eNewsletter - September 2009
Ask the Expert: Birth Control Options
There are literally dozens of reliable choices for women who do not want to become pregnant. A women's health specialist can help you choose the one that best fits your lifestyle and future plans.
One of the first things that I ask my patients is how often do you want to think about not getting pregnant? Do you want to think about it every time you have sex; every day; once a month; once every three months; once every five or 10 years; or never? In many cases, the choice comes down to how much time and worry the patient is willing to invest in her birth control. A careful review of a patient's medical and family history also will guide the choice. Finally, different insurance plans have varying degrees of coverage for birth control. It's wise to check your plan before you visit your doctor to determine your coverage. The most important thing is to choose something you are confident that you will use.
Every time
The barrier method of birth control is both readily available, but must be used correctly and consistently, to be highly effective. Condoms, male and female, have the added advantage of protecting users from sexually transmitted diseases. In fact, I always remind patients who have multiple or new partners to continue to use latex condoms to protect themselves from disease, even when they are using another form of birth control.
Most of my patients are familiar with male condoms, but fewer know about the newer female condoms. They are designed to be inserted into the vagina before intercourse, with one end slightly outside of the vagina. Contrary to popular belief, they are not the same as diaphragms. A diaphragm must be individually fitted to the woman and is placed entirely inside the vagina.
Another barrier option is a cervical cap, which is inserted in much the same way as a diaphragm but covers just the cervix instead of the entire top of the vagina. Diaphragms and cervical caps are most effective if they are used along with a spermicidal agents. Finally, spermicidal agents, including sponges, are readily available and can be used alone.
Every day
Birth control pills have broad appeal for their ease of use and relatively low cost. There are more pills on the market every day, but they fall into two main classes: progesterone only, and combined estrogen and progesterone pills.
Progesterone only pills work by thinning the uterine lining and thickening the cervical mucus, making it more difficult for the sperm to fertilize the egg. They are particularly appropriate for women who can't take estrogen for medical reasons such as high blood pressure or a history of clots, and for nursing mothers. One downside of progesterone only pills is that they must be taken at the same time every day. If a woman misses the time by more than three hours, she will not be protected.
Combined oral contraceptives come in many, many different combinations, with varying levels of estrogen and progesterone. They work by inhibiting ovulation. Some offer an anti-androgen component that counteracts male hormones. These pills are appealing to women who have problems with bloating or acne. Some are marketed specifically to suppress periods for an extended length of time. These preparations are attractive to women who do not want the inconvenience or pain of a monthly period. While there are no medical risks with suppressing periods, evidence suggests that the longer a women suppresses her period, the more spotting she may experience. I suggest that you start by taking the pill the way the box recommends, then work closely with your physician to find the most appropriate schedule. Fortunately, there are so many choices that if you aren't happy with the particular pills you start with, there are plenty more to try.
Once a week or once a month
There are two birth control methods that use the same basic ingredients as pills, but have different applications. The birth control patch provides medication through the skin, can be placed almost anywhere on the body, and only needs to be changed once a week. An even newer option, the vaginal ring, is a flexible ring that is inserted into the vagina once every three weeks and provides a continuous level of medication. If inserted correctly, the ring cannot be felt and can be left in place during intercourse or removed briefly if desired.
Once every three months
Another great option is a birth control shot given once every three months in your doctor's office. Because it includes progesterone only, this is appropriate for nursing mothers and women who can't tolerate estrogen. Some women experience irregular bleeding during the first three months, but it usually resolves after the second injection.
Once every three years
One of the newest forms of birth control is Implanon, a small plastic rod that contains progesterone and is implanted just under the skin in a physician's office. While older birth control implants were associated with problems due to the difficulty in removing several rods, this system uses just one, easy to remove rod.
Once every five or 10 years
Today's intrauterine devices (IUDs) are not your mother's IUD. The older devices were associated with infection, but this problem has not be found with newer IUDs. IUDs must be inserted in a physician's office, and may or may not include hormones. IUDs are especially well-suited for women who are planning to delay their next pregnancy for several year, although they can be removed at any time.
Never
For women who are sure that they do not want to become pregnant in the future, permanent sterilization may be the way to go. This is a major, life-altering decision that should involve both partners in any relationship. While male sterilization (vasectomy) is less risky than female sterilization, newer procedures continue to simplify the surgery for women. Look for a surgeon who has been trained in the recently developed hysteroscopic method of sterilization, called Essure, which can be done through the vagina. Some providers offer Essure as an office procedure eliminating the risks associated with anesthesia.
Devorah Wieder, MD is an OB-GYN in Cleveland Clinic's Center for Specialized Women's Health.
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