Birth Control Options
There are many methods of birth control. Each method has good points, as well as side effects. Birth control allows a woman to plan her family, both the number and spacing of children.
At any given time, a couple may find one method of birth control suits their needs better than others. Most women and couples use many methods over a lifetime.
Birth control options for women include: oral pills, vaginal ring, skin patch, injections, intrauterine device (IUD), diaphragm, cervical cap, natural family planning, condoms, spermicide, and sterilization. Emergency contraception is available as back-up protection when your form of birth control fails.
With hormonal contraception a woman takes hormones estrogen and progesterone similar to those her body makes naturally. These hormones prevent ovulation. When there is no egg available for fertilization pregnancy cannot occur. A number of very effective and reversible hormonal contraception are currently available.
Combined Oral Contraceptives (COC’s)
COC’s, which contain both an estrogen and progestin, are the most popular method of reversible contraception in the US. Most women are unaware of the non-contraceptive benefits of birth control pills which include: protective effects against endometrial cancer, ovarian cancer, benign breast disease, ovarian cysts, ectopic pregnancy, pelvic inflammatory disease and anemia. In contrast, most women are aware of the pill’s positive effects such as effectiveness, safety, viable option throughout reproductive years, reversibility, menstrual benefits, decreased hirsutism, and acne improvement. Also available is a ‘progestin only’ birth control pill that lacks estrogen, and is commonly referred to as “the mini-pill”. This progestin only pill is primarily used for women who can’t use estrogen products or those who are breastfeeding.
Indications for COC use include: heavy, painful or irregular menstrual periods, recurrent ovarian cysts, premenstrual symptoms, cyclic headaches, or cyclic depression, family history of ovarian cancer, birth control reversibility, recent delivery and not breastfeeding, endometriosis, chronic anovulation, acne, hirsutism (increased body/facial hair growth) and need for emergency contraception.
Contraceptive Patch and Vaginal Ring
In addition to the pill form of estrogen/progestin there are now other routes of administration such as the patch and vaginal ring. The patch is applied weekly to the skin and the hormones are absorbed through the skin and into the blood stream. This is an alternative for those who forget to take a pill daily. The vaginal ring is inserted vaginally and remains in the vagina for three weeks until it is removed and a withdrawal bleed occurs. Since hormones can be absorbed from anywhere in the vagina, the ring does not have to be placed in a specific position like a diaphragm.
Disadvantages and cautions with estrogen/progestin use , although uncommon, may include: lack of protection against sexually transmitted diseases, expense, menstrual cycle changes, nausea, vomiting, headaches, exacerbation of some types of depression, decreased libido, risk of cardiovascular disease including blood clots, hypertension, atherogenesis, glucose intolerance, acceleration of gallbladder disease and benign liver tumors.
Currently, the only injectable contraceptive available in the US is depot medroxyprogesterone acetate, which is a progestin-only contraceptive and administered every 3 months. Depo Provera injections are 99% effective with perfect use. Indications include: those who cannot take estrogen, women who have difficulty remembering to use birth control, management of pain associated with endometriosis, and women who desire decreased or no menstrual flow. Advantages of all progestin only methods are scanty or no menses, less anemia, decreased pain with ovulation, decreased risk of ovarian and endometrial cancer, no drug interaction, no daily commitment to birth control, and high efficacy.
As with any medication there are disadvantages and side effects. Knowing the potential side effects can help you determine the most appropriate contraception for you. Precautions include lack of protection against sexually transmitted infections (STI’s), menstrual cycle disturbance, weight gain, breast tenderness, depression. Disadvantages of using Depo Provera injection: office visit every 12 weeks for injections, decrease in bone mineral density with long term use, lipid changes in HDL, allergic reaction, no immediate discontinuation (if you experience side effects it takes it may take several months for the body to clear the medication) and although Depo Provera injections don’t cause infertility, a return to fertility may occur for up to 18 months after stopping this form of contraception.
Intrauterine Device/System (IUD/IUS)
The IUD/IUS represents the most effective method of reversible contraceptive available in the United States. Currently, two intrauterine contraceptives are available: the Paragard (IUD), which can remain in place for up to ten years, and Mirena, the levonorgesterel-releasing intrauterine system (IUS), which can remain in place for 5 years. The Paragard IUD contains no hormones and works by increasing uterine and tubal fluids. The change in fluids alter the transport of the sperm and ovum so fertilization does not occur. The Mirena, levonorgesterel-releasing intrauterine system (IUD), works the same as the Paragard IUD and contains a progestin that is slowly released over 5 years.
The advantage of adding the progestin may result in lighter or no monthly cycles and decreased menstrual cramping. Insertion of the IUD is quick, simple and done in the office.Indications of use include: women who can’t use hormonal methods may use the Copper T IUD, the IUD and IUS don’t interfere with breastfeeding, the progesterone releasing IUS decreases menstrual flow and helps with heavy cycles and requires the least amount of patient participation.
Disadvantages can include: expulsion of IUD/IUS, irregular bleeding and/or spotting especially three months after initial insertion, pregnancy, pelvic inflammatory disease and perforation with insertion. Patients are carefully screened prior to insertion and are recommended for those who are in a mutually faithful relationship, have had children vaginally and no current risk factors for HIV or other sexually transmitted infections.
The diaphragm is considered a barrier method of contraception. A diaphragm is a dome shaped rubber cup that has a flexible rim. It is inserted into the vagina prior to intercourse and should fit snugly covering the cervix from the posterior fornix to the pubic bone. A spermicidal jelly is applied to the inside of the diaphragm before insertion and it may be necessary to use spermicide. Once in proper position, the diaphragm provides contraceptive protection for up to 6 hours. The diaphragm must be left in place for at least 6 hours after intercourse and wearing it longer than 24 hours is not recommended. A diaphragm requires fitting from a trained professional and a prescription.Advantages of use include: the diaphragm is that it is hormone free and as a result they lack the side effects seen with hormonal contraception. Disadvantages include: vaginal and urinary tract infections, no protection against sexually transmitted infections, allergy to latex or spermicides, decreased spontaneity, messiness with insertion and removal, and toxic shock syndrome.
Also a barrier method of contraception is the cervical cap. It is very similar to the diaphragm except it is smaller and covers only the cervix. The cap is a soft, deep rubber cup with a firm round rim. The cap fits snugly around the base of the cervix. A spermicide is applied into the cap prior to vaginal insertion. The cap provides continuous contraception for up to 48 hours no matter how many times intercourse occurs and there is no need to reapply spermicide. Advantages and disadvantages are the same as with use of the diaphragm.
Natural Family Planning
Fertility awareness-based methods of family planning depend on identifying days each menstrual cycle when intercourse is most likely to result in a pregnancy. Accurate identification of potentially fertile days is a skill that requires a woman to apply knowledge about fertility to herself. To avoid pregnancy, couples should abstain from having intercourse during ovulation. Ovulation can be determined by multiple factors such as: body basal temperature, color and consistency of cervical secretions, cervical opening, position, and texture. Actual fertile time lasts for about 6 days each cycle, however fluctuating hormone levels make fertility signs imprecise markers of beginning and ending of the fertile time. Because of this women must abstain several days longer than the actual fertile time.
Although condoms are primarily used by males as a physical barrier method of contraception, they have an important role in reducing the risk of sexually transmitted infections. Condoms come in a variety of sizes and shapes as well as with or without spermicide. An important distinction needs to be made between “rubber”condoms and “natural or lambskin” condoms. The traditional rubber condom is made from polyyrethane and are stronger and thinner than the latex version. This type of condom helps to reduce the transmission of HIV, herpes, hepatitis B, syphilis, chlamydia and gonorrhea. In contrast, the “natural” or lambskin condom has a natural membrane with small pores that may permit the passage of viruses and bacteria. This type of condom should only be used for contraception.
Spermicides come in different formulations which include gels, foams, creams, films and suppositories. The chemical in the spermicide kills the sperm by destroying the sperm cell membrane. Most spermicides contain the surfactant Nonoxynol-9, however there are other surfactant spermicidals on the market. Efficacy of spermicides depend on consistent and correct use. Spermicide needs to be placed into the vagina no longer than 1 hour prior to intercourse. In addition, a woman may not douche for at least 6 hours and must avoid washing away the spermicide prematurely. These products don’t protect against sexually transmitted infections.
Nexplanon is a hormone-releasing birth control implant for use by women to prevent pregnancy for up to 3 years. The implant is a flexible plastic rod about the size of a matchstick that contains a progestin hormone called estonogestrel. It also contains a small amount of barium sulfate so that the implant can be seen by X-ray. Your healthcare provider will insert the implant just under the skin of the inner side of your upper arm. You can use a single Nexplanon implant for up to 3 years. However, if desired, your healthcare provider can remove the implant at any time. You may become pregnant as early as the first week after removal of the implant. Nexplanon prevents pregnancy in several ways. The most important way is by stopping the release of an egg from your ovary. Nexplanon also thickens the mucus in your cervix and this change may keep sperm from reaching the egg. Nexplanon also changes the lining of your uterus. Nexplanon does not contain estrogen.
Also known as a tubal or tubal ligation is a permanent form of contraception that requires a surgical procedure. Advantages include: high efficacy, permanence, cost effectiveness, nothing to remember or buy, no significant long term side effects, and privacy of choice. Disadvantages may include: lack of protection against sexually transmitted infections, expense at time of procedure, infection, pregnancy, permanence of method, difficult reversibility and surgical error.