Women these days have plenty of contraception options: birth control pills, contraceptive patches, vaginal rings, intrauterine devices, sponges, diaphragms, condoms, etc. And that's not even counting the age-old but unreliable coitus interruptus. However, convenience, safety, advocacy, affordability, and spontaneity vary with each method. Medical contributor Dr. Judith Reichman was invited to appear on “Today” to walk us through this veritable contraception bazaar and help each of us decide which method may be the most appropriate.
Birth control pills
There are two basic types of birth control pills. The most common contain two hormones, estrogen and progestin. Once in the body, they “fool” the pituitary gland into sensing sufficient hormones, so there's no need to add more through ovulation. If no egg is released, a pregnancy cannot occur. In addition, the hormones in the pill, especially the progestin, thicken the cervical mucous, making it more difficult for sperm to swim up the fallopian tubes. The typical failure rate for birth control pills is 8 percent, and 0.3 percent with perfect use.
Most combined estrogen/progestin pill packs have three weeks of active pills and one week of “dummy” or placebo pills. When the inert pills are taken, the level of estrogen and progestin provided by the active pills obviously plummets, causing the endometrial lining of the uterus to shed and bleed; this is the “period.”
All combined estrogen/progestin pills contain one of two formulations of estrogen. However, there are seven different types of progestin formulations. The term “low-dose pill” usually refers to the amount of estrogen; usually ranging from 20 mg to 50 mg. Monophasic pills contain equal amounts of estrogen and progestin. With biphasicpills, the amount of either estrogen or progestin changes halfway through the cycle. And to keep the phases going there are also triphasicpills, in which the dose of estrogen and/or progestin changes three times over the cycle; these are thought to more closely mimic the “natural” hormonal fluctuations that occur throughout the cycle. In some women, this type of phasing may help prevent breakthrough bleeding, nausea, bloating, and diminished libido.
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All these combinations come in higher and lower estrogen doses, as well as variations in types and amount of progestin. Finally, some of these pills are made with fewer than seven days of placebo and some have as few as two. The latter may benefit women who develop symptoms when the active pills are discontinued for more than a few days. (One brand that has just two days off is Mircette.)
Are lower estrogen pills better?
Most pills used today are low-dose, containing 35 mg of estrogen (usually ethinyl estradiol) or less. The lower the dose, however, the more likely breakthrough bleeding will occur. Also lower doses may be less effective, if not taken at the same time every day. The lowest dose pills might be right for women who develop nausea or breast tenderness on higher dose pills or for women who are petite and/or are Asian. (It's been found that certain ethnic groups metabolize the pills differently and do better on lower doses.) I prescribe the higher dose pill — 50 mg — for women who have breakthrough bleeding on lower dose formulations.
Are there differences in progestin?
Some, such as norethindrone, are more androgenic. That means they are chemically similar to testosterone (example, Lo/Ovral). This male hormone-like quality may contribute to bloating or affect PMS. On the other hand, these types of progestins may be most effective in preventing breakthrough bleeding. There are progestins that have less testosterone-like properties, such as norgestimate and desogestril. These are present in many brands, including Alesse, Levlite, Nordette, and Ortho Cyclen. The birth control pill that contains the “newest progestin on the block” (drosperenone) with an anti-androgenic effect is Yasmin. This progestin also seems to diminish bloat and acne.
What about generic pills?
Many of the components found in brand-name birth control pills are also in generic ones. The reason there are so many choices is the presence of multiple generics for the same pill. For example, Ortho-Novum 1/35 comes as Nortrel 1/35 from Barr Laboratories and Necon 1/35 from Watson Laboratories. Demulin, the brand made by Pfizer, is available generically as Zovia (Watson), and Desogen and Ortho-Cept (made by Ortho-McNeil) is the same as Apri (Barr). Mircette (again Organon) is also available as Kariva (Barr). Substituting generic pills made by established pharmaceutical makers is fine, if they're the same formulation as those in your prescription. Some pills, such as Yasmin, Estrostep, and Ovcon 35 do not have generic equivalents.
Who shouldn't take birth control pills?
If you have one of the following conditions:
- Have a history of clots, heart disease, strokes, or liver disease (If you have a family history of clots, your doctor may want to test you to see if you have abnormal clotting factors.)
- Are pregnant
- Are over 35 and smoke (and possibly even if you are under 35 and smoke)
- Have had breast or uterine cancer
Do birth control pills come in other forms?
Yes, there are progestin-only pills, which are commonly referred to as mini-pills. Brands include Ovrette, Nor-QD, and Ortho Micronor. Failure rate varies from 0.3 percent for perfect use to 8 percent to 13 percent for typical use. Like combined pills, mini-pills prevent ovulation and thicken cervical mucous. However, progestin pills are less likely to increase clotting and can be taken while breastfeeding. But they are more likely to be associated with irregular bleeding, prolonged bleeding episodes, and lack of periods.
What pills let you skip periods?
All birth control pills can be used to extend the time between menstrual cycles. Seasonale has been packaged so that the active pill is taken for 84 days, followed by seven days of inert tablets. Hence a “period” occurs only every three months. The active pills contain the exact same hormones as those in one-month pill packs of Levlin, Levora, Nordette, and Portia. Extended cycling can also be accomplished with most monophasic pills. The active pills of one pack are followed by the active pills of the next two or three packs and only after this are the placebo pills taken, at which time bleeding occurs. Extended cycling can result in breakthrough bleeding.
What about patches?
Basically hormones can enter the body and have the same effect as an oral pill when given in appropriate doses through the skin (Ortho Evra patch) or the vagina (NuvaRing). Because the patch and the ring do not require daily ingestion, the failure rate that has been established with these relatively new forms of contraception is an overall 0.3 percent. There are sure to be some failure rates in women who forget to change the ring or patch!
The patch should be changed every week for three weeks, then removed, at which time withdrawal bleeding occurs. There have been some recent concerns about an increased risk of clots with use of the patch. There may indeed be a surge in the estrogen hormone level initially. The company, however, feels that the risk of clots is probably no different than that shown in numerous studies of pill use. The patch may, however, be less effective in obese women.
The NuvaRing is quite easy to use because it only has to be inserted once every three weeks (and removed for one week to get a “period”). Obviously, it gives you the lowest chance of missing hormonal suppression of ovulation, unless of course you forget to change it.
Finally, there is a long-acting progestin called Depo-Provera that is injected into the muscle every three months. Its typical and perfect use failure rates match at 0.3 percent. A newer lower dose is available as Depo-Sub-Q Provera 104. The shot can stop period bleeding or cause periods to be irregular. It also has been shown to contribute to bone density loss. It may cause acne, weight gain and/or headaches. And although an injection may be convenient, it may take time for fertility to return once the shots are discontinued. Delays of up to two years have been reported.
Are intrauterine contraceptives safe?
The latest ones don't have the same problems as the infamous Dalkon Shield. There are two intrauterine contraceptives: Mirena intrauterine system (IUS) and ParaGard T intrauterine device (IUD). Mirena slowly releases very small amounts of a progestin similar to that in many birth control pills (levonorgestrel). This causes the cervical mucous to thicken. It also decreases egg pickup by the fallopian tube, and it may change the uterine lining, making it less conducive to implantation. Mirena has a typical failure rate of less than 0.1 percent (comparable to tubal ligation, but is reversible). It also reduces heavy bleeding and may actually prevent all bleeding, causing amenorrhea. It works for five years. There are concerns about insertion of these devices in women who are at high risk for sexually transmitted infections. And they’re not advised if a woman has had a pelvic infection in the past three months, has an untreated sexually transmitted disease or plans to have multiple sexual partners, which will increase her risk for STDs.
The ParaGard T is an IUD which is wrapped in fine copper wire. The copper causes it to work as a spermicide, inhibiting sperm motion and activity, thus preventing fertilization. It has a typical one-year failure rate of 0.8 percent versus 0.6 percent perfect use. The ParaGard T is effective for 10 years. It can cause increased period bleeding, cramping and spotting between periods. Since both of these systems are inserted through the vagina (a definitely non-sterile route), many physicians prescribe antibiotics for a few days to help ward off a possibility of infection.
How effective are condoms?
The male condom has a 2 percent perfect use failure rate and a 15 percent typical use failure rate. (It can be applied incorrectly, tear, slip off or allow spillage.) For someone who wants the greatest contraceptive reassurance, I suggest using a hormonal contraception or an IUD, and a condom (for STD protection). In some cases, condoms can cause irritation and allergic reaction (this is less likely to occur with polyurethane products). If a non-water-based lubricant is used, it can cause the condom to deteriorate.
What about sponges and diaphragms?
The diaphragm has a 6 percent perfect use failure rate and a 16 percent typical use failure rate. It does take away spontaneity, since it needs to be inserted at least 30 minutes, but no longer than six hours, before intercourse and removed no sooner than six hours afterwards. In order for it to be effective, it also must be used with a spermicide, which is applied before insertion. Sizes vary and a clinician needs to fit it. It doesn't protect against HIV and we're not sure whether it protects against other STDs.
Are spermicides effective?
There are foams, creams, jellies, films, suppositories, and vaginal tablets. They need to be inserted five minutes to 90 minutes (read the instructions) before intercourse. They are not as effective as most women would like. Failure rates range from 15 percent with perfect use to 29 percent for typical use. They can cause irritation, allergic reactions, urinary tract infections, and some studies have shown they may increase the possibility of transmitting and/or contracting STDs and HIV.
Can coitus interruptus work?
Coitus interruptus (withdrawal of the penis before ejaculation) has a failure rate of 4 percent for perfect use (if the guy really knows what he's doing.) However, the initial secretions from the penis may have a very high level of active sperm. So the typical failure rate is 27 percent.
What about the rhythm method?
Fertility awareness methods are based on refraining from having intercourse during times when ovulation and fertilization are most likely. The fertile phase of the menstrual cycle is identified either by observing cervical secretions and basal body temperature or by monitoring cycle days. But sperm can live in cervical mucous for up to a week, so intercourse before optimal fertility can still lead to fertilization. This has a perfect use failure rate of 9 percent, versus a typical failure rate of 25 percent. Women with irregular cycles may actually have even higher failure rates.
One would think that with all these available options, unwanted pregnancies would significantly diminish in this country. Unfortunately, there are still too many couples who do not consistently or correctly practice their chosen birth control method. This is not an area of life where “almost right” works. So whatever you choose, make sure that your use is “perfect” and not “typical.”
Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins.