OB/GYN On-Call

I Need Birth Control Advice

Dear Lissa: I was looking for birth control advice to print and pass on to some friends who are married. I haven't needed it for years myself, and I am amazed at all the options that are out there now. (Where were they when I was younger?)

I would really like to point my friends to someone I felt was up to date on their options and would be honest about the pros and cons of them. Also, what choices would you recommend for a young lady whose body does not tolerate the pill or patch? This lady is also married.

I know that condoms provide protection for STDs, but both of these women have been married a while and do not feel STDs are a threat. There are no OB/GYNs in our area, and these women are relying on the general practitioners in the local clinic who are covered by their HMO.

Thank you for considering my request. I will be sure to print out you answer for them.

--Birth Control

Dear Birth Control: What an important question! And yes, it's easy to get confused with all the options on the market today. So let's walk through the options for a minute. In general terms, you have to choose between barrier methods, hormonal contraceptives, IUDs, and natural family planning (rhythm methods). I could write a few chapters on this subject, but I'll try to sum up all the options except natural family planning, since that's a whole different beast.

Barrier Methods
I've listed the barrier method options below, along with the number of how effective they are. As you can see, in typical use, the failure rate is very high, but they're cheap, safe, and non-hormonal. The down-side, apart from the relatively high failure rate (and resulting unintended pregnancies) is that they're messy, sometimes difficult to use, and a real pain in the rear. But because condoms are the other way to reduce your STD risk (note that I said REDUCE, not eliminate), it's important to keep them on your radar.

Table 1: Efficacy rate (in percent) during first year of use

Hormonal Methods

Oral contraceptive pills (OCPs) fall into this category, as does Ortho-Evra (the patch), Nuva-ring (the vaginal ring), and injectable contraceptives like Depo-Provera. OCPs, Ortho-Evra and Nuva-ring are all just different delivery methods of basically the same hormones, which work by shutting off your own system and replacing your body with the hormones your own body would otherwise make in a way that inhibits ovulation (in addition to other mechanisms of action that I won't get into here). How are they different? Ortho-Evra is a slightly higher dose and is available as a patch you can attach to your skin, which must be changed weekly. Nuva-ring is a vaginal ring you insert into the vagina (it's easy to get in). Nuva-ring can stay in for 3 weeks, then you remove it to get a period. Nuva-ring seems to have fewer estrogen side effects than Ortho-Evra, in my experience. Birth control pills come in all kinds of dosages and are easier to customize to the individual woman's needs, but you must remember to take them every day.

Depo-Provera and Implanon are a bit of a different beast. While the others all contain a combination of low dose estrogen and progesterone, Depo-Provera and Implanon contain a very high dose of progesterone. Depo-Provera is an injection you get every three months, and because there is no estrogen, it can be used in women who cannot use other methods. The down side is that it has a lot of side effects (irregular bleeding and weight gain are the biggest). Frankly, I think Depo-Provera is great for teens who just can't remember to use other methods correctly, but I'd never use it myself. But that's just me).

Implanon is an implantable form of birth control which is similar to Depo-Provera in its action and in the same family as the old Nor-Plant (but supposedly with fewer side effects). Since I have no personal experience with this contraceptive, I can't comment on it further.

The advantage of these hormonal methods is they are all highly effective if you use them right.

Efficacy rate (in percent) during first year of use

My personal favorite is the IUD. IUD's come in two types- the hormonal IUD (Mirena) and the non-hormonal Copper-T. I've been using Mirena for three years, and I LOVE it. Your gynecologist puts it in, and you're good to go for 5 years (10 for the Copper-T). The Mirena may have some breakthrough bleeding in the beginning, although because I put mine in when I was breast-feeding, I didn't even have that. So I haven't had a period in three years, which, frankly, is fine by me.

With the Copper T, you do continue to have menses, and they can be heavier and crampier because of the IUD. But some women love it because the Copper T contains absolutely no hormones. Mirena does contain progesterone, which is released gradually and mostly acts locally on the uterine lining. The advantage of the Mirena is that, over time, most women get very light or no menses, since the progesterone shrinks the uterine lining. Both the Copper T and Mirena have an efficacy rate of  99 percent, making it a great alternative to tubal ligation.

With regards to your friend who doesn't tolerate the Pill or the Patch, I would recommend the Mirena IUD, and if she doesn't mind having heavier, crampier periods, the Copper T is great too. Hope that helps!