The pill's trade-offs: benefits, underappreciated risks and what it means for fertility
Sharon Malone walks through birth control's benefits, its myths and the return of the rhythm method, Sara Gottfried weighs real benefits against underappreciated risks and discusses oral contraceptives and the copper IUD, Natalie Crawford explains what birth control does and does not do to fertility, Kyle Gillett discusses oral contraceptives alongside PCOS, Stacy Sims covers birth control with iron and blood tests, Rena Malik takes up contraception, and Andrew Huberman describes how the pill interacts with odor and ovulation in attraction. Comparing these views helps women weigh contraception choices with the full set of effects in mind.
The pill prevents pregnancy, gives women control over when to have children and treats several real conditions, and it does not cause lasting infertility. Where the doctors in these conversations split is on how much weight to give its side effects.
Dr. Sharon Malone, a board-certified OB-GYN, calls the pill "probably one of the greatest modern inventions in the history of womankind." Beyond contraception, she says it lightens heavy periods and helps prevent anemia, eases severe PMS and menstrual migraines, and is a first-line treatment for painful periods and suspected endometriosis. She puts the clot risk in context: the pill raises it two to three times, while pregnancy raises it six times. She warns that the new natural methods are really a modified rhythm method, since temperature rises after ovulation, not before. For women who want to avoid the pill, she favors long-acting methods such as IUDs, which take user error out.
Dr. Sara Gottfried accepts the benefits, including about a 50% drop in ovarian cancer risk after about five years of use, but gets on a soapbox about risks she thinks are underappreciated: depleted magnesium and some B vitamins, higher inflammation, a more rigid stress axis, possible thyroid effects, and raised SHBG, which soaks up free testosterone and can lower libido, confidence and agency in sensitive women. Limited data show SHBG still elevated a year after stopping, and she says reversibility isn't known. She criticizes prescribing the pill for acne or painful periods without informed consent, and calls herself an IUD crusader for the non-hormonal copper IUD.
Dr. Natalie Crawford and Dr. Rena Malik land in between. Crawford explains that the pill doesn't change how fast eggs leave the ovary's vault, which is why it doesn't cause infertility, though it can temporarily lower AMH by up to 30%. She notes ten years of use cuts ovarian cancer risk by more than 90%, and that nothing is without risk. Malik describes a probably small subset of women whose libido drops. Dr. Kyle Gillett explains the mechanism: synthetic estrogen sharply raises SHBG in the liver, and progestin choice affects clot risk. He says a fertility effect past 6 to 12 months seems very unlikely.
Stacy Sims adds effects most people never hear about: more inflammatory responses in active women, results that vary by progestin and dose, and a 2024 study linking the pill to increased fear. Andrew Huberman describes studies in which the pill flattened the peak in attraction around ovulation.
The disagreements are about size and prescribing. Malone says the risks are small, particularly for young women; Gottfried and Sims stress effects beyond reproduction; Malik sits in the middle. They also differ on how long SHBG stays up, and on copper versus hormonal IUDs.
What to do: choose a method by how long you want to avoid pregnancy, don't rely on cycle tracking as contraception, check for a family history of clots, ask about another pill if one doesn't suit you, and plan ahead before trying to conceive, since Depo-Provera can hold off ovulation for up to 18 months. Age, not contraception, drives fertility decline. These choices involve your own history and health, so make them with a doctor who will explain both the benefits and the risks.