Birth Control: hope doesn’t count

In my time in medicine, I have heard a lot of strange things. One of my clearest memories was on my Ob/Gyn rotation, when I saw a woman for a routine check-up. I asked her what form of birth control she used, and she told me “hope” (don’t worry, she left with a purse full of condoms and a follow-up appointment for a Depot shot). While birth control has become a commonplace medical conversation, it’s often taken for granted. We didn’t have regular access to birth control except for condoms until 1960, when the pill exploded on the market. This helped people control the timeline of their lives, so they could reach their own personal goals. And while there are a few well-known options, choosing the best option can be daunting. Let’s talk about how to choose birth control, and discuss the pros and cons of some of the most common contraceptive (preventing pregnancy) methods. This post is not about the political or ethical discussion revolving around birth control; this is solely an informative post about options.

We all get that birth control is important; so how do you decide what’s best for you? There are many factors that play into this, including other medical problems, your future plans, and religious/moral beliefs. Make sure to discuss all of your options fully with your healthcare provider. Here, I will try to touch on the most common options, but this discussion is by no means comprehensive. If you have any further questions, please leave a comment or message me, and I’m happy to give you any further information I have!

Obviously one of the most important things to understand when choosing contraception is how effective it is. This is usually reported in percentage of women who get pregnant using only that contraceptive method in 1 year. If the effectiveness listed is 2%, 2 out of 100 women got pregnant in 1 year. There are two commonly reported versions of it: perfect use and typical use. Perfect use implies that they took it EXACTLY as recommended it (for example, taking the pill every day at the exact same time). For most people, I would recommend basing your decision on typical use, because that’s more realistic. I would consider myself a fairly compliant patient, and even I have issues with remembering a pill at the same time every day. Below I’ve categorized birth control methods by typical use effectiveness:

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Source: CDC. Ranking of birth control methods by effective, measured in percentage of women who experience an unintended pregnancy within 1 year of typical use.

Most effective

First off- abstinence is the most effective birth control method there is, and it also prevents STDs. Some people decide to stay abstinent for a variety of reasons, and you should never feel pressured to make a decision that isn’t right for you.

IUDs and implants (like Nexplanon) are the new hot things in birth control, because they’re reversible and they’re pretty foolproof. These are called long acting reversible contraceptives, or LARCs, and you may have noticed that healthcare providers are their #1 fans. The American College of Obstetricians and Gynecologists has stated they are the most effective reversible contraceptives on the market. The percentage of women in the US using an IUD went from 2.4% in 2002 to 8.5% in 2009. Yet a lot of women are still unfamiliar with them, with up to 32% saying they didn’t know the efficacy.

First off- let’s talk about IUDs, or intrauterine devices. These are inserted in your doctor’s office, and can last from anywhere from 3-10 years. There are two types- one that uses hormones (like Mirena), and a copper device. These tend to not have systemic effects (they only affect the uterus), and so are good options for women who otherwise can’t tolerate hormones like women who have heart disease or migraines. The most common side effects are pain with insertion and changes in periods (they get heavier with copper IUDs, and may disappear with hormonal IUDs). A lot of women are concerned about the safety, but this is mostly a historical problem- in 1974, an IUD was removed from the market for causing infection, but since then they have gotten much safer. While you shouldn’t have an IUD placed if you have an active infection, there is no increased risk of infection with an IUD. There are some serious risks, including increased risk of ectopic pregnancy (a pregnancy not in the uterus), and uterine perforation (occurs in 0.1% of cases.They were previously only recommended for women who had children before, but this is no longer true.

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Implants are small sticks inserted under the skin in your arm, and release a steady stream of hormones (progesterone, which is also in injectable and pill contraceptives) for up to 3 years. You will be able to feel it, but it shouldn’t be visible. Unlike an IUD, you can get systemic side effects (like mood changes, acne, weight gain), as well as irregular periods. Both the IUD and implants are quickly reversible- after removal, fertility should return to normal within 1-2 menstrual cycles.

Somewhat effective

The pill is one of the oldest and still most commonly used birth control methods. But it also requires a lot of dedication on your part. It can also be used for a variety of other health conditions, like acne, painful/heavy/irregular periods, endometriosis, and PCOS. Contrary to what some radio hosts believe (http://www.msnbc.com/rachel-maddow-show/limbaugh-still-confused-contraception), you have to take the pill every single day, whether you plan on having sex or not. There are two forms: the combined (both estrogen and progesterone) and the mini-pill (progesterone only). There are some women who are not able to take estrogen, like women with a history of blood clots or migraines, who may be able to use the mini-pill. However, it’s VERY important to take the mini-pill at the exact same time every day to get full efficacy. Both have a risk of systemic side effects, which differ in severity by individual and hormone dosage. You may have seen some pills that allow you to skip periods, what’s the deal with that? Women don’t need to have periods, so these packs skip the placebo (or sugar pills) at the end of the pack; there’s no risk to this, but some women get concerned if they don’t get a period every month, so it’s about personal preference.

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Injectable birth control, like Depo-Provera, is a shot of progesterone that prevents pregnancy for up to 3 months. This requires a little bit less daily commitment, but you still have to go to the doctor’s office every 10-12 weeks to get the shot. If you’re 1-2 weeks late getting your injection, they may have you take a pregnancy test before giving you the shot. It has all the same side effects of other hormonal birth control, including period irregularities.

So you may have been surprised that condoms fall in this category… If condoms are used perfectly every single time you have sex, there are 98% effective. But it is very user dependent, and you have to use it perfectly every time, so the efficacy with regular use is 85%. There are some other advantages, including that it is one of the only birth controls that prevents STDs. But to make sure they are most effective as birth control, use them every time and combine it with another contraceptive. For more information on how to use condoms appropriately, go to Planned Parenthood’s website.

Withdrawal, or the pull-out method, is probably the world’s oldest form of birth control. It does have some advantages, including that it’s free and there are no side effects, as well as it may be compatible with religious beliefs that usually discourage contraception. However, it has a high failure rate because it is often not performed correctly and sperm can be present before ejaculation. While this is rarely recommended as the only form of birth control, it may increase the efficacy of another contraceptive method when used together.

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Just kidding… mostly

Least effective

Fertility-based planning is the practice of tracking your menstrual cycle (either by periods or body temperature) to avoid having sex on days that you’re most fertile. In theory, this is actually somewhat effective; there are usually only 5-6 days per month that you can get pregnant. However, that is only if you have completely regular, predictable cycle, and you actually avoid having sex on all of the days that you are fertile. If your cycles differ in length, it’s much harder to predict what day you’re ovulating. There are a variety of reasons some women decide to use this, either because of moral beliefs or intolerance of other contraceptive methods, and I’m supportive of whatever is the best choice for you. However, I’m here to tell you it is one of the least effective methods of contraception, and you should take this into consideration in your decision.

Spermicides, like foam or lubricant, are designed to kill sperm. Thing is, they don’t do that very well. They can, however, improve the efficacy of other birth control, and so may be recommended in combination with other birth control, like condoms.

Emergency contraception

Things happen, and sometimes you either forget to use contraception or it isn’t used correctly. In this case, there are a few options. The most effective option is a copper IUD; if it is placed within 5 days of unprotected sex, it prevents pregnancy in 99.9% of cases. The most common is the morning-after pill. This is NOT the abortion pill- the morning-after pill is just a larger dose of the hormone that is in normal birth control pills. You can take it up to 5 days after unprotected sex, but the longer you wait the less effective it is. You don’t need a prescription or need to be over 18 for the morning-after pill, simply go to a drugstore or pharmacy (it may be behind the counter but you can just ask for it).

Preventing STDs

While all of the methods described above prevent pregnancy, only a couple prevent transmission of sexually transmitted diseases- male and female condoms. These should be used at every sexual encounter, including oral, vaginal, and anal sex. For more details on how to use female condoms, you can go to this page at Planned Parenthood. If you want to learn more about why STIs are awful, you can read my post about it here.

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The best birth control option is different for everyone; you have to make the best decision for you. Make sure to consider your health and personal beliefs, as well as be honest with yourself about how regularly you will use different methods. Now go out there and plan your future!

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