Contraception Options

As a physician who has counseled families for almost twenty years, I have had to discuss contraceptive options many times and in my assessment, there is a great deal of misconception about what, where, when, and how they are used. I highly encourage all of my patients to ask questions, then ask more questions so they can make the best decisions for themselves.

I’m going to run through the options quickly with some pertinent information that previous patients have found useful.

The only 100% effective contraception is abstinence. That’s it. To clear up any doubt, mostly abstinent is not actual abstinence.

Second major point, contraception and sexually transmitted disease prevention are two separate topics. Preventing pregnancy does not include prevention of other potential infections including HIV, herpes, chlamydia, trichomonas, hepatitis, gonorrhea, HPV, or syphilis. While all of these diseases can be treated, not all of them are curable. And I hate to break it to you, but people are not always truthful or considerate, particularly with their sexual histories. Like every other activity you may or may not engage in, my advice is to play responsibly.

Contraception is pregnancy prevention. Each option has its own advantages and disadvantages. Reversible options include: barrier (condom, diaphragm, spermicide, cervical cap), hormonal (pill, ring, patch), IUD (hormonal, copper), progestin shot (Depo Provera), and progestin implant. Partially reversible contraception options are tubal ligation (severing path for egg to reach uterus) and vasectomy (severing path for sperm to reach seminal fluid).

Barrier methods result in pregnancy 13% of the time. To be effective, barriers need to be in place before any penile-vaginal contact as pre-ejaculate seminal fluid contains sperm. This is why the “pull-out” crowd so commonly become parents (pull-out method results in pregnancy 22% of the time). Barriers include condoms, diaphragms, and sponges. Water based products may be used with all barriers, but oils can decrease the effectiveness of latex (note: spermicides are water-based). If the barrier is not applied or removed correctly (condom break, sponge slips, etc), efficacy is lost. Full fertility is restored at discontinuation.

Hormonal options include pills which must be taken daily at roughly the same time every day, patches which should be applied weekly and the vaginal ring which is inserted for three weeks at a time. Pregnancy rate with this method is 7% and they work by suppressing ovulation (release of egg from ovary) and thinning the uterine lining. The pill is probably the most common and comes in varying amounts of estrogen and progesterone combinations. As estrogen can cause blood clots, contraindications include smoking in those age > 35 or liver adenomas. The additional benefits of this modality include improvement of menstrual cramps, lighter periods, and improvement of acne. This option cannot be started immediately and is initiated at the next menstrual period. Some of my patients who are faithful about dosing can predict when their period will start down to the hour. If inconsistent use, efficacy falls. Fertility is restored at discontinuation. (Special note, other medications can interfere with this method, most commonly antibiotics. If you start any other medication, clarify with that provider if it will interfere with your birth control.)

Depot medroxyprogesterone acetate (DMPA) commonly referred to as the Depo shot which is administered in the upper outer buttock area. This method results in pregnancy < 4% of the time when taken appropriately every three months. There is only progestin and no estrogen in DMPA and it works by suppressing ovulation (release of egg from ovary) as well as thickening cervical mucus (blocking sperm from entering the uterus). Your provider will require a pregnancy test prior to initiation and may need to adjust the initiation date based on your menstrual cycle. It is quite common for women to have initial spotting for several months before they may stop having periods altogether. The other significant side effect is reduction in bone density when used long-term (>2 years). Upon discontinuation, bone density returns to normal levels. When stopped, fertility returns to normal after several months, but not immediately.

The contraceptive implant is placed under the skin (commonly inner upper arm above elbow) and is effective for three years. Pregnancy rate is < 1%. It works by a continuous progestin release similar to previously discussed depot medroxyprogesterone and works similarly by thickening cervical mucus and suppressing ovulation. It may also cause spotting initially followed by loss of periods. Placement must be performed by trained personnel. Fertility is restored upon removal of implant.

The intrauterine device is a tiny T shaped device that is placed inside the uterus. Pregnancy rate is < 1%. A more thorough evaluation must be performed before insertion including pelvic exam, pregnancy test and sexually transmitted disease testing to detect potential complicating factors. The copper IUD is not hormonal, can last ten years and works by destroying sperm. It should not be used if heavy, painful periods or iron deficiency present as it can make bleeding heavier. The hormonal IUD can last anywhere from 3-7 years based on brand and works by increasing cervical mucus, thinning uterine lining and sometimes even suppressing ovulation. The hormonal IUD is effective at reducing heavy painful periods. Fertility is restored upon removal of device.

Fertility Awareness Planning (aka “Rhythm method”) is timing sexual encounters outside of the five days before ovulation until 24 hours after ovulation to prevent pregnancy or using alternative contraception like condoms during that fertile time period. If periods are regular (every 26-32 days), this method is an option. If periods are irregular, this method much less effective. The pregnancy rate is variable from 5-20% based on effective use. This method requires close monitoring by using a calendar, checking daily temperatures, checking cervical mucus or a combination of all three for ovulation detection.

Tubal ligation and vasectomy are two surgical interventions that are not easily nor completely reversible. A tubal ligation must be performed in the operating room versus a vasectomy is performed as an office procedure with local anesthetic. Pregnancy rate for both is < 1%. The tubal is effective immediately. As there may be residual sperm in the tract after the procedure, the vasectomy can take three months before effective. Follow up testing highly recommended to make sure sperm has been fully cleared. Neither procedure will affect sexual performance.

As mentioned previously, choosing birth control can be complicated and requires open and shared discussion. There is no perfect method for everyone. My goal is to steer my patients in a direction that is effective and suits their lifestyle while minimizing potential side effects.

(A special note for adolescents who won’t discuss this with their physician for fear that their parent will find out that they are having sex. Would you prefer your parent to know you are having sex responsibly or that you are pregnant? During routine well child checks, I will often screen for contraceptive needs, but if I don’t have all the facts, I can’t be as helpful. Never be afraid to talk about how to stay healthy.)