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6.1: Contraception

  • Page ID
    46039
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    Purpose and Effectiveness of Contraceptives

    Using Contraceptives has two main purposes:

    1. Reduce the chance of unwanted pregnancies
    2. Reduce the transmission of Sexually Transmitted Diseases

    Some birth control methods may be more effective for reducing unwanted pregnancies, whereas other methods may be more effective for reducing the transmission of STD’s. There are many different types of contraceptives, it is important to know and understand the effectiveness from both perspectives in order to make the best decision.

    In terms of reducing unwanted pregnancies, the effectiveness is also impacted by the way in which the contraceptive method is used. If a person uses the method perfectly, Perfect Use Effectiveness, it will have a higher effectiveness than those who are considered typical users, Typical Use Effectiveness.

    The contraceptive effectiveness rate, or failure rate, is calculated based on typical use as the percentage of typical couples who use the method for one full year and experience an unintended pregnancy.

    There are two main categories for birth control methods, reversible methods and permanent methods. Reversible methods may use hormones, a barrier, or fertility awareness to reduce the chance of pregnancy.

    Reversible Methods for Birth Control

    Reversible methods for birth control refer to birth control methods where users can stop using the method and become pregnant. There are three main types of reversible contraceptives, hormonal methods, barrier methods, and Fertility-Awareness Methods.

    Hormonal Methods

    When a woman is pregnant they no longer release an egg each month and if there is no egg released, they cannot become pregnant. Hormonal methods reduce the chance of pregnancy by providing hormones to the woman that tricks the woman’s body into thinking they are pregnant, thus the egg is not released each month. There are several different hormonal methods that each provide the hormones to the woman in a different way.

    Note

    HORMONAL METHODS DO NOT PROTECT AGAINST SEXUALLY TRANSMITTED DISEASES BUT ARE EFFECTIVE FOR BIRTH CONTROL.

    Barrier Methods

    In order for pregnancy to occur the egg from a woman and the sperm from a man must meet. If the sperm fertilizes the egg then conception, or pregnancy, occurs. Barrier methods of birth control work by creating a barrier in which the egg and sperm cannot meet.

    Permanent Methods of Birth Control

    Permanent methods of birth control are also referred to as sterilization. These methods are for those who are sure that they do not want to conceive a child. Women choosing a permanent method can have their fallopian tubes tied or closed off, called a tubal ligation, or they can choose to have a small tube inserted into the fallopian tubes, called transcervical sterilization, which irritates the fallopian tubes causing scar tissue to form and close off the tubes. Men commonly get a vasectomy which is an outpatient procedure in which the tube that carries sperm it cut.

    Tubal ligation, or getting your “tubes tied,” is a highly effective procedure that will permanently protect against pregnancy, but it’s not reversible, so women need to be certain about never wanting to become pregnant.

    The minimally invasive procedure can be done during a C-section or right after a vaginal birth as well as at any other point. Another option is a salpingectomy, a procedure that involves removing one or both fallopian tubes.

    Vasectomies are quick, highly effective surgeries in which doctors cut and seal sperm-carrying tubes in the scrotum.

    The procedure typically takes 20 minutes and can be performed in an office setting or under conscious sedation, said Dr. Puneet Masson, the director of Male Reproductive Medicine and Surgery and an assistant professor of clinical urology in surgery at Penn Medicine.

    While vasectomies can be reversed, patients should consider the procedure to be permanent contraception, Dr. Masson said.

    “If you’re looking for a reversible form of contraception, I would move away from both vasectomy and female sterilization,” Dr. Cron of Weill Cornell Medicine/New York-Presbyterian said. “It’s really not meant for somebody that has any doubts about future fertility.”

    Highly Effective Reversible Birth Control Methods

    • Abstinence

      • Description: The only 100% effective means of unintended pregnancy and STD transmission is abstinence from oral, anal, or vaginal intercourse
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 0%
    • IntraUterine Device (IUD), Copper IUD (ParaGard), Levonorgestrel-Releasing IUD (Mirena)

      • Description: As the name suggests, this is a device that goes inside (intra) the woman’s uterus.

        Women’s health experts consider intrauterine devices, or IUDs, to be among the most effective forms of birth control, in part because people using them don’t need to remember to take or apply them, like a pill or a patch. A doctor inserts one of the T-shaped devices into the uterus, a procedure that typically lasts five minutes. Depending on the type, the IUD can remain effective for three to 12 years. 

        There are two types of IUDs currently available:

        Hormonal, which secretes progestin. “Very little” of the hormone is absorbed into the bloodstream, compared with oral contraceptive pills, Dr. Rosen said, so patients tend to experience fewer mood-related side effects. People who receive hormonal IUDs can have abnormal bleeding or spotting during the first three to six months after insertion. Then the bleeding typically becomes lighter and more regular, or goes away completely.

        Copper, which doesn’t contain hormones. However, people with heavy or painful periods may want to avoid copper IUDs, Dr. Rosen said, because they can cause longer periods and heavier flows for some.

        The Copper IUD can stay in the uterus up to 10 years and the hormonal IUD, the levonorgetrel-releasing IUD, can remain in the uterus for 5 years.
      • Type: Reversible, some are hormonal methods
      • Use: The IUD is inserted into the Uterus by a physician during a routine office visit through a non-surgical procedure.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: less than 1%
    • The Implant, Implanon, Nexplanon

      • Description: The hormonal implant is a small match sized stick that is inserted into the woman’s upper arm and releases hormones (progestin only) for 3 years. 

        Nexplanon is a type of implant that is inserted under the skin of the upper arm and lasts for around three years. It also has the lowest failure rate of all birth control methods, according to Dr. Nippita.

        A doctor or nurse inserts the small rod, which is about the length of a matchstick, and the process takes only a few minutes. No pelvic exam is required.

        Side effects can vary from person to person. About a third of patients will experience “daily, abnormal, bothersome” spotting, said Dr. Rosen; another third will not experience bleeding at all; and the other third will simply have lighter, infrequent spotting. Some people with the implant also report mood swings, headaches, weight gain and acne.

      • Type: Reversible, hormonal method 
      • Use: The implant is a minor surgical procedure. Woman choosing the implant must make an appointment with their doctor for the procedure. The stick is inserted into the inside upper arm just under the skin.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 0.05%

    Moderately Effective Reversible Birth Control Methods

    • The Pill, combination pill, mini-pill

      • Description: The pill is an oral contraceptive. The combination pill includes both estrogen and progestin, however the mini-pill contains only progestin. The Progestin only mini-pill may be a good option for woman who cannot take estrogen. Pill packs contain 28 pills. For three weeks, 21 days, the pills contain hormones and the fourth week the pills are placebo pills without hormones. The week with no hormones is when the menstrual cycle occurs.
      • Type: Reversible, hormonal method
      • Use: Women who choose to use the pill swallow a single pill every day. It is very important that the pill is taken at the same time each day. The effectiveness of the pill is lowered if it is not used correctly. If the pill is ingested at different times each day or if the woman forgets to take a pill and takes two the next day it will not be as effective at reducing the chance for pregnancy. Some people report mood changes related to the pill and other forms of hormonal birth control. One review of studies found that users of hormonal contraceptives were more likely than nonusers to have higher rates of depression, anxiety, fatigue and anger.
    • The Progestin-Only Pill
      • Sometimes called the “mini pill,” this form of birth control contains only progestin, a synthetic form of the progesterone hormone. The biggest advantage of the progestin-only pill is that is doesn’t contain estrogen, making it more accessible to people who are at risk of developing medical complications from the hormone, said Dr. Aparna Sridhar, an associate clinical professor in obstetrics and gynecology at UCLA Health.
      • “For those who actually cannot tolerate estrogen for any reason, the progestin-only pill is a great option,” Dr. Sridhar said.
      • The progestin-only pill is about as effective as the combination pill if it’s used correctly, she said.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 9%
    • The Shot, Injectable contraceptives, Depo-Provera

      • Description: Depo-Provera is an injection that contains progestin and protects against pregnancy for three months. A health care provider typically administers it, in an arm or the buttocks, every 12 to 14 weeks.Some people may experience spotting or other period irregularities after the first few shots, but they usually go away over time. Weight gain can also be a side effect for some people. Depo-Provera can also cause depression, migraines, seizures and liver problems in some patients.
      • Type: Reversible, hormonal method
      • Use: Woman who choose an injectable contraceptive get a shot either once every three months.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 6%
      • One of the newest forms of birth control to hit the market, Phexxi, is a hormone-free option that requires a prescription. It was about 93 percent effective when used correctly in clinical trials reviewed by the Food and Drug Administration, and 86 percent effective in practice.
      • But it’s a gel that the user inserts in the vagina before intercourse, not a long-acting form of contraception, and some reported side effects include vaginal burning and itching. Also, because Phexxi is so new, some insurance companies may not cover it.

    • The Patch, dermal (placed on the skin for absorption), Ortho Evra

      • Description: The skin patch provides hormones to women by means of absorption through the skin. The patch uses a combination of hormones similar to those found in the ring and many oral contraceptives — estrogen and progestin — but instead of taking a daily pill, the user places a patch on their skin once a week.

        Patches come in packs of three; the user puts on a new patch each week for three weeks, then has a patch-free week during which a period typically occurs. Patches can be worn when showering or swimming.

        “It’s great for people who can’t remember or don’t want to take a pill every single day,” said Dr. Julia Cron, vice chair of the department of obstetrics and gynecology at Weill Cornell Medicine/New York-Presbyterian. “It also gives you some of the other advantages that the pill gives, like cycle control, less bleeding, less pain.”

        Side effects include irregular bleeding, headaches, breast tenderness and, for some, nausea and mood changes, Dr. Cron said.

      • Type: Reversible, hormonal method
      • Use: Woman using the patch place it on their body typically on the buttocks, stomach, or upper body. The patch is replaced every week for three weeks and the fourth week no patch is used.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 9%
    • The Ring, Hormonal Vaginal Contraceptive Ring, NuvaRing

      • Description: The vaginal ring is a soft silicon ring closely resembling a bracelet in size. The Ring contains hormones that are absorbed into the woman’s body for 3 weeks. There are two vaginal rings available: the NuvaRing, which lasts for about a month, and the Annovera ring, which lasts for about a year. For both rings, the user inserts the ring, leaves it in for about three weeks and then removes for a week; someone using the NuvaRing would insert a new ring each month, while someone using the Annovera ring will reuse the same ring. They use similar hormones as the pill and the patch, but because they can be worn for longer periods of time, some find them less bothersome than the pill, which has to be taken every day, and the patch, which has to be applied nearly every week.

        Because the ring contains estrogen, it can have similar side effects to the pill or patch, said Dr. Siripanth Nippita, a clinical assistant professor of obstetrics and gynecology at NYU Langone Health. These can include mood changes, nausea, breast tenderness and headaches.

      • Type: Reversible, hormonal method
      • Use: The ring is inserted into the vagina, similarly to the way a tampon is inserted, and stays in place for 3 weeks while slowly releasing hormones. The ring is removed for the fourth week and menstrual flow begins.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 9%
    • Diaphragm or cervical cap

      • Description: The diaphragm and Cervical Cap both have the same purpose, to cover the entrance to the uterus by providing a barrier to prevent sperm from entering the woman’s body. Both are shaped like a small cup and used along with spermicide. A consultation with a doctor is important to ensure the proper size is used. If a woman gains or loses significant weight or gives birth the woman will need to see a doctor again to ensure the correct size is used.
      • Type: Reversible, barrier method
      • Use: The woman inserts the diaphragm or cervical cap along with spermicide.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 12%

    Least Effective Reversible Birth Control Methods

    Condoms are the most popular option for over-the-counter birth control, and don’t require a prescription or doctor’s visit. They can help prevent pregnancy and sexually transmitted infections, but not everyone knows how to use them correctly, said Dr. Melissa Simon, vice chair for research at the department of obstetrics and gynecology at the Northwestern University Feinberg School of Medicine. And condoms fail about 13 percent of the time, according to the Centers for Disease Control and Prevention.

    Spermicide, a sperm-killing chemical that comes in gels, foams and the like, is also sold over-the-counter but is not considered effective as other options at preventing pregnancy by itself, said Dr. Monica Woll Rosen, an OB-GYN at University of Michigan Medical School.

    • Male Condom

      • Description: The male condom is a thin sheath that covers the penis, thus creating a barrier that should not allow the sperm to enter the woman’s body. Male condoms are usually made from latex, however there alternative materials such as “natural” or “lambskin”. Research shows latex are more effective for reducing STD’s and pregnancies.
      • Type: Reversible, barrier method
      • Use: It is very important to use male condoms correctly! Correct use means purchasing the appropriate size, checking to make sure they are stored correctly and used before the expiration date, putting the condom on before any penetration, opening the condom carefully and ensuring to pinch the tip of the condom prior to carefully rolling the condom onto the erect penis, not using oil based lubricants, not reusing a condom, and not using more than one condom at a time.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 18%
      • STD Protection: When used correctly, the male condom can be an effective method to reduce the transmission of STD’s. Studies have been conducted comparing HIV infection rates between condom users and non-condom user and have shown high effectiveness in reducing the transmission of HIV.

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    • Female Condom

      • Description: The female condom is a thin pouch that is inserted into the vagina in order to create a barrier to stop the sperm from entering the woman’s body.
      • Type: Reversible, barrier method
      • Use: The female condom is used with a lubricant and can be inserted into the vagina up to 8 hours before intercourse.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 21%
      • STD Protection: In terms of HIV transmission, when used correctly, the female condom can be as effective as the male condom to reduce the transmission of STD’s.

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    • Fertility Awareness Method (FAM)

      • Description: Fertility Awareness is a natural method of birth control that is based on understanding a woman’s reproductive cycle. Beginning in puberty and until menopause, women typically release one egg each month from their ovaries. The time around when the egg is released is considered the fertile time of the month. Couples who use the Fertility Awareness Method, and do not want to conceive a child, abstain from intercourse during the fertile days. Many couples use the Fertility Awareness Method when they are trying to conceive as well.
      • Type: Reversible, Natural
      • Use: Women who choose to use FAM must spend several months, or up to a year, tracking their menstrual cycle. Two common ways to track fertility are the Calendar Method and Basal Body Temperature Method.
        • The Calendar Method:
          • Woman choosing the calendar method must track their menstrual cycle using a calendar to identify the length of their cycle. Women typically track their cycle for 8-12 months. The average length of the menstrual cycle is 28 days, but normal cycles vary between 21 to 35 days. Day 1 of the menstrual cycle is the first day of menstruation (bleeding). To calculate the day the egg is released take your total cycle length and subtract 14. For example, if the total cycle length is 28 days, then the date of ovulation (egg released) is on day 14. If the total cycle length is 31 days, ovulation occurs around day 17. Abstaining from intercourse on day of ovulation is not enough, you must take into account days preceding ovulation and the days after ovulation. After the egg is released (ovulation) it has two days to become fertilized by a sperm. If the egg does not get fertilized by a sperm then it dies and is shed during menstrual flow. Sperm can live inside a woman’s body about 4 days, so you must account for these possible fertile days prior to ovulation.
          • Because most women have varying cycle lengths, to calculate the fertile days, subtract 18 from your shortest cycle and subtract 11 from your longest cycle.
        • Basal Body Temperature Method:
          • Basal Body Temperature is your body temperature when you wake up in the morning. During ovulation a woman’s body temperature rises slightly. Women who use this method record their basal body temperature every morning and note then there is a slight increase. The slight increase indicates ovulation, the release of the egg. Women using this method abstain from intercourse 2-3 days prior to ovulation and 12-24 hours after ovulation.
      • Contraceptive Effectiveness Rate, or Typical Use Failure Rate: 24%
      • STD Protection: There is no protection against STD’s.

    There are two “morning-after pills” available: Plan B, which is available over the counter at drugstores and pharmacies, and Ella, which requires a prescription. Both delay ovulation and allow sperm in the reproductive tract to die out.

    People concerned about pregnancy should take Plan B within 72 hours after unprotected sex. Ella can be effective for up to five days after unprotected sex. For both medications, “the sooner you take it after unprotected sex, the better,” Dr. Nippita said. The pills are made of different ingredients: Plan B contains levonorgestrel, while the active ingredient in Ella is ulipristal acetate.

    These pills may make you nauseous or cause vomiting, and your next period might be shorter than usual after taking them.

    According to the C.D.C., the copper IUD can be used as emergency contraception, but it needs to be placed within five days of unprotected sex. Research shows the hormonal IUD may also be effective as emergency contraception.

    Several popular types of birth control, including many of the oral contraceptives, the patch and the ring, contain estrogen, so you’ll see a lot of the same concerns about who can and can’t use them.

    Anyone with high blood pressure, a history of blood clots or strokes, some forms of breast cancer or migraine headaches with aura, may be advised to find other methods. Also, anyone who is over 35 and smokes cigarettes may have a higher risk of complications like strokes.

    One of the most difficult parts of navigating birth control options can be parsing the literature on weight limits for contraceptives. Although there is conflicting data on how effective hormonal contraceptives are for people above a certain body mass index, or B.M.I., some birth control methods may not be recommended for people who are overweight or those with obesity. 

    There is also contradictory guidance on whether people who have a certain B.M.I. can or should take emergency contraceptive pills. Clinical trials showed that Plan B and Ella are most effective for women who are under a B.M.I. of 30, Dr. Nippita said. However, the F.D.A. stated in 2016 that it had reviewed the available scientific data on whether emergency contraceptives containing levonorgestrel, like Plan B, were effective in women who weighed over 165 pounds, and concluded that “all women, regardless of how much they weigh, can use these products to prevent unintended pregnancy following unprotected sexual intercourse or contraceptive failure.” Dr. Nippita said that she would not preclude prescribing emergency contraception to a patient based on B.M.I.

    Between Medicaid and the Affordable Care Act’s requirements for insurance companies, birth control costs should be covered, said Ms. Gandal-Powers, of the National Women’s Law Center. That means most people should have no out-of-pocket costs, including for doctor’s visits associated with obtaining birth control, such as consultations and implantations for IUDs. But insurance coverage doesn’t always translate into access, she said. “Just because you have coverage doesn’t mean you have a provider near you who can insert an IUD,” she said.

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    This page titled 6.1: Contraception is shared under a CC BY-NC-SA license and was authored, remixed, and/or curated by Kelly Falcone.