Birth Control: Which is the Right Option for You?

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?
• 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 and what is covered "free of charge" may only be a generic pill that may or may not be best for you.

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 reducing the risk of from sexually transmitted infections (STIs). In fact, I always remind patients who have multiple or new partners to continue to use latex condoms to reduce their risk from disease, even when they are using another form of birth control. Condoms reduce STIs but do not prevent all STIs. Being involved in a mutually monogamous relationship is important to help protect your health.

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. Spermicides must be used with the diaphragm and the diaphragm needs to be refitted after pregnancy or with any weight gain or weight loss of more than 10 pounds.

Every day

Birth control pills (or patch or vaginal ring) 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
• 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
• History of clots
• 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. There are long cycle pills to have a menses every 3 months or never! One does NOT have to menstruate. There are non-contraceptive benefits to hormonal contraceptives. There is a rare risk of blood clot with any estrogen/progesterone pill (or patch or ring). Some of the newer birth control pills do not appear to have a higher rate of clot than other birth control pills despite this being publicized by plaintiff attorneys. Those birth control pills include:

• Beyaz (like the older Yaz with the long acting active folic acid-levomefolate)
• Safyrl (like the older Yasmin with levomefolate).

Pregnancy and delivery are much higher risks for blood clot than any hormonal contraceptives. However, if you or a family member has had a clot, you need to discuss this with your physician. Beyaz and Yaz have been FDA approved to treat severe PMS called PMDD-Premenstrual Dysphoric Disorder.

One newer pill, Natazia, is the only hormonal contraceptive pill that is also approved to specifically treat abnormal menstrual bleeding. It also contains bioidential estrogen/estradiol and has been studied in women up to age 50. Healthy women who don't smoke, do not have blood clot history in the legs or lungs and who have normal blood pressures can stay on hormonal contraception to menopause (and many bypass the perimenopausal symptoms as well!)

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:

1. Birth control patch
2. Vaginal ring

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. Depo-provera 105 mg subcutaneous is available. If you are on depo-provera for more than two years and have no menses, you may need to be checked for low estrogen and have a bone density.

A 2024 study published in the British Medical Journal found that women who used Depo-Provera for more than a year were more than five times as likely to develop meningiomas. Another study found that women who used Depo-Provera or its generic versions were at a much higher risk of developing meningiomas. 

Once every three years

One of the newer forms of birth control is Nexplanon, 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.This device is easier for your doctor to insert than the older Implanon and it shows up on imaging studies.

The newest approved form of birth control is the three year Intrauterine System Skyla. It is a bit smaller than the six year Mirena and also coated with levonorgestrel, which can cause the menses to be lighter or even stop. Since it is smaller, it is a bit easier to insert into a woman who has not yet had a baby.

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 years, although they can be removed at any time. The copper IUD lasts for 10 years and is overall the cheapest form of long term contraception. The Mirena Intrauterine System is coated with levonorgestrel and is also approved to treat heavy menstrual bleeding and lasts for six years.

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. You might want to 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. A bilateral tubal ligation, through the belly button, under anesthesia can also be done.

Devorah Wieder, MD is a Board Certified OB-GYN in Cleveland Clinic's Center for Specialized Women's Health.