Family Planning - Birth control

Spacing of pregnancies can be controlled by birth control. Several options are available to couples who wish to prevent pregnancy either permanently or temporarily. Temporary measures mean that, once the method of control is stopped, the woman can become pregnant. Permanent birth control is almost always surgically achieved and it involves cutting or removing part or all of the reproductive system. Once a permanent surgical procedure has been done, it is extremely difficult or impossible to reverse. For that reason, it is rarely performed on patients who have never had children.

In the discussion of different types of birth control, a failure rate is given. The failure rate is determined by the number of people who conscientiously use the birth control and still get pregnant. The rate is per year, not per use. So if one person in one hundred has a failure, that means that one woman in hundred gets pregnant during one year of use.

Oral Contraceptives

The birth control pill comes in various types. The main ingredient in all of them is synthetic estrogen. Synthetic estrogen has two common types: mestranol and estradiol. The quantity of estrogen in a pill can vary from .03 milligram to .1 milligram for the average dosage. The pill will also contain synthetic progestogen, of which there are several types. Commonly used progestogens are norgestrel, norethindrone, and ethynodiol diacetate. Levels of progestogen can vary from .15 milligram to 2 milligrams.

The two hormones work in combination to prevent ovulation. Pills with the hormones are taken every day for 21 days. Some pill packages come with seven extra pills containing inactive ingredients. The cycle is 28 days, so the schedule will either be 21 days on pills, 7 days off, or 21 days on hormone pills, and 7 days on placebos (pills with no effect). The reason doctors prescribe the 21/7 set of pills is that the patient is less likely to forget a pill if one is taken every day without exception.

After the 21st pill with hormones is taken, the level of estrogen drops as the placebo (or no pill) is used. After 24 to 48 hours, the menstrual cycle will begin. It will usually be lighter in flow and take fewer days than previous periods. The pill may also eliminate cramping.

The effectiveness rating of the pill is less than one pregnancy for 100 women (a year) for pill doses of .35 milligrams or higher of estrogen. For pill doses of less than .35 milligrams of estrogen, there is a very slightly higher pregnancy rate.

Some women experience side effects with oral contraceptive pills. Side effects may be minor, from headaches to weight gain, or they may be major, from blood clots to strokes. The increase in risk is directly affected by the patient's age and smoking habits. Women over the age of 35 or smokers increase the risk of heart attack, stroke, and blood clots considerably by taking the pill. The pill does not have any linkage to uterine cancer, cervical cancer, or breast cancer. If a woman already has breast cancer, taking the pill is not recommended because it may stimulate tumor growth, but it is not linked to beginning cancerous development.

Oral contraceptives can only be obtained through prescription by a licensed physician. The physician will determine the dosage the woman takes, and will usually start on the lightest effective dosage. Dosage is insufficient if the woman experiences bleeding during the 21 day cycle, heavy menstrual flow, or other unusual symptoms. Consult with your prescribing physician if you experience problems. Occasionally switching from one type of synthetic estrogen to another, without increasing dosage, can remedy a problem.

Once on the pill, women who decide to get pregnant should stop taking the pill. Restarting ovulation may take a few months so it may be a while before the woman becomes pregnant. It is not dangerous for a woman to become pregnant immediately after stopping oral contraceptives. It is not a major health concern if pill taking overlaps pregnancy slightly. It may cause some problems if pill-taking continues past the first trimester.

There is no medical reason for stopping the use of oral contraceptives if there are no side effects. It was once believed that a woman should cease pill taking for a period of months, either every year or every ten years. Neither has proved to be of medical benefit.

The Mini-Pill

The mini-pill is the nickname of the progestin-only oral contraceptive. For women who run higher health risks by taking estrogen, the progestin pill may be an alternative. The risk of pregnancy is at least 1 percent higher than for the combination pill, and missing a day increases the likelihood of unwanted pregnancy (a higher risk than missing a combination pill). The risk of ectopic pregnancy (the fetus develops outside the uterus, usually in the fallopian tube) is also greater. Ectopic pregnancy can be an extremely painful, serious complication with the risk of sterility to at least one fallopian tube. Any woman on the mini-pill who suffers from lower stomach pain should be tested immediately for a possible ectopic pregnancy.

IUDs

Intrauterine devices (IUDs) are small metal pieces inserted semi-permanently into the woman's uterus. Barring complications they remain in place for one to two years. One type sold in the United States is a form called the Copper T. It is made of copper and is t-shaped, measuring less than 1 inch in length. The other is a double s-shape. Two small threads descend from the tail of the device, through the cervix into the vagina. These threads are used to check position of the IUD and to withdraw the IUD after the prescribed period of time.

IUDs are recommended only for women who have already had one successful delivery, are active in a mutually monogamous relationship, and who do not plan on getting pregnant for a few years. The device is inserted at the doctor's office after verification that the woman is not pregnant, has no current pelvic infection or disease, and has never had an ectopic pregnancy.

Because of the problematic history of the IUD, most of the devices were taken off the market. The Dalkon Shield was associated with a number of serious problems and triggered numerous lawsuits against the company. Since then, research and testing of IUDs has improved. However, there are still serious potential complications from using an IUD, so a woman who gets one is required by the IUD manufacturer to sign a Patient Consent, after the side effects have been explained by her doctor. The side effects are too numerous to list here, but the major ones are septic or spontaneous abortion, perforation of the uterus or cervix, ectopic pregnancy, or fetal damage during pregnancy. Common minor complaints are cramping, heavy menstrual flow, anemia, or amenorrhea (no period).

Pregnancy rates for IUDs vary from less than 1 pregnancy for 100 women using the device, to 8 pregnancies per 100. Individual devices have varying rates and their effectiveness is also determined by the size of the woman's uterus. The larger the uterine cavity, the less likely she will conceive while using the IUD. Some women accidently expel the IUD; this occurs less frequently with the large size IUDs inserted into larger width uteruses.

Condoms

Condoms are rubber or natural material sheaths that fit over the glans and shaft of the penis. Natural material condoms are usually made from sheep intestinal tissue and will protect against unwanted pregnancy but may allow the AIDS virus to pass through. For this reason, rubber condoms are preferred for both protection against pregnancy and disease.

Several types of condoms are available to the general public. They are purchased without a prescription at a drug store, pharmacy, or other general merchandise shop. They come with or without lubrication on the rubber, and with or without a reservoir tip. The reservoir tip is intended to hold the semen after ejaculation.

Similar to the male-worn condom is the female-worn condom—a rubber sheath inserted into the vagina. The physical appearance of the female-condom is a tube, with a sealed ring at the top. The plastic ring, similar to a diaphragm ring, fits against the cervix at the top of the vagina. Attached to the diaphragm-like ring is the long, round sheath of rubber. The sheath covers the entire vaginal wall and the end of the sheath (another, larger ring) remains outside the body around the vaginal opening.

Condoms, even without the use of a spermicide, have a low failure rate. When used correctly, the rate is 2 pregnancies for every 100 users. In actuality, the pregnancy rate is closer to 10 percent, since the condom is frequently used incorrectly. One of the more common errors is placing the tip of the condom too close to the glans of the penis, leaving no room for the semen after ejaculation. Other reasons are tearing or mispositioning of the condom during intercourse, although this is extremely rare. Another, more common problem is the use of petroleum jelly for lubrication. Petroleum products deteriorate rubber material. Only water-based lubricants should be used. Also, the penis should be withdrawn while still erect, to insure that the condom remains in place throughout intercourse. Correct storage of the condom, away from heating sources, helps keep the condom in good condition.

Condoms, when used with spermicides, have an even lower failure rate. The spermicides kill sperm that may pass beyond the condom barrier. Condoms, and condoms with spermicides, offer the best protection against contracting sexually transmitted diseases during intercourse.

Spermicides

Spermicides are sold as creams, foams, jellies, tablets, or suppositories. They can be inserted into the vagina with a plastic applicator or in tablet or suppository form. Directions, which vary from type to type, must be followed carefully. Usually the spermicide must be applied less than 30 minutes before intercourse. It must be reapplied for each episode of intercourse and remain in place for about 8 hours afterward. Spermicides are most commonly used with diaphragms, condoms, and cervical caps. On their own, spermicides have an estimated failure rate of 20 percent. Some people may have allergic reactions to spermicides.

Diaphragms and Other Barriers

Barrier methods of birth control work by placing a physical barrier, usually of rubber, over the cervical opening to the uterus. The barrier remains in place for at least several hours after intercourse to prevent sperm from entering into the uterus. Barriers are used in conjunction with spermicidal creams, foams, or jellies to enhance protection against sperm passage.

The single-most common form of barrier is the diaphragm. The diaphragm is prescribed by a health professional after sizing a women for the dimensions of the diaphragm. If a woman loses or gains more than ten pounds, or becomes pregnant, she should be checked to see if the diaphragm size has to be changed.

The diaphragm is coated with a spermicide and inserted before intercourse. The device will protect for up to 6 hours, but reapplication of spermicide is required for each episode of intercourse. After the last intercourse the diaphragm should be left in place for at least 6 hours but no longer than 24. The diaphragm should then be washed thoroughly before reuse.

Although the diaphragm used with spermicide can be an effective method of birth control, it is difficult to use this method correctly. The success rate depends on a number of factors, including the proper positioning of the diaphragm, use of a diaphragm of the correct size, and the timing of its use. The failure rate with this method can be as high as 20 percent.

Cervical caps are smaller types of rubber barriers designed to fit around the cervix. They must be prescribed and sized by a health professional. They are also used with spermicides and can remain in place for up to 48 hours. Again, due to such variables as correct positioning and size, the failure rate is high and can be as much as 40 percent.

The vaginal sponge is a doughnut-shaped device with spermicide that covers the cervix. The failure rate for this method can be as high as 25 percent.

Injection or Implantation Devices

In 1992 the FDA approved Depo-Provera, a contraceptive for women that contains the hormone progestin. It is available only through prescription. A health professional must administer an injection of Depo-Provera to the woman once every three months. The failure rate is extremely low, approximately 1 percent.

Norplant is an implantation device that was first approved for use in 1990. Norplant 2 was approved in 1996. Both devices contain progestin that is held in small rubber tubes about the size of matchsticks. A health professional surgically places these tubes under the skin of a woman's upper arm. Norplant provides protection for up to five years. Norplant 2 protects for up to three years. Also, either device may be surgically removed to stop its contraceptive properties. The failure rate is about 1 percent. Possible side effects include inflammation at the surgical site and irregular menstrual bleeding. In addition, it is sometimes difficult to remove these devices.

Natural Birth Control Methods

Natural birth control is called that when it requires no outside prevention method for pregnancy. Natural methods include rhythm method, withdrawal, and abstinence.

The rhythm method involves determining the characteristics of the woman's ovulation cycle and avoiding intercourse during the days before and after ovulation. Ovulation occurs on average 14 days before the next period. This is only reliable for a woman who has an exact 28-day cycle with the normal ovulation timing. (Many women do not have such a cycle.) To determine ovulation patterns, it is first necessary to chart changes in vaginal body temperature and monitor vaginal secretions for several months. Anyone using the rhythm method should consult with a doctor for specific details of monitoring temperature and secretion patterns. This is a complex birth control method and requires a great deal of commitment by both partners to make it effective. When used correctly the rhythm method has a failure rate as high as 20 percent. The failure rate is much higher when it is used by couples inexperienced in monitoring ovulation.

Withdrawal method refers to the withdrawal of the penis prior to ejaculation, during intercourse. The risk in this method is that preejaculative liquids can contain enough sperm to impregnate a woman. Also, semen on the exterior of the vagina, or the labia, can also travel back into the uterine cavity and fertilize an egg. Timing on withdrawal is essential and should be done prior to any ejaculation. Because of this, withdrawal is often considered an inadequate form of birth control. It can be emotionally and physically dissatisfying. It also has an exceedingly high failure rate, estimated between 20 and 40 percent. This is only slightly better than no birth control at all.

Abstinence is the decision to not engage in intercourse. It is the only method of birth control that is 100 percent effective. For individuals who are not involved in mutually monogamous relationships, it is the most effective method of preventing AIDS and other sexually transmitted diseases.