Ricki Lake and the Business of Being Wrong about Birth Control

The pill doesn't induce a menopause-like state

Isabel Pavia, Getty Images

From time to time I’m asked about a video clip or comments about Ricki Lake’s movie, “The Business of Birth Control”. Normally, I just scroll along, because the movie is terrible. It cherry picks “information”, relies on anecdotes, and brushes over the wealth of data on the pill. And frankly, the amount of effort needed to undo the bullshit in the movie is far greater than the effort it took for Lake and co. to vomit it into the ether. 

Look, the movie promotes a competitive product with the pill, a basal-body thermometer called Daysy with a “fertility algorithm” that currently sells for $319, and is advertised as a “hormone-free solution for managing your fertility, cycles, and health.” Daysy is owned by Valley Electronics. And who, you might ask, provided some of the funding for Ricki Lake to shit on the pill? Why Valley Electronics. You wouldn’t be faulted for missing that, because that nugget is buried until the end.

There are other backers for the film who are also financially invested in having people not take hormonal contraception. Imagine if I made a movie about the pill and it was funded by three pharmaceutical companies who made oral contraception and I didn’t disclose that until the fine print at the end of the movie? People would be rightly outraged. 

Then again, I don’t take money from industry. 

But it gets worse. A study about the pregnancy rates with Daysy was flawed. Dr. Chelsea Polis PhD, a noted researcher in the field, pointed out some serious issues with the study including “egregious flaws in data collection and analysis.” The editors of the journal where the study was published eventually agreed and concluded, “Independent post-publication peer review has confirmed that there are fundamental flaws in the methodology which mean that the conclusions are unreliable due to selection bias and the retrospective self-reporting of whether pregnancies were intentional.”

Dr. Polis rightfully stated the following on her blog, “A company marketing a $330 device as a contraceptive method in over 30 countries did not see it fit to spend money to conduct the appropriate studies, which would have enabled them to market the device honestly, and avoid misleading people into unintended pregnancies.”

Did Daysy thank Dr. Polis for pointing out their errors? No, they sued her. Fortunately, the case was dismissed.

The association with Daysy is, in my opinion, reason enough to avoid Ricki Lake’s movie. But recently, I saw something so medically nonsensical from Lake’s campaign of contraception chaos that I needed to reply. According to the people who are in the business of scaring people about birth control, the birth control pill induces a “menopause-like state.”

No really. Here’s the screenshot from the Business of Birth Control Instagram account. I admit, I took a double take because this is so wrong. Like it’s wroooooooong. 

I wouldn’t expect a layperson to know that the pill doesn’t induce a “menopause-like state”, but I’d expect any provider who manages reproductive health to know. I’d actually expert a fourth year medical student to know.

I actually wondered if Briden has been misquoted by the Business of Birth Control Instagram account, but on her website I found exactly the same disinformation. 

Le sigh. 

The Menstrual Cycle

Anyone with ovaries was born with all the follicles they will ever have, and it’s these follicles that contain the developing egg. The menstrual cycle is a complex, coordinated sequence of hormonal interactions that guides the follicle to ovulation and prepares the lining of the uterus for implantation.

By a process we don’t yet completely understand, at the beginning of a cycle a small group of follicles starts to develop and the rest stay dormant. A hormone called follicle stimulating hormone, or FSH, is released by the pituitary gland in the brain and stimulates this group of follicles that have been called up to the major leagues to develop, which leads them to produce estradiol (an estrogen). Estradiol levels rise and along the way a dominant follicle is selected. When estradiol levels are high enough, this triggers a change in hormone signals, there is a surge in a hormone called luteinizing hormone or LH, and ovulation occurs.

After the egg leaves, the tissue from the follicle that’s left behind organizes into a structure called the corpus luteum, which produces high levels of progesterone. Progesterone prepares the endometrial lining for implantation, but it also sends signals that reduce FSH and LH, but especially LH. This prevents another follicle from attempting to ovulate, and so progesterone is often thought of as a brake on ovulation.

If pregnancy doesn’t occur, progesterone levels drop and menstruation happens. A new group of follicles gets called up from the minors and the pituitary gland in the brain, free from its progesterone brake, can now release FSH again to trigger more follicles to develop. And so on and so on.

With Menopause

With menopause, follicles collectively start to lose their ability to develop and produce estrogen. In response, the brain starts producing more FSH. I think of this as the pituitary needing to raise its voice to get a response from the follicles. Eventually, it gets to the point where the follicles are just not capable of developing and producing estrogen, no matter how high the level of FSH, and ovulation stops as does menstruation. 

While some people have a rise in estradiol before a drop, eventually menopause is characterized by very low levels of estradiol (typically less than 20-25 pg/ml depending on the assay used) and high levels of FSH, and no follicular development. Menopause is not reversible.

The Birth Control Pill and Follicles

Hormones from the pill suppress the pituitary’s ability to produce FSH and LH, and the major player here is the impact of the progestin (a progesterone-like hormone) on LH. Remember, progesterone is a very effective brake on ovulation, which is why the first hormone studied for the pill was progesterone in an attempt to replicate the way progesterone from the corpus luteum and the placenta suppress ovulation during pregnancy. 

So what is happening in the ovary with the pill?

With FSH levels low due to the hormones in the pill, the follicles that the ovary sends up to the major league each cycle don’t get the stimulation they need to develop. Basically, they are stuck warming the bench, but they still produce low levels of estradiol, around the levels found on cycle day 3. After a while, these follicles regress, because they can’t stay in limbo forever, and a new group gets called up. Follicles get recruited with the hope of ovulating every cycle whether someone is on the birth control pill or not. Obviously, that doesn’t sound anything like menopause.

I appreciate this is a new concept for a lot of people, but the follicles keep to their cyclic rhythm while someone is on the pill, it’s just they don’t develop past day 3. This is likely why the pill doesn’t delay menopause, because follicles still develop and are lost each cycle, whether you are on the pill or not. 

Ideal levels of estradiol on cycle day 3 are <60-80 pg/ml (from a fertility standpoint). One of the earliest studies that looked at estradiol levels on the pill found levels of 20-80 pg/ml for most women, but a few participants had levels in the 10-20 pg/ml range. Another study looking at estradiol levels on different pills and found an average range of 33-57 pg/ml. And a review article comparing a couple of different regimens found a range of 15-80 pg/ml, depending on the regimen and the day of the cycle. (It’s probably better to use newer data as it reflects the current doses and regimens).

Having an estradiol level at the lower end of the early follicular phase, or even a little lower, doesn’t mean that someone is in a menopause-like state. The physiology of the pill and menopause are very different. Also, menopause is more than estradiol levels and levels of estradiol don’t correlate well with symptoms of menopause. And finally, the pill is not associated with the symptoms or the medical outcomes that can be associated with menopause. 

What Do Other Experts Say?

Even though this is a blog and not a documentary film, I’m not content to go by what I learned in four years of medical school and a five year residency and what I double-checked with the references below. I also fact-checked with two board certified reproductive endocrinologists, meaning super experts in reproductive hormones, and asked them what they thought about the pill being compared to a menopause-like state.

Dr. Jani Jensen, a reproductive endocrinologist in Minneapolis MN, told me, “Birth control pills suppress ovulation and keep the body hovering in a state similar to the first few days of the menstrual cycle. This is very different from menopause, where estrogen levels are low because there are no eggs available to develop. To say that birth control pills cause menopause or a menopause-like state is wrong.” 

And Dr. Lucky Sekhon, a reproductive endocrinologist in New York, NY, also explained that the pill and menopause are nothing alike and with the pill the level of estradiol, “is equivalent to Day 3.” And she also confirmed that the ovaries keep producing follicles each cycle, whether someone is on the pill or not. 

So The Pill and Menopause are Nothing Alike

Right! Completely different physiology. If you think the pill induces a menopause-like then you would have to also think that the early follicular phase is a menopause-like state, and obviously it is not. 

The pill has many health benefits, but some people don’t like how they feel on the pill and there is a low risk of serious side effects. And it’s also true that some healthcare providers don’t discuss the benefits and risks of hormonal contraception as well as they should with their patients. But the answer to that problem isn’t spreading incorrect information about the pill. 

Let’s Recap

I even made a handy chart. 

Why would the people behind “The Business of Birth Control” promote the fallacy that the pill creates a menopause-like state? The only ideas I can come up with are they didn’t fact check or perhaps the idea of the pill inducing a menopause-like state was just too good a sound bite to achieve their goals of fear-mongering about the pill? Who knows?

What I do know is promoting disinformation about the pill is big business. In addition to the worlds of movie making and fertility monitoring, there are many people selling books, coaching, and supplements-none of which have any safety testing–to supposedly “fix” issues caused by the pill. That’s for another time.

The Business of Birth Control movie isn’t feminism. In my opinion, when you partner with a company that sued a researcher who was correct about a flawed study and you provide disinformation about women’s bodies you, my friend, are the patriarchy.  

To write this post, I read through multiple articles on hormone levels on the pill. I re-read parts of three book chapters that I’d previously read. I read an interview with Dr. Polis and the relevant parts of her blog. And I messaged two OB/GYN experts who were gracious with their time. And then of course all the time to write this piece hopefully in a way that makes sense.

Meaning yeah, the amount of energy to undo bullshit is exponentially greater than the effort it takes to create it.

References

Lindsay Gellman, Who’s Afraid of Birth Control? The Cut https://www.thecut.com/2022/05/business-of-birth-control-documentary-review.html Accessed 12/12/22.

Chelsea B. Polis Ph.D.  Personal Blog http://chelseapolis.com/blog/how-an-unethical-company-daysy-responded-to-retraction-of-their-study Accessed 12/12/22.

In a defamation lawsuit, the hype around digital health clashes with scientific criticism. Kate Sheridan, Kate Sheridan  and Casey Ross. STAT News https://www.statnews.com/2022/03/02/health-fertility-thermometer-valley-polis/ Accessed 12/22/22.

USA Daysy site. https://usa.daysy.me/shop/products/daysy-en/?gclid=CjwKCAiAv9ucBhBXEiwA6N8nYHZcHNhQ3BBFafJNIhPqDhthWhhyLRYtiVhb6VCEfLT8fRqRxymDKxoCJNMQAvD_BwE

Infertility workup for the women’s health specialist. ACOG Committee Opinion No. 781. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e377–84.

Ping G. Tepper, John F. Randolph, Jr., Daniel S. McConnell, et. al. Trajectory Clustering of Estradiol and Follicle-Stimulating Hormone during the Menopausal Transition among Women in the Study of Women's Health across the Nation (SWAN). J Clin Endocrinol Metab. 2012 Aug; 97(8): 2872–2880.

D R Mishell Jr, I H Thorneycroft, R M Nakamura, et al. Serum estradiol in women ingesting combination oral contraceptive steroids. Am J Obstet Gynecol. 1972 Dec 1;114(7):923-8.

Gaspard UJ, Remus MA, Gillain D, et al. Plasma hormone levels in women receiving new oral contraceptives containing ethinyl estradiol plus levonorgestrel or desogestrel. Contraception 1983;27:577-590.

London A, Jensen JT. Rationale for eliminating the hormone-free interval in modern oral contraceptives. International Journal of Gynecology and Obstetrics. 2016;134: 8–12