Choosing a Birth Control Method
Did you know that birth control is commonly taken to reduce period symptoms and to reduce bleeding even when it's contraceptive effect is not needed? Of course plenty of people do use birth control as a contraceptive too. During 2015–2017, 64.9% of the 72.2 million women aged 15–49 in the United States were currently using contraception. Today I'll cover all the different types and let you know what I've observed after prescribing it for nearly a decade. I hope this information empowers those are using or planning to use contraception to find the best method for them and that it opens up conversations about contraception in our homes, provider's offices, and in the community.
The best thing about modern contraception is the variety - the variety of methods and the variety of progestins (man made progesterone). Some contraceptives (aka birth control) contain two hormones that play different roles. Estrogen reduces the chance of bleeding in the middle of a cycle while progestins thicken cervical mucus so sperm can't get through to fertilize an egg. Over time, progestins also thin the lining of the uterus that is shed each month which means lighter periods! Some contraceptives contain both (aka combined) and others only contain a progestin. It is a common misconception that these hormones prevent pregnancy by stopping an egg from being released. Most women still ovulate (release an egg) most months on birth control. Until I get to the topic of IUDs, the methods I discuss need to be used consistently for 1 week to become effective.
When contraceptives are mentioned, we first think of the pill. Which makes sense because it's been around for a while and a lot of women use it. It gets a bad rap for it's history of causing weight gain, nausea, and mood changes. But now days, the pill is offered in very low doses so those side effects are typically mild if they do happen at all. When the pill was new, one pill contained a dose of hormones that was like taking a whole pack at once today. Of course women gained weight and were nauseous on that high of a dose. While we get less side effects, the down side of today's super low dose pills is that they don't control bleeding as well, especially with a missed pill. Sometimes they have to be taken consistently for a few months for that to clear up. And they really do need to be taken daily to be most effective. One trick is to add taking the pill to a well established habit like brushing your teeth. If you realize you've missed a pill, take it right away. If you go to take your pill and yesterday's is still there, take them both at the same time. There are days of the week stickers in each pack or they come prelabeled to help avoid missed pills.
Another great thing about the pill is that there are so many varieties. While the estrogen is the same, the progestins vary giving us lots of choices to find the best fit for each person. So if you've tried the pill but didn't like the side effects, it doesn't mean the pill is a bad choice for you, try one with a different progestin.
If remembering a pill daily doesn't sound good, then the patch and the ring are worth considering. Change the patch once a week for three weeks then no patch for a week. Yes you can shower and swim with it on. Sometimes the adhesive causes irritation. Rotating where it's placed helps - thigh, hip, shoulder, lower abdomen (nowhere near the breasts though because they're sensitive to estrogen). There are also different brands that use different adhesives so trying a different one often solves the problem.
Similar to the patch, the ring is used for three weeks. Place the ring vaginally - just pinch it and slide it in, you can't put it in too far. Leave it for three weeks then remove it for a week. The ring can be left in or removed during intercourse, just check that it's not in the sheets afterwards because it won't do you any good there. It can be out for a maximum of 3 hours a day and still be effective. Currently, there are two rings on the market in the United States, Nuvaring and Annovera. They are about the same size but Annovera is thicker and the one in the photo. Nuvarings, like monthly contacts, need to be tossed after a month. They also have to be kept in the fridge until it's time to insert them. With Annovera however it's a once a year trip to the pharmacy because one ring is good for 13 cycles and it does not have to be refrigerated.
The combined pill, the patch, and the ring are not for everyone though because people with a history of blood clots (think DVT and stroke not menstrual blood clots), liver disease, migraines with aura, and smokers over 35 years old can't take estrogen. That's where progestin only methods step in. But without the estrogen, breakthrough bleeding is common for the first few months with these methods.
There's the "mini pill" - a low dose progestin only pill that's great for breastfeeding mommas but otherwise I don't recommend because most women bleed all the time on it. Slynd is a higher dose (but still low dose) progestin only, again without estrogen so breakthrough bleeding is common but typically stops after a few months of use.
Progestins are also available in the long acting devices - Nexplanon, Skyla, Kyleena, Liletta, and Mirena. Once they're in, you don't have to worry about birth control for 3-7 years but they can be removed at any time. Because they are always in place, there is no break from the progestin. The uterine lining thins and periods become less frequent or stop. This reduction of the uterine lining (endometrium) reduces the risk of endometrial cancer. However, women of childbearing years who are not on a progestin and rarely have periods are at increased risk of endometrial cancer and should follow up with their women's health provider.
Nexplanon is a single rod that is placed just under the skin of the upper, inner arm by a healthcare provider and is good for up to three years. It's typically easy to remove - a little numbing medicine, a 2-3 mm incision, and out it comes. This method can be used for women of any reproductive age but I found it was a very popular choice among teens. It's not the best choice for people with heavy periods though because they generally continue to bleed too much on it.
The other long acting devices are placed in the cavity of the uterus (intrauterine devices aka IUDs) by a healthcare provider. While they have different dosages of progestin, they're all low dose and all IUDs are effective immediately with insertion. These are the devices available currently in the US. Skyla, used for up to 3 yrs, is great for teens and adults who have never been pregnant. Mirena, used for up to 7 yrs, is great for those with heavy cycles. Mirena is also a great option for managing heavy bleeding caused by fibroids. Mirena often stops bleeding completely so for women who want to continue to see signs of their cycle, Kyleena, used for up to 5 yrs, should be considered. Liletta, used for up to 7 yrs, may be the best option when insurance will not cover an IUD because their patient savings program reduces the out of pocket cost to $100. While IUDs cost the most up front, they are effective for years. Over time, they are cost effective. For example, a Mirena costs around $950 and lasts 7 years which comes to $10.44 a cycle. For those that love IUDs, when it comes time, IUDs can be removed and replaced on the same day.
The only non-hormonal IUD is the Paragard. Instead of a progestin, it has copper wrapped around it that makes a toxic environment for eggs and sperm. The paragard is for women who do not want to take any hormones but still want contraception. Commonly, Paragard makes periods longer and heavier so not a great choice for women who already have heavy periods.
IUD insertion is quick but more painful than the removal so I always told my patients to take 800mg of Ibuprofen 30-60 min before the insertion. There can be some cramping afterwards too. There is some debate that since the skyla is the smallest IUD, it is the least painful to be inserted but I found that it really depends on the person's pain tolerance, the provider's technique, and how firm the cervix is. I've inserted all types of IUDs in women who've recently had a baby and a lot say they didn't even feel it or that it barely hurt. Whereas I've put the Skyla in women who've never had a baby and have a tight cervix and they say it hurts a lot. Rarely, I've prescribed a sedative like valium to take upon arrival at the office so they can tolerate insertion. I've never had to put someone to sleep for it. The biggest risk with IUD insertion is that instead of sliding into the space inside the uterus, it goes into the wall of the uterus or through the wall of the uterus. Then it has to be surgically removed. This is a rare occurrence but it can happen.
Tubal ligation has changed somewhat recently in the US and world wide. Now most surgeons remove both tubes completely (salpingectomy) instead of clamping or burning them. This change happened as studies have shown that removing the tubes reduces the risk of ovarian cancer. The fallopian tubes are the passageways for eggs to get into the uterus and the opening inside is as narrow as a straight pin. Any inflammation or injury to a tube can easily block it so when a tube is clamped or cut, it is very difficult to reverse. The chance of a reversal working even with an experienced surgeon is very slim. A tubal should be considered as permanent, there's no going back. I recommend seeing a fertility specialist for assistance in conceiving after any version of a tubal. Vasectomy on the other hand has a higher reversal rate because the passageway for sperm isn't as narrow. When considering a tubal or vasectomy, remember that there are risks with surgery such as infection, injury, bleeding, and reactions to anesthesia. Most tubals today can be done laparoscopically, meaning no large incisions. The fallopian tubes are deep in the pelvis making a tubal ligation a more complex procedure than a vasectomy.
You've probably been wondering why I haven't been talking about effectiveness and can imagine the charts showing IUDs and tubal ligation at the top. The problem with these charts is that they prioritize effectiveness and disregard the complexity of contraceptive decision making. When used consistently and correctly, all the methods I've discussed are pretty similar in effectiveness and they are more effective than condoms alone. The only 100% effective method is abstinence, which is effective until it isn't (a hard truth I've discussed with moms of teens, myself being included as I've got a 19 year old daughter who had a boy problem at 16). It's almost always best to start contraception before it's needed because then there's time for it to become effective and time to try different methods if needed. Sometimes people immediately stop their contraceptives during a breakup which I don't usually recommend. Stopping in the middle of a pack of pills can cause dysfunctional bleeding. It's best to stop at the end of the pack. I'm also an optimist and realist. As people heal and recover, they can find someone wonderful that they do want to be with. We are social beings, we need each other and intimacy is part of that.
All these options I've discussed do not prevent sexually transmitted infections so the use of condoms correctly and consistently to reduce the risk is essential.
Considerations for breastfeeding - Rates of pregnancy complications and miscarriage increase when pregnancies are spaced closer than 12 months apart. While solely breastfeeding without supplementing does provide some protection against pregnancy for the first 6 months, starting birth control about 6 weeks after the birth of a child is a great idea. Most women have a significant decrease in milk supply if they start an estrogen containing contraceptive so the mini pill, any of the progestin methods, and the copper IUD should be considered. Occasionally, I have prescribed estrogen containing contraceptives for breastfeeding mommas with postpartum depression. Estrogen levels typically don't return to pre-pregnancy levels while breastfeeding and these low levels can significantly contribute to postpartum depression. I am all for supporting breastfeeding but sometimes starting a combined pill to improve mood is worth a decreasing milk supply and each situation must be considered carefully.
I hope that this information finds you well and helps you have open and informed discussions about birth control options with your partners, loved ones, friends, and your healthcare provider. If you like what you've read, please share it and subscribe to my monthly newsletter at the bottom of this page. Love to you all and happy quilting!
*Although I am a Nurse Practitioner, please consult with your health care provider.
