Choosing a Contraceptive
Choosing a method of birth control is a highly personal decision, based on individual preferences, medical history, lifestyle, and other factors. Each method carries with it a number of risks and benefits of which the user should be aware.
Each method of birth control has a failure rate–an inability to prevent pregnancy over a 1-year period. Sometimes the failure rate is due to the method and sometimes it is due to human error, such as incorrect use or not using it at all. Each method has possible side effects, some minor and some serious. Some methods require lifestyle modifications, such as remembering to use the method with each and every sexual intercourse. Some cannot be used by individuals with certain medical problems.
Spermicides Used Alone
Spermicides, which come in many forms–foams, jellies, gels, and suppositories–work by forming a physical and chemical barrier to sperm. They should be inserted into the vagina within an hour before intercourse. If intercourse is repeated, more spermicide should be inserted. The active ingredient in most spermicides is the chemical nonoxynol-9. The failure rate for spermicides in preventing pregnancy when used alone is from 20% to 30%.
Spermicides are available without a prescription. People who experience burning or irritation with these products should not use them.
There are five barrier methods of contraception:
- male condoms
- female condoms
- cervical cap
In each instance, the method works by keeping the sperm and egg apart. Usually, these methods have only minor side effects. The main possible side effect is an allergic reaction either to the material of the barrier or the spermicides that should be used with them. Using the methods correctly for each and every sexual intercourse gives the best protection.
For many people, the prevention of sexually transmitted diseases (STDs), including HIV (human immunodeficiency virus), which leads to AIDS, is a factor in choosing a contraceptive. Only one form of birth control currently available–the latex condom, worn by the man–is considered highly effective in helping protect against HIV and other STDs. The FDA has approved the marketing of male condoms made from polyurethane as also effective in preventing STDs, including HIV. Reality Female Condom, made from polyurethane, may give limited protection against STDs but has not been proven as effective as male latex condoms. People who use another form of birth control but who also want a highly effective way to reduce their STD risks, should also use a latex condom for every sex act, from start to finish. The female condom, diaphragm, sponge, and cervical cap are seldomly used in the United States anymore.
A male condom is a sheath that covers the penis during sex. Condoms on the market at press time were made of either latex rubber or natural skin (also called “lambskin” but actually made from sheep intestines). Of these two types, only latex condoms have been shown to be highly effective in helping to prevent STDs. Latex provides a good barrier to even small viruses such as human immunodeficiency virus and hepatitis B. Each condom can only be used once. Condoms have a birth control failure rate of about 15%. Most of the failures can be traced to improper use.
Some condoms have spermicide added. This may give some additional contraceptive protection. Vaginal spermicides may also be added before sexual intercourse.
Some condoms have lubricants added. These do not improve birth control or STD protection. Non-oil-based lubricants can also be used with condoms. However, oil-based lubricants such as petroleum jelly (Vaseline) should not be used because they weaken the latex. Condoms are available without a prescription.
Birth Control Pills
There are two types of birth control pills: combination pills, which contain both estrogen and a progestin (a natural or synthetic progesterone), and “mini-pills,” which contain only progestin. The combination pill prevents ovulation, while the mini-pill reduces cervical mucus and causes it to thicken. This prevents the sperm from reaching the egg. Also, progestins keep the endometrium (uterine lining) from thickening. This prevents the fertilized egg from implanting in the uterus. The failure rate for the mini-pill is 1% to 3%; for the combination pill it is 1% to 2%.
Combination oral contraceptives offer significant protection against ovarian cancer, endometrial cancer, iron-deficiency anemia, pelvic inflammatory disease (PID), and fibrocystic breast disease. Women who take combination pills have a lower risk of functional ovarian cysts.
The decision about whether to take an oral contraceptive should be made only after consultation with a health professional. Smokers and women with certain medical conditions should not take the pill. These conditions include: a history of blood clots in the legs, eyes, or deep veins of the legs; heart attacks, strokes, or angina; cancer of the breast, vagina, cervix, or uterus; any undiagnosed, abnormal vaginal bleeding; liver tumors; or jaundice due to pregnancy or use of birth control pills.
Women with the following conditions should discuss with a health professional whether the benefits of the pill outweigh its risks for them:
- High blood pressure
- Heart, kidney, or gallbladder disease
- A family history of heart attack or stroke
- Severe headaches or depression
- Elevated cholesterol or triglycerides
Serious side effects of the pill include blood clots that can lead to stroke, heart attack, pulmonary embolism, or death. A clot may, on rare occasions, occur in the blood vessel of the eye, causing impaired vision or even blindness. The pills may also cause high blood pressure that returns to normal after oral contraceptives are stopped. Minor side effects, which usually subside after a few months’ use, include: nausea, headaches, breast swelling, fluid retention, weight gain, irregular bleeding, and depression. Sometimes taking a pill with a lower dose of hormones can reduce these effects.
The effectiveness of birth control pills may be reduced by a few other medications, including some antibiotics, barbiturates, and antifungal medications. On the other hand, birth control pills may prolong the effects of theophylline and caffeine. They also may prolong the effects of benzodiazepines such as Librium (chlordiazepoxide), Valium (diazepam), and Xanax (alprazolam). Because of the variety of these drug interactions, women should always tell their health professionals when they are taking birth control pills.
Methods of hormonal contraception, when used properly, are extremely effective.
Depo-Provera is an injectable form of a progestin. It was approved by the FDA in 1992 for contraceptive use. Previously, it was approved for treating endometrial and renal cancers. Depo-Provera has a failure rate of only 1%. Each injection provides contraceptive protection for 14 weeks. It is injected every 3 months into a muscle in the buttocks or arm by a trained professional. The side effects are the same as those for Nexplanon (subdermal implant)and progestin-only pills. In addition, there may be irregular bleeding and spotting during the first months followed by periods of amenorrhea (no menstrual period). About 50% of the women who use Depo-Provera for 1 year or longer report amenorrhea. Other side effects, such as weight gain and others described for Nexplanon, may occur.
Nexplanon is a hormone-releasing birth control implant that is placed under the skin for women who prefer a long-acting option. It is a soft and flexible implant that is inserted in a discreet location in the inner, upper arm. It provides contraception for up to 3 years. Women may experience longer or shorter bleeding during their periods, or have no bleeding at all. It is estimated to have a failure rate slightly less than 1%.
IUDs are small, plastic, flexible devices that are inserted into the uterus through the cervix by a trained clinician. They are T-shaped devices designed to fit inside the uterus. Only five IUDs are presently marketed in the United States: ParaGard T380A, a device partially covered by copper and effective for 10 years; Mirena, which contains a progestin released over a 5-year period; Kyleena, which contains a progestin also released over a 5-year period; Liletta, which contains a progestin released over a 4-year period; and Skyla, which is also a progestin containing device providing protection over a 3-year period. After that time, the IUD should be replaced. IUDs have slightly less than a 1% failure rate.
It is not known exactly how IUDs work. At one time it was thought that the IUD affected the uterus so that it would be inhospitable to implantation. New evidence, however, suggests that uterine and tubal fluids are altered, particularly in the case of copper-bearing IUDs, inhibiting the transport of sperm through the cervical mucus and uterus.
The risk of PID with IUD use is highest in those with multiple sex partners or with a history of previous PID. Therefore, the IUD is recommended primarily for women in mutually monogamous relationships.
In addition to PID, other complications include perforation of the uterus (usually at the time of insertion), septic abortion, or ectopic (tubal) pregnancy. Women may also experience some short-term side effects–cramping and dizziness at the time of insertion; bleeding, cramps and backache that may continue for a few days after the insertion; spotting between periods; and longer and heavier menstruation during the first few periods after insertion.
Periodic abstinence entails not having sexual intercourse during the woman’s fertile period. Sometimes this method is called natural family planning (NFP) or “rhythm.” Using periodic abstinence is dependent on the ability to identify the approximately 10 days in each menstrual cycle that a woman is fertile. Methods to help determine this include:
- The basal body temperature method is based on the knowledge that just before ovulation a woman’s basal body temperature drops several tenths of a degree and after ovulation it returns to normal. The method requires that the woman take her temperature each morning before she gets out of bed. There are now electronic thermometers with memories and electrical resistance meters that can more accurately pinpoint a woman’s fertile period.
- The cervical mucus method, also called the Billings method, depends on a woman recognizing the changes in cervical mucus that indicate ovulation is occurring or has occurred.
Periodic abstinence has a failure rate of 14% to 47%. It has none of the side effects of artificial methods of contraception.
Surgical sterilization must be considered permanent. Tubal ligation seals a woman’s fallopian tubes so that an egg cannot travel to the uterus. Vasectomy involves closing off a man’s vas deferens so that sperm will not be carried to the penis.
Vasectomy has traditionally been considered safer than female sterilization. However, this is not necessarily true anymore, as we have gained more experience with the Essure hysteroscopical sterilization for women. The vasectomy is a minor surgical procedure, most often performed in a doctor’s office under local anesthesia. The procedure usually takes less than 30 minutes. Minor post-surgical complications may occur.
Tubal ligation is an outpatient operating-room procedure performed under general anesthesia usually. The fallopian tubes can be reached by a number of surgical techniques. There are two main approaches for this surgery. The first one, a laparoscopy, involves making a small incision above the navel, and distending the abdominal cavity so that the intestine separates from the uterus and fallopian tubes. Then a laparoscope — a miniaturized telescope — is used to visualize the fallopian tubes while closing them off. However, based on new scientific evidence, the best approach for sterilization at this moment is removing completely both fallopian tubes (bilateral salpingectomy). This has proven to decrease the incidence of developing ovarian cancer, in addition to having a low failure rate.
The second one, a hysteroscopy, involves the insetion of a hysteroscope — a miniaturized telescope — through the vagina in order to insert a metal device inside both fallopian tubes. This last one is the famous Essure. It was becoming the standard of care for female sterilization. It has a small percentage of surgical complications, and it was considered the best choice for today’s active women. Patients having an Essure procedure can return to work the next day after the surgery, and most times they do not require narcotics for postoperative pain (most only use 1 or 2 Motrin pills the day of the procedure). And, since the surgery is performed through the vagina, there are no scars. However, there have been some reports of women referring problems with pelvic pain and/or abnormal uterine bleeding after having this procedure done. The FDA has looked into this and required the manufacturer of the Essure to start a study to look if these reported symptoms are caused by the Essure or not. This study started in 2016 and should be completed by 2023. On July 20, 2018, Bayer decided to remove Essure from the market by the end of this year.
Both of these methods have replaced the traditional laparotomy.
Major complications, which are rare in female sterilization, include: infection, hemorrhage, and problems associated with the use of general anesthesia. It is estimated that major complications occur in 1.7 percent of the cases, while the overall complication rate has been reported to be between 0.1% and 15.3%.
The failure rate of laparoscopy and hysteroscopy procedures, as well as vasectomy, is less than 1%. Although there has been some success in reopening the fallopian tubes or the vas deferens, the success rate is low, and sterilization should be considered irreversible.