The Institute for Women's Health

Despite decades of availability of safe and effective birth control the unintended pregnancy rate in the United States is still 49%. There are approximately 6.6 million babies born in the U.S. each year, and half of those pregnancies were unintended. That is a staggering number, with lifelong and life changing effects for the families who have those children. Babies are wonderful, amazing, precious gifts but as any parent knows they come with tremendous stress and effects on peoples’ lives, health and finances. Births resulting from unintended pregnancies are associated with increased risks for adverse outcomes for the mother and the baby. The Unites States Department of Health and Human Services Healthy People 2020 campaign aims to decrease that rate from 49% to 44%. Wouldn’t it be amazing if that number could be decreased even further? I know that not every unintended pregnancy can be prevented, but I would love to help by providing some information about the different contraceptive options that are available to women.

I like to frame my counseling to my patients about their birth control options by grouping the different methods into a few different categories, starting from least invasive and not requiring a prescription, to those that can only be obtained from your doctor, and then ending with those that are somewhat invasive. It also works that this grouping system progresses from the methods that are slightly less effective at preventing pregnancy (i.e. – more likely to result in an unplanned pregnancy) to those that are super-effective at preventing pregnancy, upwards of 99% effective.

The methods that are available to everyone, over-the-counter include: natural family planning (or fertility-awareness programs), condoms, spermicides, sponges, and the withdrawal method. These methods are considered “less effective” and typically result in about 18 pregnancies per 100 women annually who use these methods. A couple of important caveats before deciding to rely upon these methods: natural family planning really ONLY works for women who have very regular cycles. If a woman has a menses predictably every 28-32 days or so, then this method can work very well. If a woman has very unpredictable periods (say skips a month occasionally, or the menses occur more than 6 weeks apart or closer than every 3 weeks, then it’s almost impossible to reliably predict when ovulation occurs, and I wouldn’t recommend NFP for those patients). Many women don’t know it, but for those who are NOT on birth control, ovulation happens 2 weeks before the period begins and that is their ‘fertile window’. NFP involves timing your menstrual cycles, and avoiding intercourse on days when a woman is fertile. Couples can be educated to check for ovulation by checking for changes in the types of vaginal discharge that a woman has at the time of ovulation, and by closely monitoring her basal body temperature as well.

Barrier methods are those that put up a ‘wall’ to prevent sperm from getting into the upper reproductive tract, where fertilization occurs. These include condoms, diaphragms, and female sponges.

Condoms can be very effective and I am very supportive of my patients who choose to use condoms because they have the added benefit of providing some protection against some STDs. The effectiveness of condoms in preventing pregnancy in women who use them with EVERY act of vaginal intercourse is in the range of 90-95% protection. That’s called “perfect use”, but women who only use them occasionally, or even “most of the time” will have a higher rate of unintended pregnancy. With typical use (‘sometimes’ or ‘most of the time’), condoms are about 80% effective at preventing pregnancy. This applies for both male and female condoms.

The female sponge provides a degree of ‘barrier’ protection, but typically also has a spermicide component that kills many/most of the sperm that are released. Sponges are better at preventing pregnancy in women who haven’t had a baby vaginally, due to changes in the shape and size of the cervix (which they are intended to cover/block) that occur after a woman has given birth vaginally. For women who haven’t delivered naturally, sponges are 85-90% effective at preventing pregnancy, and for women who have had vaginal deliveries, they are only 75-80% effective.

Diaphragms are not used very much anymore, but are still available. A patient has to be fitted for a diaphragm by her gynecologist, and instructed on how to use it, and it is intended to be used with spermicidal agent as well. These are up to 90% effective at preventing pregnancy.

From here, we move into the categories that require some regular effort, outside of at the time of intercourse.

Birth control pills, contraceptive patches and the vaginal contraceptive ring are also popular methods of contraception, chosen by about 20% of those women who use contraception. These methods can be very effective at preventing pregnancy when used correctly, which means for a birth control pill, taken every day at approximately the same time. In women who use the pill, the patch or the vaginal contraceptive ring, there occur between 6 and 12 pregnancies per 100 women users per year. In other words they are about 90% effective for most patients. These methods have some other benefits to users, termed non-contraceptive benefits, that can include: making a woman’s period very regular and predictable, lighter, shorter and less painful. For women who desire to have fewer periods, these methods can also be used to control one’s periods so that a woman can choose to have fewer periods or no periods if desired. The contraceptive patch works in the same way as the pill, but it gets applied to the skin on a woman’s hip, and it only needs to be changed once a week. The vaginal ring gets put in place, then left in for 3 weeks, then removed, and one week later a new ring gets placed. Some women experience some side effects from these methods including: headaches, bloating, irregular bleeding, mood changes, nausea, weight changes, but most of these symptoms will go away after a month or so of using the new method. If they don’t – then it may not be the best method for them and other methods can be tried.

There are a few medical reasons why it would be unsafe for a woman to use these methods. It’s important for women to know that if they have a personal or family history of developing blood clots in the deep veins of the legs, or in the lungs, called deep venous thrombosis or pulmonary embolism , that it is dangerous for them to use oral estrogens and even the patch or the nuvaring can significantly increase their risk for these dangerous, potentially fatal complications. Women over the age of 35 who smoke should not use estrogen containing birth control pills because it significantly raises the risk of developing blood clots. Estrogens increase the risk for strokes and blood clots, and birth control pills increase those risks. For most women who are healthy, young and do not smoke, birth control pills, patches and rings don’t significantly increase the risks for those conditions and are safe to use. Also, if women have classical migraines, where they see flashing lights in their visual fields, or if they experience temporary blindness with their migraines, then estrogen-containing birth control pills increase their risk of having a stroke. Other methods are safer and better for those women. Women with active liver disease shouldn’t take estrogen-containing birth control pills either. Some seizure medications can interact with the birth control pills to decrease their effectiveness and the pills can decrease the effectiveness of their seizure medications as well, so women taking seizure medications need to inform their doctor of all of their medication uses.

The next group of birth control methods is referred to as LARC’s (this is an acronym, and stands for long-acting reversible contraception). These have the benefits of excellent effectiveness and convenience on their side over the other methods.

The contraceptive implant is an extremely effective method of birth control.  It’s super-effective, preventing pregnancy almost 100% of the time in appropriately selected women.  It is extremely convenient, very safe and very easily placed in the doctor’s office in a very brief procedure that takes only five minutes or less.  It does not contain estrogen so it may avoid some of the estrogen-related risks and side effects of birth control pills that contain estrogen.  It lasts for up to 3 years, and it does not have a negative impact on the future fertility of it’s users.  It’s side effects can include irregular bleeding in about 10% of users, headaches, mood changes,  weight changes, and it can stop periods completely in about 20% of women who use it. It is very important to know, that it has not been proven effective in women who are obese,  who have a BMI greater than 35.

The contraceptive injectable shot is another very effective method, that does not contain estrogen. It is more than 99% effective if received on time, and only requires a visit to the doctor’s office every 3 months to receive the injection. It is a very strong dose of progestin hormone that suppresses a woman’s body from ovulating. It’s side effects include: the risk of irregular bleeding, (but most women stop having their periods entirely if they use depo provera), mood changes, weight gain, and it does have a risk of causing bone loss (osteopenia) in patients who use it for more than 2 years. It is recommended that women who have used the contraceptive injections for more than 2 years to get their bone density checked before continuing on it.

Intrauterine devices are the next category of long-acting, reversible contraception. There are 3 IUDs available on the U.S. market. These are extremely effective, providing an efficacy of > 99% at preventing pregnancy. The best known IUDs are the Paragard and the Mirena. The Paragard offers excellent prevention of pregnancy without any hormonal side effects, and that is a strong advantage of this method for those women who want birth control without the hormone-related side effects. It lasts for up to 10 years. The Mirena IUD has progestin hormone in it, and lasts for up to 5 years, with greater than 99% efficacy at preventing pregnancy. The beneficial effect of the progestin component is that it causes a woman’s periods to be lighter, and often results in cessation of the menstrual cycles in women who use it. It is also approved as a treatment for heavy menstrual bleeding, so could treat both conditions in someone who experienced heavy bleeding and needed reliable birth control. IUD’s require a visit and procedure in you doctor’s office for placement. The procedure involves very strong cramping, and lasts for only a few minutes. IUD’s have a small risk of causing a few dangerous complications, including the risk of accidentally poking a hole in the wall of the uterus at the time of placement, causing persistent pain, or irregular bleeding, infections developing after placement, or after exposure to sexually transmitted infections. Very rarely, those infections could spread to cause serious infections (pelvic inflammatory disease or abscesses in the fallopian tubes) that could require hospitalization, surgery or result in sterility. Another rare complication that can occur is expulsion (or pushing out of the IUD), or migration, which is a situation where the IUD moves from it’s intended place inside of the uterus to become located in the abdomen, which could require a surgery for removal. While these complications are very rare they must be considered before deciding to have an IUD placed. IUDs are considered safe and effective for women who have not had a pregnancy, including adolescent women, though they need to be thoroughly counseled about all of these risks and about their options for birth control. The newest IUD available in the U.S is called Sklya and it is similar to the Mirena, except that it lasts for 3 years instead of 5, and it slightly smaller, and was designed or intended for use in patients who have not had a child.

The last method of birth control to mention is sterilization. I will only discuss female sterilization, but do want to mention that vasectomy for men is widely available. Vasectomy is safer, less invasive, slightly more effective than female sterilization, and in my own humble opinion, the logical choice since the women have already gone through the pain and suffering of conceiving, carrying and delivering the child. But for those women who seek permanent sterilization, it is a safe, minimally invasive procedure. Obviously intended only for those women who are 100% certain that they do not desire to conceive ever in the future. It can be done in 2 different ways, one that can be done in your doctor’s office under lighter anesthesia, that does not involve any incisions on the abdomen and carries virtually no down time for recovery, and the older fashioned method, done in a hospital, under general anesthesia, involving creation of 1 or 2 small incisions, and various methods of either cutting, burning, and or clipping the tubes to block them. It should be noted that while sterilization is intended as permanent, irreversible birth control, that it is 99% effective, and that in rare cases pregnancies can occur after sterilization, and these pregnancies carry a high chance of being ectopic pregnancies (which develop in the fallopian tube are very dangerous conditions requiring immediate medical or surgical treatment).

Dr. Wendy Askew
The Institute for Women’s Health

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