Methods of Birth Control

In choosing a method of birth control or contraception, you and your partner should understand the following:

  • how the method works
  • how and when to use it
  • reasons for not using it
  • undesirable side effects of the method and what, if anything, can be done about them
  • the effectiveness rate of the method

There are many different birth control methods. They include oral contraceptives, hormone implants and injectable contraceptives, barrier methods, intrauterine devices, rhythm methods, and surgical sterilization.

Oral Contraceptives

The oral contraceptive, commonly called the pill, stops the ovaries from releasing eggs (ovulation) and blocks sperm from reaching an egg, or it prevents a fertilized egg from attaching to the wall of the uterus. Oral contraceptive pills contain either a combination of progestin (a synthetic form of the female hormone progesterone) and estrogen (the key female sex hormone) or progestin alone. The combination pills are taken daily for 3 weeks, stopped for a week to allow for the menstrual period, and then started again. They prevent the ripening and release of the egg.

A variation of the combination pill is the multiphasic pill. This newer version varies the amount of estrogen and progesterone throughout the menstrual cycle to more closely match the hormone changes that occur naturally. Simply put, the pill's hormones trick the body into thinking it is pregnant. After ovulation, elevated levels of estrogen and progesterone prevent the release of another egg during the menstrual cycle. The pill provides these hormones on a daily basis, suspending ovulation.

Progestin-only pills, also called minipills, are taken every day of the month, but they do not suspend ovulation. They work by making the mucus that lines the cervix (the opening into the uterus from the vagina) so thick that sperm cannot pass through it and reach the egg. Bleeding usually occurs during the last few days of the menstrual cycle.

Birth Control

When used properly, combination pills are as effective as the progestin-only pill and are more effective for long-term use. The progestin-only pill is usually prescribed only when estrogen might be harmful to the woman, such as when she is breast-feeding.

The pill can sometimes cause problems, such as fluid retention, weight gain, irritability, and a change in sex drive. Women over 35 who smoke and women with active liver disease such as hepatitis B, or who have advanced diabetes are advised not to take the pill as a precaution against possible complications.

Increasing evidence indicates that the pill provides health benefits in addition to preventing pregnancy. For example, the pill has beneficial effects on benign breast tumors and ovarian cysts, and significantly reduces the risk of ovarian and endometrial cancers, iron-deficiency anemia, pelvic inflammatory disease, and ectopic pregnancy. The longer a woman takes the pill, the greater the protective effects.

The so-called morning-after pill is a series of birth-control pills containing the female sex hormones estrogen and progestin. The first dose must be taken within 72 hours of the unprotected sexual intercourse. This inhibits growth of the lining of the uterus so it cannot sustain a fertilized egg. Morning-after pills are highly effective in preventing pregnancy when used correctly. Possible side effects include nausea, breast tenderness, and spotting (light vaginal bleeding).

Hormone Implants and Injectable Contraceptives

Hormone implants are soft capsules containing the hormone progestin. The capsules are inserted under the skin of a woman's upper arm by a doctor who has been trained in this procedure. For up to 5 years the capsules release a steady, low dose of progestin to block ovulation (release of an egg from an ovary). Hormone implants are a highly effective means of birth control. The most common side effect is irregular periods. Also, removing the implant may be difficult and painful.

Injectable contraceptives contain the female hormone progestin. They are injected by a physician at regular intervals, usually about every 3 months. Injectable contraceptives prevent sperm from reaching the uterus by thickening the mucus that covers the cervix. Some doctors consider this to be the most effective reversible contraceptive method available. The most common side effect is irregular menstrual periods. Injectable contraceptives also have positive health effects—an increase in blood iron levels as well as protection against pelvic inflammatory disease, ovarian cancer, and endometrial cancer.

Barrier Methods of Contraception

Barrier methods physically block access of sperm to the uterus. They include male and female condoms; diaphragms; cervical caps; and spermicidal foams, creams, gels, and suppositories.

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Barrier Contraceptives

A male condom is a thin, transparent, latex sheath that covers the erect penis and prevents sperm from entering the vagina. Male condoms are the most widely used nonprescription contraceptive, and they are 90 to 97 percent effective when used properly. Although there are no side effects from using condoms, some men claim that condoms dull the physical sensation and tend to interrupt sexual intercourse. Some of these complaints may only be a matter of becoming accustomed to using condoms. To learn how to use a condom correctly, see page 182.

A female condom was approved by the US Food and Drug Administration in 1992, but it has had limited appeal in the United States. The device is inserted into the vagina and held in place by a ring. However, because the female condom has a higher failure rate, the male condom is preferred.

A diaphragm is a dome-shaped, latex cup with a flexible rim that fits over the cervix to block sperm from entering the uterus. Diaphragms come in different sizes and must be fitted by a doctor or a nurse to be sure the diaphragm covers the entire cervix without causing discomfort. If properly fitted, neither the man nor the woman should notice its presence. A diaphragm should always be used with a spermicidal jelly or foam, which not only lubricates the diaphragm for insertion but also offers some protection against pregnancy if the diaphragm is dislodged during intercourse. The diaphragm should be left in place for 6 to 8 hours after intercourse. When used with spermicidal jelly or foam, the diaphragm is about 85 to 90 percent effective.

A cervical cap is similar to a diaphragm, only smaller and more rigid. It also is available in various sizes and must be fitted over the cervix. A cervical cap is more difficult to insert than a diaphragm; therefore a woman needs to be trained to insert it correctly. Although some women leave the cap in place for days or weeks, it must be removed during menstruation to allow menstrual blood to flow from the body.

A great variety of spermicidal gels, foams, creams, and suppositories are available in pharmacies without prescription. Basically they all work the same way—by killing sperm before they can reach the egg. No single type of spermi-cide has been found to be more effective than another. By themselves, however, spermicides are not as effective as other contraceptive products and may be only about 70 percent effective. To be effective, the product must be inserted into the vagina as close to the time of intercourse as possible, but no more than an hour before. After an hour, spermicides start to disintegrate. For best results, they

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198 should be used with a diaphragm or a condom. No serious side effects are

The associated with these products, but some people have experienced skin or vagi-

Reproductive nal irritation.

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Intrauterine Devices

An intrauterine device (IUD) is a small plastic object that is placed inside the uterus by a physician, nurse, or midwife. How an IUD works to prevent pregnancy is not known for certain. In the United States, two types of IUDs are available. One type releases the female hormone progesterone and must be replaced every year. The other is made of copper and is effective for at least 10 years.

In rare cases, contractions of the uterus during menstruation can expel an IUD. If you can feel your partner's IUD with your penis during sexual intercourse, suggest that she see her doctor to check whether the IUD is being expelled.

Rhythm Methods

Rhythm methods (also called fertility awareness or the ovulation method) depend on avoiding sexual intercourse within 4 days before egg release. Most women release an egg from an ovary about 14 days before the start of their menstrual cycle. The unfertilized egg survives for only 24 hours, but sperm can survive for 2 to 7 days after intercourse, so fertilization may occur from intercourse that took place up to 7 days before release of the egg and 3 days after.

There are three variations of the rhythm method. In the temperature method, a woman determines her basal body temperature (her body temperature at rest) by taking her temperature before she gets out of bed each morning. This temperature drops slightly (about 0.2 degree Fahrenheit) just before ovulation. A day or so after the drop, a distinct rise (about 0.6 to 0.8 degree Fahrenheit) signals the beginning of ovulation. The couple avoids unprotected intercourse from the time the woman's temperature drops through the time it remains elevated for 3 consecutive days. The problem with this approach is that other factors, such as illness, can alter a woman's body temperature.

In the mucus method, a woman observes the changes in the consistency of her cervical mucus. Its consistency changes from dry immediately after menstruation to very slippery or watery shortly after an egg is released. The woman can have intercourse with a low risk of conception immediately after her menstrual period ends and up to the time she observes an increased amount of cervical mucus. When both the temperature and the mucus methods are used together, it is called the symptothermal method.

The calendar-rhythm method requires a woman to carefully keep track of her menstrual cycles over a year's time. She then subtracts 18 days from the shortest and 11 days from the longest of the previous 12 menstrual cycles. For example, if a woman's cycles last from 26 to 29 days, she must avoid intercourse from day 8 through day 18 of each cycle. This is the least reliable of the three rhythm methods. When it is used together with the symptothermal method, however, its effectiveness may reach the higher end of the estimated 53 to 86 percent range given for the rhythm methods. Note, however, that the low end of this range is little better than chance (50/50).

Surgical Sterilization

Sterilization is a procedure that makes a person incapable of reproducing. Surgical sterilization is the most common method of birth control among Americans. Surgical sterilization for a man is called vasectomy. This procedure involves cutting both vas deferens, the tubes that carry sperm from the testicles. This procedure can be performed on an outpatient basis in a hospital, clinic, or doctor's office. It takes about 20 minutes and requires only a local anesthetic. An incision is made on both sides near the base of the penis. On each side, the vas deferens is freed from the spermatic cord, pulled up through the incision, made into a loop, cut, and tied. (The vas deferens may also be cauterized, or sealed off, with an electric current.) The incision is closed with three or four sutures. When the local anesthetic wears off, the man may experience a mild, dull ache or pain for a few days. The man still ejaculates but the semen does not contain sperm.

The man is usually advised to rest in bed for 24 hours. Complications from vasectomy are rare (fewer than 5 percent of cases); the most common complications are bleeding and swelling of the scrotum. Most men return to work within a few days. Some doctors advise wearing tight-fitting underwear or a jock strap for 4 to 6 weeks to prevent swelling and pain in the scrotum.

It is important to remember that viable sperm may still be present in the seminal vesicles (the small sacs that store semen) after a vasectomy. For this reason, a man or his partner should continue to use some other form of contraception until those sperm are either ejaculated or die. The man is considered sterile only after a laboratory test confirms that two successive samples of ejaculate, collected 2 to 4 months after the procedure, are free of sperm.

Birth Control

Loop of vas deferens pulled through

Cut ends of vas deferens are cauterized and sealed

Incision is stitched

Loop of vas deferens pulled through

Cut ends of vas deferens are cauterized and sealed

Incision is stitched

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200 Contrary to what some men believe, vasectomy does not interfere with ejacu-

The lation, orgasm, or sex drive. In fact, several studies have shown that many men who have this procedure experience an increase in sexual desire. Vasectomy has been known occasionally to be associated with psychological problems or regrets about having the procedure. When these problems affect sexual performance, counseling is advised.

Women are sterilized by tubal ligation—the cutting and tying of the fallopian tubes, which carry the egg from the ovaries to the uterus. A variety of procedures are currently being used in the United States: abdominal tubal ligation, tubal coagulation by laparoscopy, and minilaparotomy. The first two methods require hospitalization and usually are performed under general anesthesia; the third can be performed on an outpatient basis.

Currently, the trend is for more tubal ligations done by laparoscopy. A thin tube (laparoscope) is inserted through a small incision in the woman's abdomen (usually through the navel). The doctor cuts the fallopian tubes and ties off the ends. (The ends of the tubes also may be cauterized.) The woman usually goes home the same day. Complication rates for this procedure are very low.

About a third of all married couples in the United States who use family planning methods choose sterilization of either partner. It is the method most often chosen by couples in which the woman is more than 30 years old. Vasectomy is more common than tubal ligation because it is simpler, just as effective, less expensive, and has fewer potential complications.

For couples who know that they do not want more children, sterilization is the most effective way to prevent pregnancy. Because the surgical procedures to reverse either vasectomy or tubal ligation are complicated and expensive, the results should be considered permanent. Although researchers are studying ways to easily reverse these procedures, they are not yet available.

If you have questions about any contraceptive method, ask your primary care doctor, a urologist (a physician who specializes in treating disorders of the urinary tract), or a gynecologist (a physician who specializes in treating disorders of the female reproductive system).

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