BIRTH CONTROL 101
- sweatandscalpels
- Feb 25, 2018
- 7 min read
Updated: Nov 14, 2018
This post has been a long time coming but there is sooo much information within this topic that I wanted to do it right! My goal here was to basically write out the information that I give my patients whenever they come in for contraceptive counseling. This can get confusing but I've hopefully broken it down in a way that makes sense to you all. Note: for this post, I left out emergency contraception and permanent sterilization options because those will be their own posts in the future.
Before, I go into the details of the different methods, let's talk about typical and perfect use. These are terms we use to describe the the well-known {and somewhat obvious} fact that many of the birth control options have an efficacy that is lower in patients we see than the reported efficacy. This is because the reported efficacy is for a patient who is using her birth control perfectly. So, "perfect use" means never missing a pill, never forgetting a condom, never being a day off in replacing a patch or vaginal ring. Well, obviously people aren't perfect and "typical use" takes into account that patients will miss a pill here or there. Obviously, the typical use statistics are not as high as the perfect use ones. I will be listing the typical use efficacy rates with the methods below because that is the most relevant information for a woman trying to decide on which method would work best for her life.
The sources I used are at the bottom of this post, but a more user-friendly resource that I give to my patients in the office is Bedsider. I cannot recommend their website enough! They have great infographics like this one that make all this information a little less overwhelming.
Alright, now that that's out of the way, let's jump right in!
I start my counseling by first breaking down the different categories of birth control options:
Combination hormonal methods contain both estrogen and progestin {synthetic progesterone}. Combination methods include pills, the skin patch, and the vaginal ring.
Progestin-only hormonal methods include pills {also called "the mini-pill"}, the Depo-Provera shot, the implant {Nexplanon} and the hormonal IUDs. If you can't take estrogen, a progestin-only method may be an option for you.
Non-hormonal methods include the barrier methods {condoms} and the copper IUD. Natural family planning also falls under this category but has the lowest efficacy rate of any of the methods so I won't really be going into it.
Now let's break it down even further in terms of each method's usage time frame, from shortest to longest.
Barrier Methods
Barrier methods include the diaphragm, cervical cap, male condom {which is the condom most people are referring to when they say that word}, the female condom, and spermicidal foam, sponge, gel, or film. These all work by blocking sperm from entering the uterus and reaching the egg.
PROs:
There are few side effects with these methods {unless you have a latex allergy in which case please use lambskin or other condoms}.
Condoms {male or female} are the only method of birth control that protect against getting or spreading STDs like herpes, chlamydia, gonorrhea, trichomonas and HIV. So regardless of whether you are using another type of birth control, it is important to use condoms in all sexual encounters, especially with new partners.
CONs:
Typically, barrier methods are not highly effective. Their efficacy ranges from 71-88%, with diaphragms being the most effective at 88%, condoms middling at 82% and spermicide the lowest at 71%. Despite these numbers, it's important to remember that spermicides and condoms can be used together or along with another method to increase their effectiveness.
Barrier methods also tend interrupt sex because they must be used every time you have sex so you have to remember to have them on hand and also remember to use them.
Pills
Combination pill and the Mini-Pill {aka progestin-only pills or POPs}
PROs:
The combination pills can help to reduce acne, pain during ovulation and premenstrual symptoms.
Both types of pill reduce heavy bleeding and cramping.
Some pills can also help to reduce the severe mood and physical symptoms that some women get before they start their monthly periods, known as premenstrual dysphoric disorder {PMDD}.
Unlike the combination pill, the progestin-only pill can be taken by almost all women, including those who are breastfeeding.
You can take the combination pills continuously if you want fewer or no periods at all. An added bonus is that birth control pills have been shown to reduce the risk of ovarian and uterine cancer in later years.
CONs:
Depending on when you start taking either type of birth control pill, you may need to use a backup birth control method for the first week.
The combination pills cannot be taken by women who have migraines with aura or smokers who are >35 yrs old.
Can cause side effects such as headache, mood swings and breast tenderness.
Both types of pills must be taken every day to remain efficacious.
The progestin-only pills must be taken at the same time every day or it risks losing its efficacy within 2 hours of a missed dose. With this in mind, the typical efficacy of both types of pills at preventing pregnancy is around 91%.
You must still use condoms for STD protection.
The Patch
PROs:
Patches are similar to the combination pills, but they don't require taking a daily pill. The patch is changed weekly, with one week off during which you have your period and 3 weeks with the patch on.
These can also be used continuously to reduce the number of periods you have.
Their typical efficacy is also 91%.
CONs:
The adhesive can sometimes cause irritation.
Can cause side effects such as mood swings and breast tenderness.
You must still use condoms for STD protection.
The Ring
PROs:
Vaginal rings are again, similar to combination pills however, the ring is changed monthly (with 1 week off after 3 weeks of use).
Typical efficacy is also 91%.
CONs:
You need to be comfortable placing this vaginally.
If placed incorrectly, it can sometimes cause discomfort and/or be felt by your partner during sex.
You must still use condoms for STD protection.
The Depo Shot
PROs:
The injection is given once every 3 months.
It is progestin only so it can be used by most women, even those who are breastfeeding.
Its typical efficacy is 94%.
CONs:
The most common side effects of the depo shot include increased appetite {NOT weight gain} and reversible bone mineral density {BMD} loss. The depo can lead to weight gain because it causes appetite stimulation but it does not cause weight gain in and of itself. I always make this distinction with my patients because it is completely preventable if you are mindful of what you are eating. In terms of the bone loss, the depo shot leads to a decrease in BMD in the same way that pregnancy and breastfeeding. This loss is almost fully reversible after discontinuation, though how long this recovery takes depends on the site of the BMD loss (i.e., recovery at the hip and femoral neck can take longer than at the spine or long bones). There is unfortunately not any high quality data on whether depo affects fracture risk later in life.
Though the shot is every 3 months, you generally need to come into the office for a nurse to give it to you which can be a hassle for some patients.
You must still use condoms for STD protection.
The Nexplanon
PROs:
The Nexplanon lasts for up to 3 years.
It is progestin only and therefore can be used in almost all women, including those who are breastfeeding.
It is discrete. The actual implant is about the size of a matchstick and is inserted under the skin on the inside of the upper arm.
It can lead to fewer or no periods at all.
Besides a tubal, this is the most effective hormonal option we offer. There is no "typical" use since once it's in place it's working and you don't have to worry about remembering anything. Its efficacy is >99%.
CONs:
It must be inserted and removed by a trained health professional, usually an OBGYN but sometimes a primary care physician.
Its most common side effect is unpredictable spotting or bleeding, especially in the first 6 months or so, though this sometimes persists throughout its use. Can also cause headaches, mood swings and breast tenderness.
You must still use condoms for STD protection.
The IntraUterine Devices (IUDs)
An intrauterine device is exactly as its name states - a device that is placed in the uterus to prevent pregnancy. There are two main types of IUDs: the copper IUD and the hormonal IUDs. When an IUD is in place, it can provide birth control for 3 to 10 years, depending on the type. Note: ALL of the IUDs are contraindicated in the case of an abnormally-shaped uterine cavity, active infection and suspicion of pregnancy or malignancy.
The only non-hormonal {copper} IUD is the Paragard
PROs:
This IUD is effective for up to 10 years.
It is non-hormonal for those who prefer to avoid hormones and can be used by almost all women.
Its efficacy is >99%.
It is a quick, in-office procedure that usually only takes 5-10 minutes.
CONs:
This IUD leads to heavier and sometimes longer periods.
It is therefore not recommended in women who already have heavy or long periods, abnormal bleeding or anemia.
Some patients cannot tolerate IUD placement in the office.
There is a 3-5% chance of expulsion {i.e., that your body will push the IUD out}.
You must still use condoms for STD protection.
The hormonal IUDs include the Skyla and Kyleena {marketed towards women who have never had children} and the Mirena and Liletta. The Skyla and Kyleena are slightly smaller in size than the other two and have lower doses of progestin.
PROs:
All of these methods last several years: Skyla lasts up to 3 years, Liletta lasts up to 4 years (though it should soon be approved for 7 years), and Kyleena and Mirena last up to 5 years.
These are the only non-systemic hormonal options that we have (i.e., they work locally in the uterus and do not tend to have effects throughout the body).
These IUDs typically reduce menstrual flow and cramping over time and can often lead to no periods at all.
It is a quick, in-office procedure that usually only takes 5-10 minutes.
All of them are >99% effective at preventing pregnancy.
CONs:
Spotting is a common side effect, especially in the first 6 months though it can persist throughout use. Other side effects can include mood swings and breast tenderness, though these side effects occur less frequently than with the other progestin-only methods.
Some patients cannot tolerate IUD placement in the office.
There is a 3-5% chance of expulsion {i.e., that your body will push the IUD out}
Phew, that was a ton of info but hopefully it was helpful and not too confusing. Let me know your thoughts or questions in the comments below! Like I said int he beginning, I left out permanent sterilization methods as well as emergency contraception because those can be a post of their own.
*Sources include the CDC, ACOG, NIH and the product websites for manufacturer's data.
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