Contraceptives 101

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I'm so happy that so many of you showed interest in a post outlining all our contraceptive options! It's truly amazing how far we have come in the past couple of decades to provide women the freedom of choice in the way we go about family planning. I'd like to preface this post by saying that I am by no means encouraging you to participate in sexual activities. That is entirely up to you, your partner, and whomever you decide has a say in that decision. 

However, I do believe that the abstinence-only mindset is outdated and dangerous. The gym teacher from Mean Girls may be hilarious, but it is NOT true that if you have sex, you will die. Only by knowing your options and ways in which you can practice safe sex, can you efficiently plan for a family. In this post, I will be discussing reversible contraceptive methods, meaning they are methods that consist of using a barrier (condoms, cervical caps), changing your behavior (fertility awareness method, abstinence), and using hormones (oral contraceptives, contraceptive shot, implant, intrauterine, ring). Permanent methods include tubal ligation, hysterectomy, or vasectomy, but I will not be discussing those in this post. I will also not include the price of each method, as everyone's insurance is different.

1. Condoms

Condoms are pretty straightforward, and the most common form of contraceptive we learn about. They are the only method of contraceptive that prevents against STD/STIs. There are two main types: male + female.

Male Condoms: There are also the most common type made of Latex, and some made with lambskin or plastic. For a male condom, you simply slide the thin condom onto your partner's penis, and it collects the semen during climax so that it does not enter your vagina. Condoms prevent pregnancy in this way, but they can also break if they are expired, or rip during intercourse. Synthetic condoms, like latex and plastic condoms, also prevent sexually transmitted diseases by acting as a physical barrier between your bodily fluids and your partner's bodily fluids. Keep in mind that there is still a risk of the condom ripping or being perforated in any other way. Condoms, if used perfectly, are 98% effective at preventing pregnancy. That's pretty darn good. And if you're worried about the comfort level of some condoms, they come in a variety of sizes and thickness levels at the grocery store.

Female Condoms: Female condoms look like pouches that you can put inside your vagina, and they are usually made with polyurethane, synthetic nitrile, or latex. They protect against pregnancy if used correctly, but usually are not recommended to be your primary source of contraceptive because they can become dislodged during intercourse. However, they are easy to use and control.

2. Oral Contraceptive Pills 

"The Pill" seems to be the most popular form of contraceptive these days. Depending on the provider, prescribing hormonal oral contraceptives is quick and easy. However, without careful consideration and analysis of family history and current physiological status, many underlying risk factors can go unnoticed, such as blood clots and other clotting disorders. It is of the utmost importance, not only with obtaining a prescription for birth control, but also with any meeting with your provider, to ask questions. It is also very important to note that oral contraceptives do NOT protect against STDs/STIs. If you are engaging in sexual activities with more than one partner, it's recommended to use condoms while also on HCPs.

First and foremost, hormonal contraceptive pills (HCP) contain hormones in some combination of estrogen and progestin, or progestin alone. These hormones are hormones that your body produces naturally, but the pill will increase the amount in your body. Estrogen and progestin work together to inhibit luteinizing hormones and follicle stimulating hormones. LH and FSH are naturally released by your pituitary gland and prepare the egg and lining of the uterus for an embryo to be successfully implanted.

Progestin-Only Minipills: These pills do not contain any estrogen, and therefore do not produce any estrogen related side effects, such as breast tenderness, headaches, nausea and vomiting. These are ideal for women with pre-existing counterindicative health conditions, such as thromboembolitic, migraine, and cardiovascular diseases, as well as history of ovarian cysts and ectopic pregnancy. However, these require women to be very careful and meticulous with daily consumption, as missing a minipill may result in a higher risk of pregnancy than combination pill.

Combination Pill: These estrogen + progestin pills suppress ovulation. They are easy to use, readily available and prescribed, effective, and are proven to protect against ovarian and endometrial cancer. However, they are pesky in the way that you must remember to take them every single day at the same time (with a 12 hour window), and you must follow a regimen if you miss 1 or 2 pills. With some pills, you may experience break-through bleeding while your body starts to adjust to the levels of hormones. 

HCPs are also broken up into 3 groups: monophasic, biphasic, and triphasic.

Monophasic pills, such as Lo Loestrin Fe (ethinyl estradiol + norethindrone), Junel 1.5/3 (this is the one I first took - my personal review at the end of this post), and Yaz (ethinyl estradiol + drospirenone), respectively contain the same amount of estrogen+progestin for 21 days. The last 7 pills are placebo pills, which are usually sugar/iron pills that you can choose to take to keep track of your consumption, or throw out. These are usually providers' first method of HCP because they are easy to take, as the first 21 days contain the same amount of hormones, and there is no confusion with which week's pills you're taking. Monophasic pills are the easiest pill to skip a period with.

Biphasic pills, such as Mircette (Ethinylestradiol + desogestrel) and Jenest (norethindrone + ethinyl estradiol), contain the same amount of estrogen in all 21 pills, but contain 2 different amounts of progesterone - the first half containing less, and the second half containing more. 

Triphasic pills, such as TriNessa (ethinyl estradiol + norgestimate), Ortho Tricyclen, and Tri-Sprintec, contain 3 different levels of estrogen + progestin in each week, usually increasing in estrogen, or both estrogen and progestin. These are all colored differently, so it is fairly easy to track which pills you are taking each week. However, it is very difficult to skip a period while on triphasic pills.

HCPs are proven to decrease the risk of ovarian and endometrial cancer depending on time of exposure to HCPs. However, they are also proven to increase the risk of breast, cervical, and liver cancers. (Click here to access the full study published by American Journal of Obstetrics and Gynecology) Some other risks of consumption of HCPs are: blood clots and pulmonary embolisms, which is why family history and extensive conversation is vital before starting HCPs. Other risks include: smoking, diabetes, hypertension, and obesity.

3. Intrauterine Device (IUD)

An IUD is a small, plastic device placed in your uterus to prevent pregnancy. This method has become widely popular because it consists of localized hormonal release (only in your uterus), while HCPs consist of systemic hormone release (all throughout your bloodstream). There are currently 5 IUDs approved by the FDA: Mirena, Skyla, Kyleena, Paragard, and Liletta. All are localized hormonal IUDs, except the Paragard, which is a nonhormonal, copper IUD that lasts up to 12 years. IUDs are 99% effective, making it one of the most effective options! Some pros: you can also forget about it for however long you want to be protected, you can't mess it up by forgetting to take it one day like the pill, and you don't have to worry about getting refills. 

Many of you responded to my Instagram story singing your praises of the Mirena IUD, a 6 year IUD that is mostly recommended for women who have had children, due to its larger size. Kyleena lasts for 5 years, Liletta for 4, and Skyla for 3 years. These hormonal IUDs contain progestin, which prevents pregnancy by thickening the cervical mucosa (and trapping those bastards), and preventing ovulation. They are highly effective, and can be taken out whenever you decide that you want to start trying to have kids. Doesn't that sound awesome?

However, there are cons of hormonal IUDs: They reportedly hurt like hell when getting them placed (makes sense - the uterus may be able to hold a baby because of the hormone relaxin produced during pregnancy, but it isn't as tough when you're not pregnant). However, this can be easily avoided with some ibuprofen before the procedure. They can also become dislodged, causing a myriad of other problems, pain being the least of them. They don't protect against STDs, causes some cramping and breakthrough bleeding upon the first couple of days to weeks, and they can simply fall out. Now, a pro/con = you may not have your period because of the consistent dosage of progestin.

Now the copper IUD - it lasts a whopping 12 years. That's amazing and it's super cost-effective. However, it works by releasing copper, which induces an inflammatory reaction in your uterus that's toxic to sperm. Because it works without hormones, you do get your period once a month, and it's been reported to give you heavier periods. Also because it works via releasing copper, and therefore inducing inflammation in your uterus, the side effects are: painful cramps, bloating, bleeding between periods, inflammation of the vagina, backache, severe menstrual pain, and pain during intercourse.

4. Patch

The birth control patch is also an option! The Evra patch is approved by the FDA and works kind of like HCPs, containing both estrogen + progestin. You wear a new patch on your belly, butt, upper arm, or back, every week for 3 weeks, then take it off for a week for your period. The hormones in the patch are absorbed through your skin, then systematically flow through your bloodstream to prevent ovulation and thicken your cervical mucosa. Though the patch doesn't protect from STDs, it's really simple and easy to use because you don't have to remember to take a pill every single day at the same time. However, you do need to remember to put a new patch on exactly a week later, and ensure that it doesn't fall off. It's also important to note that the patch may not work up to its 99% effectiveness if you are overweight)

There are also certain medications/herbs that can cause the patch to become less effective: certain antibiotics, certain HIV meds, certain anti-convulsants, St. John's Wort, and the anti-fungal, Griseofulvin. The side effects are the same as the ones of combination HCPs because they both release estrogen + progestin systematically.

5. Vaginal Ring

The NuvaRing is a small, round piece of plastic that you insert into your vagina for 3 weeks. You take it out for your period, then insert a new one for another 3 weeks. It is a hormonal birth control option, consisting of a combination of etonogestrel and ethinyl estradiol, so it suppresses ovulation and thickens your cervical mucosa to prevent sperm from reaching your eggs. It's unique in the way that you can place the ring yourself each month, giving you independence from taking a pill every day. The side effects listed on the NuvaRing website are as follows: irritation inside your vagina or on your cervix, headache (including migraine), mood changes (including depression), the ring slipping out or causing discomfort, nausea and vomiting, vaginal discharge, weight gain, vaginal discomfort, breast pain, discomfort, or tenderness, painful menstrual periods, abdominal pain, acne, and less sexual desire. Note that these are common side effects to all hormonal contraceptives, but side effects specific to the NuvaRing are vaginal discomfort + possibilities of the ring slipping out. The NuvaRing does not prevent against STDs.

6. Implant

Implanon and Nexplanon are your implant options. The implant is small, about the size of a matchstick, and is placed in your upper arm to systematically release progestin to thicken your cervical mucosa and also suppress ovulation. It's a simple 5-10 minute procedure, and it lasts 4 years. Because it consists of only progestin and is estrogen-free, you likely won't experience the side effects of estrogen, such as nausea, breast tenderness, hair loss, skin hyper-pigmentation, cramping, and weight gain to name a few. Like the IUD, you can forget about it after you get it placed, and you don't have to remember to take it out or take a pill, which makes this method so easy and increasingly popular. A lot of women also love the implant because it's not placed anywhere near your reproductive organs, preventing any possibility of damage to your uterus, cervix, or vagina.

Though it protects you from pregnancy the moment you get it implanted and is 99% effective, you will experience break-through bleeding and spotting for the first 6-12 months. Other side effects include pain/infection where the implant is placed, pain when accidentally striking the area where the implant is, headaches, breast tenderness, ovarian cysts, and weight gain. Note that side effects of progestin + estrogen overlap. 

7. Shot

The Depo-Provera shot is a non-invasive form of contraceptive that you receive in your arm or butt every 12 weeks. It consists of progestin and is estrogen-free, but it doesn't protect you from STDs. Though it is 99% effective, you run the risk of forgetting to receive a shot in a timely manner. It's popular because it does not require daily use, nor does it require for you to have a device sitting in your body for a prolonged amount of time. However, many women report weight gain, mood changes, depression, migraines, and heavier periods.

8. Fertility Awareness Method

This method is completely natural, but requires full attention and responsibility, as it depends on your ability to track the changes in your cervical fluid, body temperature, and your menstrual cycle. Basically, you're learning when your ovulation and are the most fertile, and abstaining from sex during this time, or using another form of contraceptive such as condoms in this time. FAM is 75% effective if used perfectly. 

The Ovulation/Cervical Mucus Method requires you to inspect your cervical fluid/discharge every day, noting the differences in color, consistency, and amount, using a chart like this. You are most fertile when your discharge is like a raw egg white - clear, loose, and large in quantity. This is your ovulation phase. You should avoid vaginal intercourse during this time, or use another form of contraceptive. After ovulation, you are less fertile when your discharge is sticky, white in color, and less in quantity.

The Basal Body Temperature Method is exactly what it sounds like. Every morning upon waking up, you take your oral temperature before drinking/eating anything. During ovulation, when you're most fertile, your basal body temperature is higher than in the rest of the month. You should do this for at least 1-2 months before completely depending on this method. Also note that your temperature probe may err, or you may have a fever unrelated to your menstrual cycle which can disrupt your family planning. 

The Calendar Method depends entirely on your previous cycles and predicts that your next cycle will be similar to your last cycle as to when you ovulate.

The combined method of the 3 methods, or the Sympto-Thermal Method is not only eye-opening, it is also empowering in the way that you get to know exactly how your unique body works during your menstrual cycle, and gives you the autonomy of choosing when to have sex. It really requires you to be meticulous and diligent in family planning, and is the ultimate responsibility if you choose to abstain from using any other contraceptive option. 

There are many resources out there for you to be successful with this method, and you need to use these to effectively prevent pregnancy. A good resource is Taking Charge of Your Fertility by Toni Weschler.

9. Diaphragm

A diaphragm is a small, silicon cup that you attach to your cervix before intercourse to prevent pregnancy. It's recommended to be used in conjunction with spermicide, a cream/gel that kills sperm, because the diaphragm is merely a physical barrier for sperm to swim up your vagina and cervix. They're 88% effective, and are favored because they don't introduce more hormones into your body. You must use the diaphragm before intercourse every single time, and must be placed perfectly to cover your cervix. It's cheap and gives you independence from any pills or invasive procedures, but depends on your ability to stop during foreplay to insert the diaphragm. 

10. Cervical Cap

The cervical cap, or the FemCap, is a smaller version of a diaphragm. It also needs to be used with spermicide to be effective. It's more comfortable than a diaphragm because it's smaller, and you can keep it in longer (up to 2 days). However, because it's smaller, it is slightly less effective than the diaphragm. 

11. Pull-Out Method

It's as simple as it seems. Your partner pulls out before climax/ejaculation. However, it is very risky and many people do not realize that there may be sperm in pre-ejaculate(precum), especially if your partner has not cleared out his urethra before intercourse, or has masturbated/had sex soon before. It's also difficult to note when pre-ejaculate is produced. To be successful in preventing pregnancy, your partner must know exactly when he is going to ejaculate. Then, he must immediately pull out, and ejaculate anywhere away from your vagina. It is convenient and possible to be successful with this method, but it is also highly recommended that you use this method in conjunction with other methods, including the emergency contraceptive pill, Plan B.

12. Abstinence 

At 100% effective, abstinence takes the prize for being the most effective and most cost efficient. Vaginal abstinence, if we're being really clear. If you don't have sex, you can't become pregnant. It's quite simple (unless you're Jane Villanueva.)

Pros: It's free and simple.

Cons: This still doesn't mean you are protected from STDs if you participate in other sexual activities like anal or oral sex. It may be more difficult for some to abstain from sex.

Finally, my experience with contraceptives so far:


My first method of birth control was abstinence, and my knowledge of sexual health only consisted of what I was taught in middle school: STDs exist, if you have more partners, the more you're exposed to STDs, and that condoms are available to buy at the grocery store. I didn't know what birth control was until college, and I didn't know about IUDs, Implants, the Fertility Awareness Method until this past year! My first OCP was prescribed by a male physician and he picked the lowest dose monophasic pill on his little chart: Junel Fe 1.5/30. He didn't teach me anything about it, except that I need to take 1 every day around the same time, and that if I miss any, then I have instructions in my pill packet. He didn't tell me my other options, and I didn't ask. I was embarrassed, and I just wanted to get the hell out of there with a prescription and call it a day.

During the first couple of weeks, I experienced minimal breakthrough bleeding, and my period on the last week of pills was lighter than my normal period. However, I felt very very emotionally labile, switching from happy to sad in an instant. I was mostly sad, my sex drive plummeted, and I had no idea why I was experiencing these changes. I think I was mostly just hopeful that it was a phase because I was stressed with classes. It definitely didn't help while trying to set the grounds for a new relationship. I was not myself.

I finally did a little research and found that so many other people were feeling the same way as I did. I learned that although monophasic pills are low dose and easy for people to skip periods with, the equal amount of hormones did not replicate the way that my body normally produces hormones: gradually increasing throughout my cycle until my period. I asked the same doctor for a new prescription for a triphasic pill. He easily wrote me a prescription for Tri-Previfem, the generic version of Ortho Tri-Cyclen. I was happy about a change, even though this meant that it would be a lot more difficult for me to miss pills. Now I've been on this combo, triphasic pill for almost 2 years and I'm happy about the results. I haven't gotten pregnant, I've never missed a pill (I set a reminder on my phone for 5PM everyday), and it doesn't seem to affect my emotions. However, I have noticed hair loss (most likely due to the increased amount of hormones compared to the amount my body normally makes), low libido, and breakouts on week 3 (most likely due to the increased dosage of progestin). 

This past week, I got my first annual well-woman exam, consisting of a breast, abdomen, pelvic exam and a pap smear. It was done by a Family Nurse Practitioner student and another FNP, and it was a great experience because I got to poke their brains and ask them all my questions about the IUD and other methods of contraceptives. They explained that many women prefer the Mirena because it lasts 5 years, it's comfortable, it's covered by most insurances, and it only requires a painful 5 minute insertion which is unavoidable. I did ask if it matters if I have had children or not because of the size of the IUD, and they both explained that the OB will ultimately decide whether or not I'm a good candidate for the Mirena, or will have to go with the Skyla, which lasts 3 years. Both agreed that Mirena is the most popular and favored, while the Paragard (copper), is the most uncomfortable as it induces inflammation and causes lots of breakthrough bleeding. So I'm thinking of going with the Mirena, because I don't plan on having kids in the next 5 years.

With all of this said, I hope that this helps you have a general grasp on what your major options are for contraceptives! Remember that knowledge is key. If you go in asking for a pill, and your provider doesn't really care what you want or what they want to prescribe, then you'll get whatever's easiest for him/her. But if you go in with questions, ideas, and concerns, then they will reciprocate. Also, do not use this as your sole resource for your contraceptive options. Talk to your provider, talk to your friends, and make a sound, informed decision. It is easier said than done to have these conversations with your provider, but I hope that you feel encouraged and empowered to. It's your body, after all.

UPDATE: It’s less than 30 days until the wedding and I’m still on Tri-Previfem. In between graduating nursing school, switching jobs, and moving in with Caleb, there’s been a lot of change within my insurance, so I’m going to wait until we get back from honeymooning to get an IUD! I’m most likely going with the Mirena, but I’m also keeping my options open for something like Skyla or Kyleena. Let’s see what my OB has to say!

xo,

Clara

PS - Please feel free to share your experience with the contraceptive of your choice in the comment section below! However, let's make this space a space free of judgement and hate, and respect others' reproductive decisions.

Sources:

http://stayteen.org/sex-ed/article/iud

https://www.plannedparenthood.org/learn/birth-control

http://www.ajog.org/article/S0002-9378(04)00143-7/fulltext

http://www.webmd.com/sex/birth-control/birth-control-options