New forms of reversible and permanent birth control have recently been approved by the FDA. Contraception can only be as good as our knowledge of what’s available and our willingness to use it. Overall, women spend two-thirds of their reproductive years trying to avoid unintended pregnancies. “Today” medical contributor Dr. Judith Reichman, talks about the new and old methods that allow women to make responsible reproductive choices.
A new birth control pill called Seasonale has just been approved. It’s different from the usual Pill pack in that the active pill, that which contains the estrogen and progestin, is given uninterruptedly for three months. Only after the third month (84 active pink pills) are non-active pills (“sugar” pills) used, and that is when a period occurs. Until now, all our combination estrogen-progestin birth control pills (BCPs) have been geared to giving us monthly, twenty-eight day cycles. They contain three weeks of active pills, then on the fourth week contain an inactive pill. The hormone level drops during inactive pill use, causing the uterine lining to slough so a period occurs. All the birth control pills work by preventing ovulation. They stop the central pituitary command for the ovary to develop it’s eggs by preventing production of FSH (follicle stimulating hormone) and LH (luteinizing hormone). We are used to monthly periods and the Pill was created in a way that would “copy nature”. But for many women the period can be a nuisance, or worse yet, heavy and crampy to the point of causing them to be anemic. (Although in general monthly periods are lighter and less painful when on the Pill.) Moreover, when the estrogen and progestin levels drop, either naturally during the cycle or at the finish of the three-week active pills, some women develop migraine headaches, mood swings, fatigue, bloating and even hot flashes. “Dropping” just every three months means these unwanted symptoms may occur four times a year rather than twelve or thirteen. Doctors have been prescribing this type of extended Pill cycle for years with other birth control pills. They simply have had their patients take the active pill in each pack for two to three months uninterruptedly (or until break through bleeding occurs) and then go off in order to get withdrawal bleeding.
WHAT ABOUT OTHER BIRTH CONTROL PILLS?
We have some newer pills that have become popular. Yasmin was introduced two years ago. It has a progestin that is similar to that which is made by the ovaries. This progestin also has diarrhetic and anti-male hormone effects. In other words, it helps prevent water retention and is good for the skin, blocking male hormone that promotes acne. There are also studies which show it may be helpful in diminishing PMS-like symptoms.
As more of the older tried and true birth control pills become generic, other pills have been introduced by the pharmaceutical companies, often with slightly lower estrogen levels than their generic counterparts. These include Cyclessa and Ortho Tricyclin Lo.
Before we go off to other forms of contraception, just a word (or two) about the health benefits of the Pill. Birth control pills help reduce the risk of malignancies such as endometrial cancer, ovarian cancer, and perhaps even colorectal cancer, and recent studies have shown that among women age thirty-five to sixty-four, current or former birth control pill use was not associated with an increased risk of breast cancer. The pill also helps protect women from ovarian cysts, benign breast disease, ectopic pregnancy, pelvic inflammatory disease (PID), bone loss and perhaps rheumatoid arthritis. Finally, it helps manage the hormone swings and menstrual irregularities of perimenopause.
BIRTH CONTROL HORMONES, NOT THROUGH A PILL
Similar levels of the hormones we get with the Pill can be obtained through our skin and vaginal mucosa. A transdermal (patch) contraceptive system called Ortho Evra works like the Pill. The patch is applied to the lower abdomen, buttocks, upper arm or back once a week for three consecutive weeks, followed by a patch-free week to allow for a period. It is convenient for women who have trouble taking the Pill daily. It should be used with caution in women who weigh more than one hundred and ninety-eight pounds. For these women it may not be sufficiently effective.
A vaginal contraceptive ring called Nuva Ring was introduced two years ago. It consists of a soft, hollow ring that measures two inches in diameter and can be inserted by the woman (sort of like a diaphragm) and left for three weeks, then removed for a week, during which time she will have a period.
These are especially suitable for women who cannot or should not take estrogen (breastfeeding, previous history of clots or side effects). The newest form comes in an intra-uterine system (IUS). It is called Mirena and was introduced in 2000. This is a T-shaped device that is inserted into the uterine cavity through the cervix. It very slowly releases minute amounts of progestin, causing suppression of ovarian function and preventing sperm migration. An additional positive effect of this small device is that it decreases bleeding and can be an alternative to surgery for some women with heavy periods. It lasts for five years and is the most effective contraceptive available, comparable to sterilization. It has also been found to be more cost effective (cheaper) than any other hormonal ,surgical or “usual use” barrier forms of birth control
There are also “older” progestin-only pills, which include Micronor, Nor-QD, and Ovrette, as well as three-month injectable contraceptive shots (Depo-Provera). The latter is popular for young women and wonderful in developing countries where birth control access is limited.
The IUD currently available in the States contains copper and is called the ParaGard. Once inserted, it works for ten years and indeed is the most widely used reversible contraceptive in the world. However, less than one percent of American couples use it, mostly because of now unfounded fears of PID (which occurred in the past with the old Dalkon Shield).
Two products are available — Preven (which contains estrogen and progestin) and Plan B (progestin only) — and are becoming more easily obtainable, and in some States available over-the-counter. When used within 72 hours after unprotected intercourse, these can reduce risk of pregnancy by seventy-five percent.
These include the diaphragm, the Fem Cap (shaped like a sailor’s hat to fit over the cervix) and the Lea’s Shield (with a one-way valve that allows flow of fluid or blood from the cervix to the vagina). They must all be used with a spermicide in order to be effective. Then, of course, we have condoms. New brands are always being introduced. This is the only form of birth control that helps prevent sexually transmitted diseases. The level of protection from heterosexual transmission of HIV and effectiveness of preventing pregnancy is about 78 percent.
These usually contain Nonoxynol-9 (N-9) and do not prevent HIV infection.
This is still the most commonly used method of permanent contraception used by twenty-eight percent of women in the United States. (It should be noted that when done in younger women, under the age of thirty-five, as many as twenty percent may later voice regret.) It is usually performed through a laparoscopic procedure in which instruments are inserted through small incisions in the navel and used to cauterize or clip the fallopian tubes. It can also be done directly through a small incision after delivery (post-partum sterilization). The procedure requires use of an operating room facility and is usually done under general anesthesia. A new sterilization technique called Assure has recently been FDA approved. Small coils are inserted into the tubes via a scope (hysteroscope) which is placed through the cervix into the uterine cavity. When released, these coils expand and anchor in the tube, causing local “tissue in-growth” (scarring). The tubes become effectively blocked after three months. This procedure can be done in an office, without anesthesia, but requires that contraception be used for the following three months and a follow-up uterine x-ray be done to ensure that the Assure blocked the tubes.
We have many birth control methods from which to choose. Discuss them with your doctor and whatever you use, make sure you feel comfortable, experience the benefits and not the side effects, and consistently use it as long as you need it.
Dr. Judith Reichman has practiced obstetrics and gynecology for more than 20 years. She is a regular “Today” show contributor.