Choosing a Contraceptive

Choosing a method of birth control is a highly personal decision, based on individual preferences, medical history, lifestyle, and other factors. Each method carries with it a number of risks and benefits of which the user should be aware.

Each method of birth control has a failure rate – an inability to prevent pregnancy over a 1-year period. Sometimes the failure rate is due to the method and sometimes it is due to human error, such as incorrect use or not using it at all. Each method has possible side effects, some minor and some serious. Some methods require lifestyle modifications, such as remembering to use the method with each and every sexual intercourse. Some cannot be used by individuals with certain medical problems.

Spermicides Used Alone

Spermicides, which come in many forms – foams, jellies, gels, and suppositories – work by forming a physical and chemical barrier to sperm. They should be inserted into the vagina within an hour before intercourse. If intercourse is repeated, more spermicide should be inserted. The active ingredient in most spermicides is the chemical nonoxynol-9. The failure rate for spermicides in preventing pregnancy when used alone is from 20% to 30%.

Spermicides are available without a prescription. People who experience burning or irritation with these products should not use them.

Barrier Methods

There are five barrier methods of contraception:

  • male condoms
  • female condoms
  • diaphragm
  • sponge
  • cervical cap

In each instance, the method works by keeping the sperm and egg apart. Usually, these methods have only minor side effects. The main possible side effect is an allergic reaction either to the material of the barrier or the spermicides that should be used with them. Using the methods correctly for each and every sexual intercourse gives the best protection.

For many people, the prevention of sexually transmitted diseases (STDs), including HIV (human immunodeficiency virus), which leads to AIDS, is a factor in choosing a contraceptive. Only one form of birth control currently available – the latex condom, worn by the man – is considered highly effective in helping protect against HIV and other STDs. FDA has approved the marketing of male condoms made from polyurethane as also effective in preventing STDs, including HIV. However, at press time, they were not yet being sold in this country. Reality Female Condom, made from polyurethane, may give limited protection against STDs but has not been proven as effective as male latex condoms. People who use another form of birth control but who also want a highly effective way to reduce their STD risks, should also use a latex condom for every sex act, from start to finish.

Male Condom

A male condom is a sheath that covers the penis during sex. Condoms on the market at press time were made of either latex rubber or natural skin (also called “lambskin” but actually made from sheep intestines). Of these two types, only latex condoms have been shown to be highly effective in helping to prevent STDs. Latex provides a good barrier to even small viruses such as human immunodeficiency virus and hepatitis B. Each condom can only be used once. Condoms have a birth control failure rate of about 15%. Most of the failures can be traced to improper use.

Some condoms have spermicide added. This may give some additional contraceptive protection. Vaginal spermicides may also be added before sexual intercourse.

Some condoms have lubricants added. These do not improve birth control or STD protection. Non-oil-based lubricants can also be used with condoms. However, oil-based lubricants such as petroleum jelly (Vaseline) should not be used because they weaken the latex. Condoms are available without a prescription.

Female Condom

The Reality Female Condom consists of a lubricated polyurethane sheath with a flexible polyurethane ring on each end.

One ring is inserted into the vagina much like a diaphragm, while the other remains outside, partially covering the labia. The female condom may offer some protection against STDs, but for highly effective protection, male latex condoms must be used. (The female condom should not be used at the same time as the male condom because they will not both stay in place.)

In a 6-month trial, the pregnancy rate for the Reality Female Condom was about 13%. The estimated yearly failure rate ranges from 21% to 26%. This means that about 1 in 4 women who use Reality may become pregnant during a year.

Sponge

The contraceptive sponge is made of white polyurethane foam. The sponge, shaped like a small doughnut, contains the spermicide nonoxynol-9. Like the diaphragm, it is inserted into the vagina to cover the cervix during and after intercourse. It does not require fitting by a health professional and is available without prescription. It is to be used only once and then discarded. The failure rate is between 18% and 28%. An extremely rare side effect is toxic shock syndrome (TSS), a potentially fatal infection caused by a strain of the bacterium Staphylococcus aureus and more commonly associated with tampon use.

Diaphragm

The diaphragm is a flexible rubber disk with a rigid rim. Diaphragms range in size from 2 to 4 inches in diameter and are designed to cover the cervix during and after intercourse so that sperm cannot reach the uterus. Spermicidal jelly or cream must be placed inside the diaphragm for it to be effective.

The diaphragm must be fitted by a health professional and the correct size prescribed to ensure a snug seal with the vaginal wall. If intercourse is repeated, additional spermicide should be added with the diaphragm still in place. The diaphragm should be left in place for at least six hours after intercourse. The diaphragm used with spermicide has a failure rate of from 6% to 18%.

Barrier methods, which work by keeping the sperm and egg apart, usually have only minor side effects.

In addition to the possible allergic reactions or irritation common to all barrier methods, there have been some reports of bladder infections with this method. As with the contraceptive sponge, TSS is an extremely rare side effect.

Hormone Contraceptives

Hormonal contraception involves ways of delivering forms of two female reproductive hormones – estrogen and progestogen – that help regulate ovulation (release of an egg), the condition of the uterine lining, and other parts of the menstrual cycle. Unlike barrier methods, hormones are not inert, do interact with the body, and have the potential for serious side effects, though this is rare. When properly used, hormonal methods are also extremely effective. Hormonal methods are available only by prescription.

Birth Control Pills

There are two types of birth control pills: combination pills, which contain both estrogen and a progestin (a natural or synthetic progesterone), and “mini-pills,” which contain only progestin. The combination pill prevents ovulation, while the mini-pill reduces cervical mucus and causes it to thicken. This prevents the sperm from reaching the egg. Also, progestins keep the endometfium (uterine lining) from thickening. This prevents the fertilised egg from implanting in the uterus. The failure rate for the mini-pill is 1% to 3%; for the combination pill it is 1% to 2%.

Combination oral contraceptives offer significant protection against ovarian cancer, endometrial cancer, iron-deficiency anemia, pelvic inflammatory disease (PID), and fibrocystic breast disease. Women who take combination pills have a lower risk of functional ovarian cysts.

The decision about whether to take an oral contraceptive should be made only after consultation with a health professional. Smokers and women with certain medical conditions should not take the pill. These conditions include: a history of blood clots in the legs, eyes, or deep veins of the legs; heart attacks, strokes, or angina; cancer of the breast, vagina, cervix, or uterus; any undiagnosed, abnormal vaginal bleeding; liver tumors; or jaundice due to pregnancy or use of birth control pills.

Women with the following conditions should discuss with a health professional whether the benefits of the pill outweigh its risks for them:

  • High blood pressure
  • Heart, kidney, or gallbladder disease
  • A family history of heart attack or stroke
  • Severe headaches or depression
  • Elevated cholesterol or triglycerides
  • Epilepsy
  • Diabetes

Serious side effects of the pill include blood clots that can lead to stroke, heart attack, pulmonary embolism, or death. A clot may, on rare occasions, occur in the blood vessel of the eye, causing impaired vision or even blindness. The pills may also cause high blood pressure that returns to normal after oral contraceptives are stopped. Minor side effects, which usually subside after a few months’ use, include: nausea, headaches, breast swelling, fluid retention, weight gain, irregular bleeding, and depression. Sometimes taking a pill with a lower dose of hormones can reduce these effects.

The effectiveness of birth control pills may be reduced by a few other medications, including some antibiotics, barbiturates, and antifungal medications. On the other hand, birth control pills may prolong the effects of theophylline and caffeine. They also may prolong the effects of benzodiazepines such as Librium (chlordiazepoxide), Valium (diazepam), and Xanax (alprazolam). Because of the variety of these drug interactions, women should always tell their health professionals when they are taking birth control pills.

Methods of hormonal contraception, when used properly, are extremely effective.

Implants & Injections

Hormonal contraception for women is available in the form of implants or injections that release the contraceptive into the body over a sustained period of time. 

Hormonal implants and injections are very effective if used correctly, but can cause side effects. Speaking with a doctor or nurse can help you to choose the method of contraception that best suits your needs.

Other forms of hormonal contraception include oral tablets (the combined pill and the mini pill), the hormonal IUD and the vaginal ring.

Contraceptive implant

The contraceptive implant (sold as Implanon NXTTM) is a hormonal implant the size of a matchstick, which is inserted under the skin at the inner side of the upper arm. This 4 cm-long implant contains etonogestrel, a progesterone-like hormone that prevents ovulation.

This hormone also thickens the mucus in the cervix (entrance to the uterus), preventing sperm from getting through. The implant is inserted and removed under local anaesthetic by a specially trained doctor. 

Advantages of the contraceptive implant include that:

  • It is close to 100 per cent effective.
  • It lasts for three years.
  • It costs about $36 for Medicare card holders (less for healthcare card holders).
  • At most, it takes just one week to start working (depending on when the implant is inserted).
  • It is safe to use when breastfeeding.
  • It can be used by most women who cannot take synthetic oestrogens.
  • Women usually start ovulating again within three weeks of removing the implant.

Disadvantages of the contraceptive implant:

  • Some bruising and discomfort around the implant is common and may last for up to a week.
  • It can cause irregularities with periods, such as unscheduled bleeding.
  • It can cause headaches, acne, breast tenderness and increased appetite.
  • It can move from its original position under the skin.
  • There is a slight risk of infection and bleeding around the implant.
  • The contraceptive implant does not provide protection from sexually transmissible infections (STIs).
  • Some medications, particularly some that are used to treat epilepsy, and the herbal remedy St John’s Wort, can make it less effective.

Contraceptive injection

The contraceptive injection, known as Depo (sold as Depo-ProveraTM/ Depo-RaloveraTM) is a long-acting, injectable contraceptive that contains only the synthetic form of progesterone, depot medroxyprogesterone acetate (DMPA). Each injection of DMPA prevents an unplanned pregnancy for 12 to 14 weeks. 

The contraceptive injection prevents ovulation and thickens the mucus in the cervix, preventing sperm from getting through. It can also be used to treat women with menstrual problems.

You will need to talk with a doctor or nurse before you start using the contraceptive injection, as this method is not suitable for all women.

Advantages of the contraceptive injection include that:

  • It is very effective and convenient.
  • It is safe to use when breastfeeding, especially if the baby is over six weeks old.
  • About 50 per cent of women using the contraceptive injection do not have periods, which some women see as an advantage.
  • There are no medications that make it less effective.

Disadvantages of the contraceptive injection include that:

  • It cannot be reversed or withdrawn, which means side effects may last for 12 to 14 weeks.
  • It can cause unpredictable irregularities with periods.
  • There is a delay in return to fertility after the contraceptive injection is stopped.
  • It can be associated with a reduction in bone density.
  • Some women experience side effects such as weight gain, headaches and depression.
  • The contraceptive injection does not provide protection from sexually transmissible infections (STIs).
  • Male injectable contraceptives are currently being trialled.

Intrauterine Devices

An intrauterine device (IUD) is a small contraceptive device that is inserted into the uterus (womb) to prevent a pregnancy. The two types available are the copper IUD and the hormonal IUD (sold as MirenaTM). The hormonal IUD contains progestogen, which is a synthetic version of the naturally occurring hormone progesterone. Both types are very effective methods of contraception and can stay in place for at least five years.

IUDs affect the way sperm move and survive in the uterus, preventing these cells from reaching and fertilising the ovum (egg). IUDs can also cause changes to the lining of the uterus to stop a fertilised ovum from developing. The hormonal IUD can thicken the mucus made by the cervix (entrance to the womb), preventing sperm from getting through. It can also affect ovulation by altering the hormones that cause an ovum to be released each month. 

Different methods of contraception may suit you at different times in your life. A doctor or nurse can advise you on the risks and benefits of using the copper or hormonal IUD, as well as on the alternative methods available. Alternative methods include the contraceptive implant or injection, the vaginal ring or the combined oral contraceptive pill.

Copper IUD

The copper IUD is a small plastic device with copper wire wrapped around it and a fine nylon string attached to the end. When the device is in place, the string comes out through the cervix into the top of the vagina. This piece of string lets you check that the IUD is still in place and makes it easy for a doctor to remove it. You cannot feel the string unless you put your finger deep inside your vagina.

Hormonal IUD

The hormonal IUD (sold as MirenaTM) is a small plastic T-shaped device that contains progestogen. This is a synthetic version of the naturally occurring hormone progesterone. The device has a coating (membrane) that controls the release of progestogen into the uterus. Like the copper IUD, it has a fine nylon string attached to the end to make checking and removing it easier. 

Advantages of IUDs

Advantages of using the copper or hormonal IUD include:

  • Both the copper and hormonal IUD are more than 99 per cent effective in preventing a pregnancy.
  • Both types last between five and ten years.
  • Once inserted, you will only need to check the string each month.
  • The device can be removed at any time by a specially trained doctor or nurse.
  • Your ability to become pregnant will return as soon as the copper or hormonal IUD has been removed.

Disadvantages of IUDs

Disadvantages of using the copper or hormonal IUD include:

  • Both types must be inserted by a doctor or nurse who has been specially trained in the technique.
  • You may have additional costs and difficulty accessing the service.
  • There is a small risk of infection at the time of insertion.
  • There may be an increased risk of pelvic inflammatory disease (an infection of the pelvic organs including the fallopian tubes) if you are at risk of sexually transmissible infections (STIs).
  • There is a small risk of perforation, which is when the IUD tears the wall of the uterus during insertion.
  • There may be complications with unplanned pregnancies.
  • The device can fall out.
  • Neither type provides protection from STIs.

Differences between the copper and hormonal IUD

There are a number of differences between the copper and hormonal IUD, including:

  • Menstruation differences for:
    – Hormonal – after the hormonal IUD has been inserted, you may have three to five months of frequent and irregular bleeding between periods. After this time, your periods may be shorter, lighter, and less painful. About 50 per cent of women stop bleeding completely.
    – Copper – after the copper IUD has been inserted, you may have a few weeks of irregular bleeding between periods. After this time, your periods may be heavier and more painful.
  • Cost differences for:
    – Hormonal – the hormonal IUD is covered by a healthcare card in Australia. It costs around $6 if you are a card holder and around $36 if you do not have a card.
    – Copper – the copper IUD is not covered by a healthcare card and may cost around $150 outside a public hospital setting.
  • Side effects differences for:
    – Hormonal – the hormonal IUD may cause headaches, acne, breast tenderness and an increase in appetite in the first few months of use.
    – Copper – the copper IUD has no hormonal side effects.
  • Medical conditions differences for:
    – Hormonal – the hormonal IUD should not be used if you have had breast cancer in the last five years. 
    – Copper – with rare exceptions, the copper IUD will not have any known impact on existing medical conditions.

Other types of contraception
There are a number of contraceptive choices available in Australia. Speaking with a doctor or nurse will help you understand your options. The method you choose will depend on your general health, lifestyle and relationships. It is important to weigh up the benefits and disadvantages of each method, and to consider your current and future needs. 

Periodic Abstinence

Periodic abstinence entails not having sexual intercourse during the woman’s fertile period. Sometimes this method is called natural family planning (NFP) or “rhythm.” Using periodic abstinence is dependent on the ability to identify the approximately 10 days in each menstrual cycle that a woman is fertile. Methods to help determine this include:

  • The basal body temperature method is based on the knowledge that just before ovulation a woman’s basal body temperature drops several tenths of a degree and after ovulation it returns to normal. The method requires that the woman take her temperature each morning before she gets out of bed. There are now electronic thermometers with memories and electrical resistance meters that can more accurately pinpoint a woman’s fertile period.
  • The cervical mucus method, also called the Billings method, depends on a woman recognizing the changes in cervical mucus that indicate ovulation is occurring or has occurred.

Periodic abstinence has a failure rate of 14% to 47%. It has none of the side effects of artificial methods of contraception.

Surgical Sterilization

Surgical sterilization must be considered permanent. Tubal ligation seals a woman’s fallopian tubes so that an egg cannot travel to the uterus. Vasectomy involves closing off a man’s vas deferens so that sperm will not be carried to the penis.

Vasectomy is considered safer than female sterilization. It is a minor surgical procedure, most often performed in a doctor’s office under local anesthesia. The procedure usually takes less than 30 minutes. Minor post-surgical complications may occur. This is not a procedure that Dr Holland performs.

Tubal ligation is an operating-room procedure performed under general anesthesia. The fallopian tubes can be reached by a number of surgical techniques, and, depending on the technique, the operation is sometimes an outpatient procedure or requires only an overnight stay. In a minilaparotomy, a 2-inch incision is made in the abdomen. The surgeon, using special instruments, lifts the fallopian tubes and, using clips, a plastic ring, or an electric current, seals the tubes. Another method, laparoscopy, involves making a small incision above the navel, and distending the abdominal cavity so that the intestine separates from the uterus and fallopian tubes. Then a laparoscope–a miniaturized, flexible telescope–is used to visualize the fallopian tubes while closing them off.

Both of these methods are replacing the traditional laparotomy.

Major complications, which are rare in female sterilization, include: infection, hemorrhage, and problems associated with the use of general anesthesia. It is estimated that major complications occur in 1.7 percent of the cases, while the overall complication rate has been reported to be between 0.1% and 15.3%.

The failure rate of laparoscopy and minilaparotomy procedures, as well as vasectomy, is less than 1%. Although there has been some success in reopening the fallopian tubes or the vas deferens, the success rate is low, and sterilization should be considered irreversible.