Contraception Quickie
There are SO many options for effective contraception! How does one choose? For some, it’s all about effectiveness. For others, choosing the right contraception means choosing the right side effect profile. Important considerations like impact on acne, menses, mood, hormones, body weight, and ease of access and use are often deciding factors. Below are the basics, how the contraception works, and the side effects one might experience.
While I am an aspiring OB-GYN finishing medical school this year, please, please, please: before starting a new medication and/or discontinuing your current medication, see your doctor and make sure it’s a safe option for you. This is not an exhaustive list of options or side effects, just a jumping off point for your further research and discussion with your doctor.
Note: The percentages listed are the rates of “failure” at one year – what percentage of users has an unintended pregnancy after one year of typical use.
Most Effective
The most effective options for preventing pregnancy are surgical sterilization, the arm implant, and intrauterine devices. The arm implant and intra-uterine devices are referred to as LARCs, or long-acting reversible contraception. Their effectiveness is on-par with surgical sterilization—without the surgery or sterilization.
Arm Implant: 0.05%
How does it work? The arm implant, brand name Nexplanon, releases a progestin (an analogue to your bodies natural hormone progesterone). Progestin-based contraceptive options generally work by thickening cervical mucus, inhibiting tubal motility, and suppressing ovulation. In other words, at the level of your pelvic organs, it makes it hard for the sperm and egg to meet. At the level of your hormonal axis, it suppresses the monthly release of an egg from your ovary.
Why some love it? It is highly effective, safe in breast-feeding, and user error-proof.
Why some ditch it? This is typically not preferred by those who want a predictable or easy-to-control period. Irregular bleeding and persistent spotting are common side effects. Most women who have the arm implant removed do so because they find the irregular bleeding to be too bothersome. While some methods of contraception that cause irregular bleeding for the first year or so continue to improve, women who are experiencing irregular bleeding at 1 year with an arm implant are likely to continue to experience the same level of irregular bleeding for the remainder of the time they are relying on this method.
Intra-Uterine Devices: 0.2%-0.8%
A brief aside: The IUD has a bad reputation to overcome. The Dalkon shield was a seriously problematic IUD that came onto the market in the 1970s. The oversized, poorly designed, and honestly dangerous device quickly became the root cause of many women’s pelvic pain, infections, and infertility. While these are ABSOLUTELY not problems with your 21st century options, there are still myths floating around about IUDs (sometimes even by clinicians).
So, how do they work? Depends on the type!
Copper: There is only one type on the market. The Paraguard works by making the uterus inhospitable through low-grade inflammation and its impact on sperm mobility and viability.
Progestin: The progestin acts primarily locally to thin the lining of the uterus and to thicken cervical mucus. This means sperm has a harder time making its way into the uterus and that a fertilized egg would not have a suitable home to implant. Although some minimal systemic absorption of progestin occurs, it is not very significant. The progestin releasing IUD options vary in size, hormone level, and years of efficacy. Depending on the dose you select, you may ovulate anywhere from 50-90% of the months the IUD is in place (unlike systemically absorbed progestin-based contraceptive whose main mechanism of action is through ovulation suppression).
Why some love it: Like the arm implant, IUDs are highly effective, safe in breast-feeding, and user error-proof.
Copper: This is a favorite among women who prefer to not interfere with their bodies’ natural hormones. It is also an excellent option for women who have a medical reason to not be on a hormonal contraception. For example, the Copper IUD is the only level 1 (meaning no restriction) safety profile for women with current breast cancer or a diagnosis within the past 5 years.
Progestin: The progestin-containing IUDs result in decreased bleeding in most users and/or amenorrhea (no bleeding) in about half of user by 1 year.
Why some ditch it:
Copper: The majority of women who have the copper IUD removed do so because of its known side effect of heavy menstrual bleeding.
Progestin: Women may change or not select the progestin IUD because they prefer to have regular menstrual bleeding. Although most women have decreased or no bleeding with progestin-releasing IUDs, a minority of women experience unpredictable, heavy, or prolonged bleeding.
Surgical Sterilization: 0.15%-0.5%
Briefly, surgical sterilization can be performed on men and women. For women, the procedure involves obstructing the egg’s path down the fallopian tube, either with a clip, a coil, or giving the tube a little snip and tie. Female surgical sterilization is essentially nonreversible whereas male surgical sterilization (vasectomy) is more easily reversed.
Very Effective:
With these options, 6-12 women in 100 will become pregnant in 1 year, the most effective being the injection and the least being the diaphragm.
Injection: 6%
How does it work? Depot medroxyprogesterone acetate, or DMPA is a progestin-only contraceptive. So, it works similarly to how the nexplanon works: it both makes it difficult for the sperm and egg to meet, and it suppresses the monthly release of an egg from your ovary.
Why some love it: It is highly effective and does not rely on remembering to take medication daily. Like with the arm implant, this progestin-only method is associated with spotting and irregular bleeding. However, unlike the arm implant the irregular bleeding continues to improve, even after a year of use. 50% of women have no menstrual bleeding at 1 year and that number increases with increased time of use.
Why some ditch it: For some women, the irregular bleeding is too bothersome—either because they want a regular bleeding or want no spotting at all. A side effect that deters women from starting DMPA is weight gain. Although it has not been proven that DMPA causes the weight gain, it is reported often by users and even included within the packaging (average 5.4 lb after 1 year, 8.1 lb after 2 years, and 13.8 lb after 4 years of use). DMPA is also associated with increased time to return of fertility. For some women, return of fertility takes up to 18-22 months. This is not an issue for everyone. However, if you plan to get pregnant shortly after discontinuing your contraception, it is something to consider.
Pills: 9%
How does it work? Pills can be progestin-only (meaning they will have the same action as the arm implant and the injections) or they can be combined oral contraception. I will focus on combined oral contraception. Briefly, the progestin-only pill formulation works the same way as your other systemically absorbed progestin-only options (the arm implant and the injections), has a similar side effect profile, and is also safe in breast feeding. The addition of estrogen allows women to have a menstrual bleeding.
Why some love it: For many, the pill is the most familiar form of contraception. It is also a great option for people who want to be able to control their monthly periods. The type and doses of synthetic progestin and estrogen analogue will impact the wanted and unwanted side effects. For example, a common non-contraceptive reason women choose this method is for improvement of acne. Some formulations are actually FDA-approved for the treatment of acne.
Why some ditch it: There are many options that do not rely on a daily medication—so some women ditch the pill for something more convenient. Other women do not tolerate the side effects of systemic estrogen and want to move to a progestin only option or more locally acting method (the IUD). The specific side effects that women experience are related to the specific formulation. So, if you like taking oral contraception but are experiencing unwanted side effects, discuss with your doctor what your other pill options are.
Rings: 9%
How does it work? The ring is another form of combine estrogen-progestin that also works by suppressing your monthly release of an egg. Local effects of the progestin also thicken the cervical mucus and alter sperm mobility. The ring is worn vaginally for three weeks then removed for one week to allow a period.
Why some love it: The ring is associated with short, light periods. Some women also like the privacy of the ring (unlike the patch or the pills, it is unlikely others will see it).
Why some ditch it: Users of the vaginal ring are usually very satisfied with this method. In general, the side effects of vaginal rings are similar to those of oral contraception. However, some of the systemic estrogen effects are reported less often such as breast tenderness and nausea (because of less systemic absorption). Women may experience more episodes of vaginitis, meaning inflammation of the vagina, but this is not usually why women discontinue this option.
Patches: 9%
How does it work? The transdermal contraceptive patch is placed weekly. It is also combined estrogen-progestin based contraception and so has a mechanism of action like your combined oral contraception options and the vaginal ring.
Why some love it: The patch is a great option for women who are not keen on the vaginal ring, but want a combined contraceptive that does not require daily dosing. Weight gain, while commonly reported by users of other forms of contraception, is not a known side effect of the patch.
Why some ditch it: Unscheduled bleeding is common is the first few months of use, but typically improves. There is only one formulation of the patch as of now. It is on the higher end of the estrogen dosing and estrogen levels typically remain in a steady state. Breast tenderness is one of the most common side effects and is due to this steady state of higher estrogen.
Diaphragm: 12%
How does it work? The diaphragm is an effective barrier method. It is a soft saucer-shaped silicone device that covers the cervix and works best when used with spermicide (so that sperm is blocked by the device and killed by the spermicide). The spermicide is effective for 2 hours, so the diaphragm with the spermicide should be placed no more than 2 hours prior to intercourse. The diaphragm should always remain inside the vagina for at least 6 hours after sex, but should not remain inside longer than 24 hours.
Why some love it: This is the most effective option that is not a medication or implant.
Why some ditch it: It is not a highly effective method and requires a certain amount of work and foresight on the users’ part.
Least Effective:
Among 100 women in 1 year, these options will result in 18 or greater pregnancies depending on the method. These options do reduce the risk of unwanted pregnancy and condoms are extremely important in reducing sexually transmitted infection risk. However, I would not recommend my sisters, friends, or future patients use these methods alone if they seriously do not want to become pregnant and have access to more effective options. Below are the some of the lesser effective options and their respective failure rates, expressed as what percent of women will have an unintended pregnancy in one year with “typical use.”
Male condoms: 18%
Female condoms: 21%
Withdrawal: 22%
Fertility Awareness: 24%
Spermicide: 28%
*Sponge: 12% failure rate in women with no prior deliveries, 24% in women with prior deliveries
*I have never heard of anyone using the sponge. I am pretty sure they are no longer available… However, there is a Seinfeld episode about this method of contraception, so I felt it should be included here. Synopsis: During a period of limited sponges, Elaine must determine who is “sponge worthy.”
—Ari