today that says, hey, listen, we've had some history

of autoimmune in our family, whether it's a guy or girl that's listening. And, you know, we have a young daughter or a granddaughter who might be coming up on that age where, you know, a physician, whether they're sexually active, whether they have problematic periods might be suggesting to them or parents having a conversation about, is birth control right for you? I mean, there's so few physicians that are maybe aware of this connection. What would you recommend to the family that is looking for how do we balance this out? Not necessarily a decision, but how do they weigh it? How do they think about it for themselves as a family? What resources could be there so that they can make the right decision? So they don't end up putting their young, you know,

daughter, granddaughter in a situation that they don't feel like is the full informed consent that the individual would want. Right. I mean, my thought, if it was my child and we had a history of autoimmune disease in the family, my inclination would be to steer away from things that are going to suppress regular endogenous hormone production. And that includes hormonal birth control, just because there's a lot with women's naturally cycling hormones that are very anti-inflammatory that are very positive in terms of

preventing autoimmune disease. And, you know, and I'm sure in your conversation with Dr. Musconi, you talked a little bit about some of the roles of hormone because she studies this in menopause. And you see in menopause that a lot of women have these experiences of changes in autoimmune profiles. And of course, you get the greater risk for Alzheimer's disease and all that sort of thing that goes on in response to these, you know, big hormonal changes. And hormones can be very protective in terms of protecting brain health and then also protecting the health of the immune system. And so my inclination would be to stay away from it. And not because I have all this stack of evidence saying that is bad because I don't. And there's not a lot of research that's

looked at, you know, long-term risk. I know with certain types of autoimmune disease and readers can or listeners can go to my book. I actually describe the ones that are out in the research science if they don't want to look at the research themselves, which of the autoimmune diseases are known to be linked with hormonal birth control use because there are some that have been well studied and it's been documented. But it's not something that's been studied well enough where we understand the role of hormonal birth control and all the different types of autoimmune pathways. But just based on everything that I know about hormones and their role. in regulating the immune system and sort of tilting us toward an anti-inflammatory type of immunological signature, my inclination would be to not use hormonal birth control if possible. Are there any other conditions or health things that people may be navigating in their history

where you would say, okay, just like autoimmunity, this would be another thing that if you have this in your family history, if you're dealing with this right now, then do you really want to risk it Or there's other alternatives. It's not like you just have the pill and you can explore those alternatives. Right. So here's a few. And some of these might surprise you. So the first one will not surprise you.

And that is like if you have severe PMS or PMDD, and this one actually goes both ways. Because if you have PMDD or severe PMS, some women respond super well to hormonal birth control. So some of those women, because a lot of the symptoms are the. result of that hormonal up and down that I told you about in a natural cycle. And so for women who are really sensitive to those hormonal changes, and that's what triggers their symptoms, they may actually find hormonal birth control to be hugely beneficial. But for some women who have these syndromes, it can make it much, much worse. And so for these people, if you have severe PMS and PMDD in the family, what I would say is talk

to your doctor about hormonal birth control use, be very careful with it. And know that, you know, work with somebody who's used to working with women with this condition because, like I said, for some women, it's really helpful. For other women, it can, you know, it's really not helpful. And so it has this very sort of divergent set of effects. And so this is just something where we need added caution, but maybe even some optimism for it being helpful to women who is helpful to. Depression and anxiety.

We know that the women who are most likely to have mental health side effects who use hormonal birth control are those who have a history of that in their family or a personal history of that themselves. And so just being really careful in monitoring the mental health side effects of women who are using hormonal birth control if they have a family history of that or consider using different options because we do know from research that women are at a greater risk of developing negative mental health side effects when that runs in their family. Alcohol and substance use. So interestingly enough, progesterone, and this is some research that we're doing in, our lab right now. But progesterone, as it's released in the body, when it gets broken down in the body, releases this really beautiful neurosteroid called alloprignanelone. And I say that it's really beautiful because it has this very calming effect on the brain, right? It increases neuroplasticity, and it allows our brain, when we're keyed up, to be able to dial things down. It's calming,

it's relaxing, and it stimulates the neurotransmitter receptors in our brain that gets stimulated when we're doing yoga, when we're sitting in front of the fireplace, and also when we drink alcohol and use some other drugs of abuse. And so when you're taking hormonal birth control and you're not ovulating, so you're not producing endogenous progesterone, which releases this really beautiful neurosteroid that has all these calming effects on the brain, then you get a shortage of it. So what we tend to see is that women who use hormonal birth control, which contain progestin, not progesterone, and progestinns, these synthetic forms of progesterone, again, they're not synthesized from progesterone.

They're synthesized from testosterone, usually. When they get broken down in the body, they don't release this calming neurosteroid. And so our research in our lab has been looking at whether women who use hormonal birth control, because they're lacking this calming, you know, sort of, you know, relaxing effect in their brain that's created by the release of aliparginalone, we've been looking at whether or not women might be self-medicating and especially turning to things like alcohol to try to stimulate these same pathways in their brain. And what we tend to find is that lo and behold, women who use hormonal birth control do have more alcohol cravings and they consume a greater number of alcoholic beverages in a

drinking session relative to women who are naturally cycling. Right. And we're further going to be looking at this with respect to other types of drugs of abuse. use because oftentimes when our brain isn't getting enough calming activity, like the types of things that it needs to be able to dial down stress and sort of regulate our mood, not only does that lead us to seek out substances like alcohol, which will simulate these same pathways, but it can also lead us to seek out other substances that stimulate other types of pathways that make our brains feel good. And so if you are somebody who has a history of substance use or particular, you know, based on our research, alcohol, you know, alcohol use or misuse, alcohol overuse. I would also be

cautious about giving hormonal birth control to women in that category given that some of our research is suggesting that it may lead to an increased craving. What other research would you like to see in the future? I'm sure the list is endless. But in terms of priority, right? And what is actually possible? Because you've also talked about how, you know, you can't ethically have somebody on a double-blind placebo control for, you know, hormonal birth control, right? That would be problematic because somebody might end up getting pregnant because they're not sure, are they on the pill or are they on something else? But realistically, what can be done and what would you like to see in terms of priority that would make the most difference for

women's health? It is very difficult to do this research, not only for the reasons that you specified, which is 100% true, but also because there's so much heterogeneity in the products that are out there, it's like really hard to, like, if you study like one type of pill, for example, we don't know that that's going to then translate to everything, every other type of pill that's out there. And so it's just, it's just really complicated to do. The research is complicated to do, but it's not impossible, right? And so like we're doing some of this research. Other people's labs are doing this research. So it is possible, but it is challenging. Nonetheless, like, what do I think are the most important topics. I mean, to me, the thing that has been studied the least that

has the most lasting impact is like what goes on developmentally. So like what we really need are good developmental psychologists looking at the way that taking hormonal birth control in adolescence changes brain development. And thankfully, there are a handful of researchers that are now actually taking this question very seriously and they're starting to examine this. And my guess is that within the next 20 to 25 years, we're going to know a lot more about that than what we do now. The research that we do know now is starting to point in the direction that surprise, surprise, changing women's hormone profile when they're still developing can have a lasting effect on brain development. And so I'm really looking forward to having that

research out there because I do think that, you know, if I could wave my magic wand, it would, you know, and just like pick one thing that could happen as a result of, you know, the work I do and the work that my amazing colleagues do is for doctors of teenagers to just be more cautious in prescribing this to girls for reasons that aren't pregnancy prevention, right? Like, I think that we can both agree that pregnancy prevention in teenagers is hugely important, right? And so, you know, and there might be other ways that teenagers can do this that don't involve hormones, right? And a better way to do that, but whatever. I would not take issue with a prescriber giving a teenage girl who's sexually active, hormonal birth control for pregnancy prevention because that's just such an important thing to do

that it might be worth the trade-offs. I do have an issue with, you know, this being given to girls for really minor issues like their skin breakouts and that sort of thing. And so I just, I hope that physicians of young girls think twice or at least discuss with the families so that way the families can think twice about whether or not, you know, even just discussing the fact that there isn't all that much research. Like in saying, hey, you know, sex hormones influence brain development and there's really not a lot of research on what taking these right now and your daughter's brain is still developing. Like, we don't really know about what that does in the long term, I think many parents would be like, we'll just tell her to wash your face more.

You know, it's like, there are solutions to things like acne and solutions to other things that I think that parents would be totally willing to do. It's just that they haven't been given those, you know, because they haven't really given all the information. And so to me, that's the thing that I think that I've, like I said, my magic wand would be, would be that just because these young girls are being put on this without any information. And then here they are as adults. And they're like, what happened to me? And it's just, that's just heartbreaking. And especially when they were on it for something like acne. And it's like there's other solutions to that. And I'm willing to bet that if the parents knew, and even if the doctor knew and the woman knew, that they wouldn't have made those

same decisions. When I listen to my community and the women that are in it who have young daughters, even if they didn't have a bad experience on the pill, and many of them have felt like there were negative experiences that they had, and everybody's different. But if I would sum up a good chunk or the majority of the thoughts, it's like, hey, I wouldn't put her through that because there's too much unknown. And there's plenty of other options. Now, my community are largely individuals that, you know, if you're listening to a health podcast and you have an hour or two hours, you probably have some economic flexibility, you know, you're not in poverty, you have some level of education. And so they understand that, hey, listen, we don't want to take away the pill because especially

for those that are most disenfranchised and being born to a single mother is a greatest predictor of poverty, we need these solutions that are out there. And they also recognize that a lot of the recommendations for my doctor are public health recommendations. We're not the best in medicine about giving a family its own unique sort of recommendations for what that family is there. We kind of lump everybody together. So the feeling is, I don't want to risk it. There's too many variability. There's too many unknowns.

And on top of that, the pill isn't the only thing we're dealing with. We're dealing with a world that has increasingly higher levels of microplastics and xenoestrogens and makeup toxins and any kind of thing that you could imagine. why introduce another variable that could go one way or another? They're sort of seeing it as sort of risking. Do you feel like that's a fair way to look at stuff? If there's still the priority and the emphasis that, hey, we want to avoid, you know, a young woman getting pregnant when she doesn't want to.

So there has to be a greater investment into education and what those solutions would be. Yeah. No, I mean, my big magic wand, so my mini magic wand about what would happen with birth control is what we had just discussed, but my big magic wand is that all of these conversations that we're having lead to the development of new solutions, right? I mean, I think we can all agree. Like, I, it's, you know, it's interesting because I've been, I've had conversations with people all over the political map because I just said this is too important of an issue to be, you know, like choosing who I talk to about this. 100% of people I talk to regardless of where they stand politically or religiously or whatever the question is.

agree that we need more options. You know, it's like women's ability to regulate their fertility is hands down, you know, one of the most important issues that women have to worry about in their lifetimes just because pacing pregnancy allows us to be able to do things like build careers and achieve goals and support ourselves. And we don't have a lot of good solutions. I mean, the fact of the matter is knowing everything that I know now, I would probably still go on hormonal birth control at the time I went on it because I needed really good birth control. And that was kind of what was there. You know, it was like where I was in my life, I would probably still do it. And I know the tradeoffs I'd be making.

And this is because this is how few solutions we have. Hi, everyone is true. Unfortunately, we lost our connection with Sarah in the interview and we couldn't re-record it. So I wanted to do a little outro to make sure, number one, please check out. Sarah's work. The book is called This Is Your Brain on Birth Control, the surprising science of women, hormones, and the law of unintended consequences. And while we were at the end of the interview, and we were talking about those unintended consequences, I truly believe that the best way to continue to highlight this work is to continue to pay attention to the people and researchers

that are out there like Sarah who are advocating for more research to protect women. This isn't just a conversation, although this is very important about acts. to birth control and avoiding unintended pregnancies and supporting women. This is a conversation about having choices that don't end up having unintended consequences. And that's the hope for the future that we make enough noise as a society, even the men out there that are looking after the women that they love and potentially their daughters in the future. We need to make enough noise that we bring this conversation to the forefront and come up

with better options and make sure that people know what they're really. risks are with certain medications that are there. Thank you, Sarah Hill, for being on the podcast. And everyone, if you wouldn't mind, we've linked to Sarah, Dr. Sarah Hill's Instagram in the show notes below. You can find her and follow and continue to follow her work there. Thank you for tuning in to the Drew Prode Show. I'll see you next week.