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In-Depth Reports

Birth control options for women

Highlights

Birth Control Options

Birth control options for women include:

  • Hormonal contraceptives, such as birth control pills, skin patch, vaginal ring, injection, implant
  • Intrauterine devices (IUDs)
  • Barrier devices, such as condoms, diaphragm, and the cervical cap
  • Fertility awareness methods
  • Sterilization

The condom is the only form of birth control that protects against sexually transmitted diseases.

FDA Reviewing Safety of Drospirenone

In September 2011, the U.S. Food and Drug Administration (FDA) announced that after reviewing several studies, the agency “remains concerned” about the safety of drospirenone. Drospirenone is a progestin contained in birth control pills such as Yasmin and Yaz. Some data indicate that drospirenone increases the risk for blood clots in the veins (venous thromboembolism or VTE) more than other types of progestins.

The FDA is planning on holding a meeting in December 2011 to further discuss this issue. In the meantime:

  • If your birth control pill contains drospirenone, do not stop taking it without first talking to your doctor.
  • Know the symptoms of VTE. They include persistent leg pain or swelling, severe chest pain, and sudden wheezing or shortness of breath. Contact your doctor right away if you experience any of these symptoms.
  • Be aware that all combination estrogen/progestin birth control pills can increase the risk for VTE. If you are considering going on birth control pills, talk to your doctor about whether you are at high risk for VTE. Obesity, smoking, and a family history of VTE are some of these high risk factors.

Emergency Contraception

In cases of unprotected sex, women can take emergency contraception to prevent pregnancy. Emergency contraceptive pills, also called “morning-after” pills, are not a substitute for regular contraceptive methods and they are not the same as the “abortion pill.” Women who are pregnant should not take emergency contraception. The only brands of “morning after” pills approved in the U.S. are:

  • Plan B One Step, Plan B, or Next Choice, which can be taken up to 3 days after unprotected intercourse and are available without a prescription to women age 17 years and older
  • Ella, which can be taken up to 5 days after unprotected intercourse and is available only by prescription

The FDA warns women to beware of fake emergency contraceptive products that claim to prevent pregnancy but may not be safe or effective.

Introduction

Contraceptives are devices, drugs, or methods for preventing pregnancy either by preventing the fertilization of the female egg by the male sperm or by preventing implantation of the fertilized egg.

Contraceptive Options

Choosing the appropriate contraceptive is a personal decision. Contraceptive options include:

  • Hormonal contraceptives (such as oral contraceptives, skin patch, vaginal ring, implant, and injection)
  • Intrauterine devices (IUDs), which contain either a hormone or copper
  • Barrier devices with or without spermicides (such as diaphragm, cervical cap, sponge, and condom)
  • Fertility awareness methods (such as temperature, cervical mucus, calendar, and symptothermal)
  • Female sterilization (tubal ligation, Essure)
  • Vasectomy [For more information, see In-Depth Report #37: Vasectomy and vasectomy reversal.]

The condom is the only birth control method that provides protection against sexually transmitted diseases (STDs).

Hormone-based contraceptives
The pill works in several ways to prevent pregnancy. The pill suppresses ovulation so that an egg is not released from the ovaries. It also changes the cervical mucus, causing it to become thicker and making it more difficult for sperm to swim into the womb. The pill also does not allow the lining of the womb to develop enough to receive and nurture a fertilized egg. This method of birth control offers no protection against sexually-transmitted diseases.

Determining Effectiveness

Contraceptive effectiveness is characterized by "typical use" and "perfect use":

  • Typical use refers to real-life conditions, in which mistakes (such as forgetting to take a birth control pill at the right time) sometimes happen.
  • Perfect use refers to contraceptives that are used correctly each time intercourse occurs.

The most effective standard female contraceptives are surgical sterilization, intrauterine devices (IUDs), and the implant. They all have an estimated failure rate of 1% or less during the first year of normal (typical) use. Vasectomy (male surgical sterilization) is the only male contraceptive that is equally effective. By comparison, the estimated failure rate of the male latex condom is 17% with typical use and 2% with perfect use. To put these rates into perspective, a sexually active woman of reproductive age who does not use contraception faces an 85% likelihood of becoming pregnant in the course of a year.

Oral Contraceptives and Combination Hormonal Methods

Oral contraceptives (birth control pills) are available only by prescription and come in either a combination of estrogen and progestin or progestin alone. Many brands of each form are available. Although both types are equally effective with typical use, the combined pill is more effective with perfect use, and most women choose this form. The birth control pill is the most popular form of contraception in the United States, used by more than 10 million American women.

Some women experience severe headaches or high blood pressure from the estrogen in the combined pill and must take the progestin-only pill. Not all combined pills or progestin-only pills are alike, and brands differ in the amount of estrogen or progestin they contain. Many oral contraceptive combined brands now use lower estrogen doses and have fewer side effects than earlier oral contraceptives.

For all oral contraceptive users, a check-up at least once a year is essential. It is also important for women to have their blood pressure checked 3 months after beginning the pill. Once woman stop taking oral contraceptives they usually regain fertility within 3 - 6 months, but some women may regain it even sooner.

Hormones Used in Contraceptives

Estrogen (Estradiol)

Estrogen is the major female hormone and is responsible for female characteristics. The estrogen compound used in most oral contraceptives is estradiol, which is always used with a progestin.

Effects on Reproduction. When used throughout a menstrual cycle with progestin, estrogen suppresses the actions of other reproductive hormones (luteinizing hormone, or LH, and follicle stimulating hormone, or FSH) and prevents ovulation.

Progesterone (Progestin)

When used in contraception, progesterone is referred to by one of several names:

  • Progesterone is the name for the natural hormone that the body produces.
  • Progestin is the synthetic form of progesterone that is used in contraceptives.
  • Progestogen is the term for any hormone, natural or synthetic, that causes progesterone effects.

Progestins may be used alone or with estrogen in oral contraceptives. In addition, certain specific progestins are used in other kinds of contraceptives, such as etonogestrel in the Implanon implant and depo-medroxyprogesterone acetate in the injectable contraceptive Depo-Provera.

Progesterone can prevent pregnancy by itself in several ways:

  • Blocking luteinizing hormone (LH) and preventing ovulation
  • Maintaining a powerful barrier against the entry of sperm into the uterus by keeping the cervical mucus thick and sticky

Progestins used in contraceptives are referred to as:

  • Second generation (levonorgestrel, norethisterone)
  • Third generation (desogestrel, gestodene, norgestimate, drospirenone). The third-generation progestins tend to have fewer side effects. However, there have been concerns that drospirenone may increase the risk for developing blood clots more than other progestins.

Combination Estrogen-Progestin Contraceptive Pills

Oral contraceptives that contain both estrogen and progestin are the more common type of oral contraceptive. At least 10 million American women and 100 million women worldwide use combination oral contraceptives. When they were first marketed in the early 1960s, oral contraceptives contained as much as 5 times the amount of estrogen and up to 10 times the amount of progestin currently used. After reports of severe complications (stroke, heart attack, and pulmonary embolisms) in young women, the hormone amounts were significantly reduced.

The estrogen compound used in most oral contraceptives is ethinyl estradiol (also called estradiol, or EE). Fifty micrograms of estradiol is considered high dose, 30 - 35 micrograms are considered average dose, and 20 micrograms or fewer is low dose. The lowest dose of estrogen, 10 micrograms, is available in Lo Loestrin FE. (The high doses found in current oral contraceptives are still much lower than earlier forms of the pill.) Doctors recommend using the lowest possible progestin and estrogen doses. Estrogen doses should not exceed 50 micrograms, as higher doses increase the risk for complications.

Many different types of progestins are used in combination with estradiol. Some common types of progestin, and popular combination oral contraceptive brands, include:

  • Desogestrel is the progestrin used in Mircette. Approved in 1998, Mircette was the first oral contraceptive to offer a low estrogen dose and a new type of dosing regimen. Some studies suggest an increased risk for blood clots with desogesterel.
  • Drospirenone is used in Yasmin, Yaz, Safyral, and Beyaz, as well as other brands of birth control pills. (Yaz contains a lower dose of estrogen than Yasmin. Safyral and Beyaz contain the same doses of estrogen and progestin as Yasmin and Yaz respectively, but they also contain a vitamin B [folate] supplement.) Because drospirenone increases blood levels of potassium, women should not use oral contraceptives containing drospirenone if they have kidney, liver, or adrenal diseases. They should also be aware that drospirenone may be associated with an increased risk for blood clots in the veins (venous thromboembolism).
  • Levonorgestrel is used in Seasonale and Seasonique, as well as many other oral and non-oral contraceptives.
  • Norethindrone is used in Loestrin. Loestrin 24 Fe and Lo Loestrin FE add an iron supplement to the placebo pills.
  • Norgestrel is used in various generic and brand contraceptives.

Types of Regimens. Combination pills are sold in 21-day or 28-day packs:

  • Each pill in a 21-day pack contains estrogen and progestin. Women take 1 pill a day for 21 days, and then wait 7 days before starting a new 21-day pack.
  • 28-day packs typically start with 21 hormone pills and add 7 placebo pills that do not contain hormones. After taking hormone pills for 21 days, a woman takes the inactive pills for 7 days. Some newer brands, like Yaz, use 24 days of active pills and 4 days of inactive pills. Mircette uses 21 days of low-dose progestin and estrogen, followed by 2 placebo days, and then 5 days of very low-dose estrogen. Loestrin 24 Fe uses 24 days of active pills followed by 4 days of iron-containing placebo pills.

Oral contraceptives may be taken in cycles that include pills of the same or different strengths. These are categorized as monophasic (one-phase), biphasic (two-phase), or triphasic (three-phase). (In 2010, the FDA approved the first “four-phasic” birth control pill, Natazia.) Monophasic pills contain the same amount of hormones in each dose and deliver the same amount of estrogen and progestin every day. Biphasic, triphasic, and four-phasic pills contain different dosages of hormones within the pill packs and deliver different amounts of progestin and estrogen at two, three, or four times within the 28-day cycle.

Because monophasic pills have a consistent amount of hormones, they tend to cause fewer hormone-fluctuating side effects than biphasic or triphasic pills. However, research shows little difference in effectiveness between these types of oral contraceptives. Monophasic pills are often recommended as the best first-choice for birth control pills.

Taking the Pills. A woman usually takes the first pill either on the Sunday after her period starts or during the first 24 hours of her period. (The first pill can be started at any time during the menstrual cycle without affecting the bleeding patterns. Ovulation can occur that month, however.) The remaining pills are taken once a day, ideally at the same time of day, until the pack is used up. If a woman has a 21-day pack, she waits 7 days before starting a new pack. If she is on the 28-day pack, she takes the 7 inactive pills. Women should use another method of birth control during the first month taking the pill.

If you skip one or more pills, take the following precautions:

  • Missing the first pill in a new cycle. Take a tablet as soon as you remember and the next one at the usual time. Two tablets can be taken in one day. Use barrier contraception for 7 days after the missed dose. [See "Spermicidal and Barrier Contraception."]
  • Missing a pill 2 days in a row. Take two pills as soon as you remember and then two more the following day. Also use back-up barrier contraception until the next pill cycle.
  • Missing more than 2 days. Discard the pack, use a back-up birth control method, and begin a new cycle on the following Sunday, even if you have started bleeding.

Continuous-Dosing Oral Contraceptives

Standard oral contraceptives come in a 28-pill pack that contains 21 active pills and 7 inactive pills. Newer "continuous-dosing" (also called "continuous-use") oral contraceptives aim to reduce -- or even eliminate -- monthly periods and thereby prevent the pain and discomfort that may still accompany menstruation in women taking oral contraceptives. Women who have medical conditions (such as endometriosis), which cause heavy or painful menstrual periods, may benefit from continuous-dosing oral contraceptives. These oral contraceptives contain a combination of estradiol and the progesterone levonorgestrel, but they use extending dosing of active pills.

Seasonale, the first continuous-dosing contraceptive, contains 81 days of active pills followed by 7 days of inactive pills. Women who take Seasonale have on average a period every 3 months. Seasonique, a follow-up to Seasonale, also produces about 4 periods a year. With Seasonique, a woman takes 84 days of levonorgestrol-estradiol pills followed by 7 days of pills that contain only low-dose estradiol.

Lybrel supplies a daily low dose of levonorgestrol and estradiol with no inactive pills. Because Lybrel contains only active pills, which are taken 365 days a year, it completely eliminates monthly menstrual periods. About 60% of women who take Lybrel completely stop menstrual periods by the end of the first year. Some women, however, experience occasional unscheduled bleeding or spotting during the first 3 - 6 months.

Progestin-Only Oral Contraceptives ("Mini-Pills")

Progestin-only pill brands include:

  • Levonorgestrel (Plan B)
  • Norethindrone (Micronor, Aygestin, Nor-QD)
  • Norgestrel (Ovrette)

Progestin-only pills, which contain only progestins, are always sold in 28-day packs, and all the pills are active. An exception is Plan B, which is emergency contraception. [For more information, see Emergency Contraception section in this report.) Progestin-only pills, also called “mini-pills,” must be taken at precisely the same time each day to maintain effectiveness. If a woman deviates from her pill schedule by even 3 hours, she should call her doctor about using back-up contraception for the next 2 days.

Progestin-only pill users experience even lighter periods than those taking combination pills. Some may not have periods at all. Because these pills do not contain estrogen, they may be a safer choice for women over age 35, smokers, and those who have other risk factors that contraindicate estrogen use.

Advantages of Oral Contraceptives

Oral contraceptives are the choice of most American women who use birth control, making them the most popular reversible contraceptives in the U.S. Oral contraceptives are among the most effective contraceptives. Failure rates are relatively low (9% with typical use) and are usually due to noncompliance.

Oral contraceptives also have the following advantages, which may vary depending on the type and brand used:

  • Reduce heavy menstrual bleeding (menorrhagia) and, therefore, reduce the risk of anemia emia
  • Reduce severe menstrual pain (dysmenorrhea)
  • May help reduce symptoms of premenstrual syndrome. Yaz and Beyaz are specifically approved for treating premenstrual dysphoric disorder (premenstrual depression).
  • Improve acne
  • Improve symptoms of endometriosis.
Endometriosis
Endometriosis is the condition in which cells from the tissue that normally lines the uterus (endometrium) grow in other areas of the body, causing pain and abnormal bleeding.
  • Reduce risks of ovarian cysts
  • Possible protection against bone loss with estrogen-containing oral contraceptives
  • Reduce risks of ovarian and endometrial (uterine) cancers with long-term use (more than 3 years)

Disadvantages of Oral Contraceptives

Common Side Effects. Many women have some side effects during the first 2 - 3 months of birth control use. These side effects usually subside. Estrogen and progesterone have different side effects, and women on the combined pill may have different effects from those on the progestin-only pill.

Common side effects of oral contraceptives include:

  • Nausea and vomiting (can often be controlled by taking the pill during a meal or at bedtime)
  • Headaches (in women with a history of migraines, they may worsen)
  • Dizziness
  • Breast tenderness and enlargement
  • Irregular bleeding or bleeding between periods
  • Weight gain

Newer formulations of combination pills that use low-dose estrogen, and newer progestins, may reduce and even lower the risk of many of these side effects, including weight gain.

Serious Side Effects. Symptoms of serious problems may include severe abdominal pain, chest pain, unusual headaches, visual disturbances, or severe pain or swelling in the legs. If you have any of these symptoms, contact your doctor immediately.

Potential Risks. Combination birth control pills can increase the risk of developing or worsening certain serious medical conditions. The risks depend in part on a woman’s medical history. You should discuss your health history with your doctor to determine if combination oral contraceptives are safe for you. This is especially important for women who are age 35 or older, smoke, or have a history of high blood pressure, high cholesterol or unhealthy blood lipid profile, diabetes, or migraine headaches.

Serious risks of birth control pills may include:

  • Venous Thromboembolism (VTE). All combination estrogen/progestin birth control products carry an increased risk for blood clots in the veins (venous thromboembolism), which can lead to blood clots in the arteries of the leg or lung (pulmonary embolism). The FDA is currently reviewing whether birth control pills that contain drospirenone carry a higher risk than other progestins. The risk for VTE is lower for oral contraceptives than for the birth control patch (Ortho Evra) or the ring (NuvaRing), which expose women to higher levels of estrogen than birth control pills. Women who smoke, who are obese, who have a personal or family history of blood clots, or who have heart disease risk factors may want to consider using alternatives to estrogen-containing contraceptives, such as progestin-only oral contraceptives ("mini-pills"), intrauterine devices, or barrier contraceptive methods. The Centers for Disease Control recommends that due to the risks of VTE, women should not use combined hormonal contraceptives for 21 – 42 days after giving birth.
  • Heart and Circulation Problems. Combination birth control pills contain estrogen, which can increase the risk for stroke, heart attack, and blood clots in some women. The risk is highest for women who smoke, are over 35, have diabetes or polycystic ovary syndrome (PCOS), or have a history of heart disease risk factors (such as high blood pressure or unhealthy cholesterol/lipid levels) or cardiac events. Women who have migraines may possibly be at increased risk for stroke and may need to consider progestin-only pills or other contraceptive methods in place of combination oral contraceptives. However, taking a birth control pills is generally safe for young, healthy women without other risk factors.
  • Diabetes. Women who have diabetes, and high blood pressure, vascular disease, kidney disease, or other diabetes-related health problems, should not take birth control pills.
  • Cancer Risks. Several studies have reported an association between increased risk of cervical cancer and long-term (greater than 5 years) use of oral contraception. Although studies have been conflicting about whether estrogen in oral contraception increases the chances for breast cancer, the most recent research indicates that oral contraceptive use does not significantly increase breast cancer risk. Long-term use of birth control pills reduces the risk for ovarian and uterine cancers.
  • Liver Problems. In rare cases, oral contraceptives have been associated with liver tumors, gallstones, or jaundice. Women with a history of liver disease, such as hepatitis, should consider other contraceptive options.
  • Interactions with Other Medications. Certain types of medications can interact with and decrease the effectiveness of oral contraceptives. These medications include anticonvulsants, antibiotics, antifungals, and antiretrovirals. The herbal remedy St. John’s wort can also interfere with birth control pills’ effectiveness. Make sure your doctor is aware of any drugs, vitamins, or herbal supplements that you take.
  • HIV and STDs. Birth control pills do not protect against any sexually transmitted diseases (STDs), including HIV. Unless they have a monogamous relationship with an uninfected partner, all women should be sure a condom is being used during sexual intercourse, regardless of whether or not they take oral contraceptives.
Cervical cancer

Other Methods for Administering Combination Hormones (Patch and Ring)

The skin patch and vaginal ring are other hormonal contraceptive methods of administering the combination of progestin and estrogen. Failure rates with perfect use (0.1 - 0.6%) are similar to those of combined oral contraceptives.

Skin Patch. Ortho Evra is a birth control skin patch. It contains a progestin (norelgestromin) and estrogen. The patch is placed on the lower abdomen, buttocks, or upper body (but not on the breasts). Each patch is worn continuously for a week and reapplied on the same day of each week. After three weekly patches, the fourth week is patch-free, which allows menstruation. (The patch remains effective for 9 days, so being slightly late in changing it should not increase the risk for pregnancy.)

The Ortho patch exposes women to higher levels of estrogen than most birth control pills, and therefore increases the risk for blood clots in the veins (venous thromboembolism). Venous thromboembolism can cause blockage in lung arteries and other serious side effects. Older women (over age 40) and women with risk factors for blood clots (such as cigarette smoking or a family history of blood clots) may find other birth control products to be a safer choice. Discuss with your doctor whether the patch is appropriate for you.

Vaginal Ring. NuvaRing is a 2-inch flexible ring that contains both estrogen and progestin (etonogestrel). It is inserted into the vagina. Women can insert the ring by themselves once a month and take it out at the end of the third week to allow menstruation. It works well and may cause less irregular bleeding than oral contraceptives. Some women find it uncomfortable, and a few have reported vaginal irritation and discharge, but such problems rarely cause a woman to discontinue use. As with the patch, NuvaRing may put women who use it at higher risk for blood clots than oral contraceptives.

Implant Contraceptives

Implant contraception involves inserting a rod under the skin. The rod releases into the bloodstream tiny amounts of the hormone progestin.

The first implant was the Norplant system, which used six rods that contained levonorgestrel. Due in part to serious complications, Norplant was withdrawn from the U.S. market in 2002. The main complication was difficulty inserting and, in particular, removing the rods. (Many women experienced scarring.) In addition, some women who used Norplant experienced heavy irregular bleeding. A two-rod implant called Jadelle is sold in other countries, but not the United States.

In 2006, the Food and Drug Administration approved Implanon, a new implant contraceptive. In contrast to Norplant:

  • Implanon uses one rod, not six.
  • It is not inserted as deeply into the skin.
  • It uses etonogestrel, a different type of progestin than the levonorgestrel used in Norplant.
  • Only specially trained health care providers are allowed to insert and remove Implanon.

Implanon insertion takes about a minute and is performed with a local anesthetic in a doctor’s office. The rod remains in place for 3 years, although it can be removed at any time. (The removal procedure takes a few minutes longer than insertion.) After the rod is removed, a new one can be inserted.

Studies indicate that Implanon is safe. Irregular bleeding and headaches are the main side effects. However, some doctors are concerned that Implanon may have some of the same risks as Norplant.

Injected Contraceptives

Injected contraceptives are given once every 3 months. Most injectables are progestin-only. In the United States, depo-medroxyprogesterone acetate (Depo-Provera) is the only approved injected contraceptive. Depo-Provera (also called Depo, or DMPA) uses a progestin called medroxyprogesterone.

Depo-Provera is very effective in preventing pregnancies. About 3 in 100 women who use it become pregnant. However, Depo also carries the risk for many mild and serious side effects including the loss of bone density (see "Disadvantages"). Because of this complication, Depo-Provera should not be used for longer than 2 years.

Administering Injections:

  • A physical examination is necessary before beginning the injections.
  • Depo is injected into a muscle in the patient's arm or buttock. During months between injections, the hormone slowly diffuses out of the muscle into the bloodstream.
  • Depo requires an injection by the doctor once every 3 months.
  • If more than 2 weeks pass beyond the regular injection schedules, the woman should have a pregnancy test before receiving the next injection.

Candidacy

Because Depo-Provera does not contain estrogen, it is safe for many women who may be riskier candidates for combination oral contraceptive use, such as women over age 35, women with high blood pressure, obese women, and smokers.

Depo-Provera should not be given to women who have a history of:

  • Current or past breast cancer
  • Stroke or blood clots
  • Liver disease
  • Epilepsy, migraine, asthma, heart failure, or kidney disease (due to the fact that the drug causes fluid retention)
  • Unexplained vaginal bleeding
  • Risk for osteoporosis

Because of the long lag time between ending treatments and restoration of fertility, Depo-Provera is not recommended for women who are thinking of becoming pregnant within 2 years.

Advantages of Depo-Provera

  • Provides highly effective reversible protection against pregnancy without placing heavy demands on the user's time or memory.
  • Does not increase risk for breast, ovarian, or cervical cancer. May protect against endometrial cancer.
  • May be useful for women with painful periods, heavy bleeding (including heavy bleeding caused by fibroids), premenstrual syndrome, and endometriosis.

Disadvantages and Complications of Depo-Provera

  • Weight gain. Most women gain an average of 5 - 8 pounds.
  • Other common side effects include menstrual irregularities (bleeding or cessation of periods), abdominal pain and discomfort, dizziness, headache, fatigue, nervousness.
  • Most users of Depo-Provera stop menstruating altogether after a year. Depo can cause persistent infertility for up to 22 months after the last injection, although the average is 10 months.
  • Long-term (more than 2 years) use of Depo-Provera can cause loss of bone density. Depo-Provera’s label warns that the decline in bone density increases with duration of use and may not be completely reversible even after the drug is discontinued. The FDA recommends that Depo-Provera should not be used for longer than 2 years unless other birth control methods are inadequate. Some studies indicate that this bone loss may be reversible once Depo-Provera use is discontinued. Some doctors recommend that women take calcium and vitamin D supplements while on Depo-Provera.
  • The injections do not provide protection against sexually transmitted diseases including HIV, the virus that causes AIDS. Some research suggests that the progestin in injected contraceptives may cause changes in the vagina or cervix that increase susceptibility to HIV. This effect has not been proven, but in any case women who use Depo-Provera should be sure a condom is in use during sexual intercourse.

Intrauterine Devices (IUDs)

The intrauterine device (IUD) is a small plastic T-shaped device that is inserted into the uterus. An IUD's contraceptive action begins as soon as the device is placed in the uterus and stops as soon as it is removed. IUDs have an effectiveness rate of close to 100%. They are also a reversible form of contraception. Once the device is removed, a woman regains her fertility.

Intrauterine device
The intrauterine device (IUD) shown uses copper as the active contraceptive. Others use progesterone in a plastic device. IUDs are very effective at preventing pregnancy (less than 1% chance per year). IUDs come with increased risk of ectopic pregnancy and perforation of the uterus and do not protect against sexually transmitted disease. IUDs are prescribed and placed by health care providers.

Intrauterine Device Forms

Two types of intrauterine devices (IUDs) are available in the United States:

  • Copper-Releasing (ParaGard). This type of IUD can remain in the uterus for up to 10 years. Copper ions released by the IUD are toxic to sperm, thus preventing fertilization.
  • Progestin-Releasing (Mirena). This type of IUD can remain in the uterus for up to 5 years. Mirena is also known as a levonorgestrel-releasing intrauterine system, or LNG-IUS. Levonorgestrel impairs sperm motility and viability, thus preventing fertilization. LNG-IUS is long-acting, safe, very effective in preventing heavy bleeding, and helps reduce cramps. In fact, some doctors describe it as a nearly ideal contraceptive. In addition to being a contraceptive, it is approved as a treatment for heavy menstrual bleeding.

Inserting an Intrauterine Device

With some exceptions, an intrauterine device (IUD) can be inserted at any time, except during pregnancy or when an infection is present. It may be inserted immediately after a woman gives birth or after elective or spontaneous miscarriage. It is typically inserted in the following manner by a trained health professional:

  • A plastic tube containing the IUD (the inserter) is slid through the cervical canal into the uterus.
  • A plunger in the tube pushes the IUD into the uterus.
  • Attached to the base of the IUD are two thin but strong plastic strings. After the instruments are removed, the health care provider cuts the strings so that about an inch of each dangles outside the cervix within the vagina.

The strings have two purposes:

  • They enable the user or health care provider to check that the IUD is properly positioned. (Because the IUD has a higher rate of expulsion during menstruation, the woman should also check for the strings after each period, especially if she has heavy cramps.)
  • They are used for pulling the IUD out of the uterus when removal is warranted.

The insertion procedure can be painful and sometimes causes cramps, but for many women it is painless or only slightly uncomfortable. Patients are often advised to take an over-the-counter painkiller ahead of time. They can also ask for a local anesthetic to be applied to the cervix if they are sensitive to pain in that area. Occasionally a woman will feel dizzy or light-headed during insertion. Some women may have cramps and backaches for 1 - 2 days after insertion, and others may suffer cramps and backaches for weeks or months. Over-the-counter painkillers can usually moderate this discomfort.

Candidates for the Intrauterine Device

Intrauterine devices are an excellent choice of contraception for women who are seeking a long-term and effective birth control method, particularly those wishing to avoid risks and side effects of contraceptive hormones. The LNG-IUS may be better suited for women with heavy or regular menstrual flow.

Around the time of insertion and shortly afterwards, women should be considered at low risk for sexually transmitted disease (mutually monogamous relationship, using condoms, or not currently sexually active).

Women with risk factors that preclude hormonal contraceptives should probably avoid progestin-releasing IUDs, although the progestin doses are much lower with LNG-IUS and probably do not pose the same risks.

Women with the following history or conditions may be poor candidates for IUDs:

  • Current or recent history of pelvic infection (the risk of pelvic inflammatory disease is higher for all women who have multiple sex partners or who are in non-monogamous relationships -- not just those with IUDs)
  • Current pregnancy
  • Abnormal Pap tests
  • Cervical or uterine cancer
  • A very large or very small uterus

IUDs have the following advantages:

  • The IUD is more effective than oral contraceptives at preventing pregnancy, and it is reversible. Once it is removed, fertility returns. (Studies have found no adverse effects on fertility with the current IUDs.)
  • Unlike the pill, there is no daily routine to follow.
  • Unlike the barrier methods (spermicides, diaphragm, cervical cap, and the male or female condom), there is no insertion procedure to cope with before or during sex.
  • Intercourse can resume at any time, and, as long as the IUD is properly positioned, neither the user nor her partner typically feels the IUD or its strings during sexual activity.
  • It is the least expensive form of contraception over the long term.

Additional advantages, depending on the specific IUD, include:

  • The progestin-releasing LNG-IUS (Mirena) is now considered to be one of the best options for treating menorrhagia (heavy menstrual bleeding). (However, irregular breakthrough bleeding can occur during the first 6 months.)
  • The copper-releasing IUDs do not have hormonal side effects and may help protect against endometrial (uterine) cancer.
  • Both types of IUDs may lower the risk of developing cervical cancer.

Complications of Specific Intrauterine Devices

Menstrual Bleeding. Both intrauterine device (IUD) forms have effects on menstruation, although they differ significantly by type:

  • Copper-releasing IUDs can cause cramps, longer and heavier menstrual periods, and spotting between periods. Prescription medications are available to control the bleeding and pain, which, in any event, usually subside after a few months.
  • Progestin-releasing IUDs produce irregular bleeding and spotting during the first few months. Bleeding may disappear altogether. (This characteristic is a major advantage for women who suffer from heavy menstrual bleeding but may be perceived as a problem for others.)

Ovarian Cysts. The LNG-IUS may increase the risk for benign ovarian cysts, but such cysts usually do not cause symptoms and resolve on their own.

Expulsion. About 2 - 8% of IUDs are expelled from the uterus within the first year. Expulsion is most likely to occur during the first 3 months after insertion. Expulsion rates may be higher than average if the IUD is inserted immediately after delivery of a child. In 1 in 5 cases, the woman fails to notice that the device is gone, and thus faces the risk of unintended pregnancy. The risk for expulsion is highest during menstruation, so women should be sure to check the strings to make sure the IUD is in place.

Pelvic infections. What was thought to be an increased risk of pelvic inflammatory disease has proven not to be true. The risk does not seem to be any greater than the risk in the general population The risk for infection may be increased around the time of insertion of the IUD, but routine screening before insertion is generally not recommended. There is also no evidence that IUD usage increases the risk of HIV infection.

Effects on Pregnancy.

  • None of the current IUDs increase the risk for infertility. Women with a history of using an IUD are no more likely to be diagnosed with infertility than those who have not used IUDs. This seems to be true both for women who have never been pregnant or women who have been pregnant previously.
  • In the very unlikely event that a woman conceives with an IUD in place, there is a higher risk of an ectopic pregnancy or miscarriage. Ectopic pregnancy is when the fertilized egg implants outside of the uterus. Most ectopic pregnancies occur in the fallopian tubes. However, overall, women who use IUDs have a significantly lower rate of ectopic pregnancies than women who do not use any contraception. Even for women who have a history of ectopic pregnancies when not using contraception, the IUD is considered safe and may even lower their risk for another one.
Ectopic pregnancy

Click the icon to see an image of an ectopic pregnancy.

If the IUD is removed right after conception, the risk for miscarriage is close to average (about 20%). There is no evidence that the IUD in a pregnant woman increases the risk for birth defects in the infant.

Perforation. A potentially serious complication of the IUD is the accidental perforation of the uterus during insertion or later perforation if the IUD shifts position. Such an occurrence is very rare, particularly if the doctor is experienced with insertion.

Spermicidal and Barrier Contraceptives

Barrier contraceptives are devices that provide a physical barrier between the sperm and the egg. Examples of barrier contraceptives include the male condom, female condom, diaphragm, cervical cap, and sponge. The condom is the only contraceptive method that helps prevent sexually transmitted diseases (STDs).

Spermicides

Vaginal spermicides are sperm-killing substances available as foams, creams, gels, films, or suppositories, and are often used in female contraception with barrier and other devices. Spermicides are usually available without a prescription or medical examination.

The active ingredient in U.S.-made spermicides is usually nonoxynol-9, which attacks the surface of the sperm cell. Nonoxynol-9 does not provide any protection against sexually-transmitted diseases or HIV (the virus that causes AIDS). Research indicates that frequent use can cause vaginal and rectal irritation and abrasions that may actually increase the risk for HIV transmission in women. In addition, use of a spermicide with a barrier device may increase the risk for a urinary tract infection in women, regardless of whether the device is a condom or diaphragm. (Non-spermicidal lubricated condoms are safe to use.)

In general, spermicides may be an appropriate choice for women who have intercourse only once in a while, or need backup protection against pregnancy (for instance, if they forget to take their birth control pills). Spermicides should not be used alone as the primary method of birth control.

The Male Condom

The condom is still the only reversible form of male contraception currently available.

Pregnancy Protection. The condom should be put on before intercourse when the penis is erect, since the male can discharge sufficient semen to cause pregnancy before ejaculation occurs. With typical use, the average rate of pregnancy for couples that rely only on condoms for protection is high -- about 17%. For those who use a condom correctly each time, the annual risk for pregnancy is 2%.

Prevention of Sexually Transmitted Diseases. Condoms are important in the prevention of sexually transmitted disease, including gonorrhea, Chlamydia, syphilis, herpes, trichomoniasis, and HIV.

Most condoms come pre-lubricated. Lubricants can also be purchased and applied separately. Only water-based lubricants (K-Y Jelly, Astroglide, AquaLube, glycerin) should be used with latex condoms. Do not use petroleum jelly or other oil-based lubricant products as these can damage the condom. In general, it's best to use a pre-lubricated condom or to apply a water-based lubricant. Unlubricated condoms may injure vaginal tissue and make it vulnerable to infections.

Condom Materials. Condoms made of latex rubber are the most common types. They are less likely to slip or break than those made of polyurethane, and they are contoured for a better fit that can provide fairly effective protection. Some people are allergic to latex, however, and in some cases the reaction can be very dangerous. The latex smell may also be unpleasant for some people. Condoms made from animal membrane (such as lambskin) can prevent pregnancy, but they are permeable and do not protect against sexually transmitted infections.

Female Condom

The female condom (Reality, Femidom) is a lubricated, loose-fitting pouch that lines the vagina. It is designed to create a physical barrier against sperm and sexually transmitted diseases by surrounding the penis during intercourse. The failure rate for the female condom is about the same as for the diaphragm and cervical cap. It is available without a prescription but may be hard to find. The female condom may be a good option for women at risk for sexually transmitted diseases and who are not certain that their male partner will use a condom.

Use and Insertion of the Female Condom. The female condom is about 3 inches wide and 6 - 7 inches long (larger than a male condom), with a flexible ring at both ends. Current products are made of polyurethane.

  • The ring at the closed end is used to insert the device into the vagina and hold it in place over the cervix.
  • The ring at the open end remains outside the vagina and partly covers the labia (lips).

The insertion process may seem difficult at first but becomes much easier with practice:

  • The female condom is inserted by hand into the vagina up to 8 hours before intercourse. (It should never be used in combination with a male condom.)
  • Although the female condom is prelubricated, extra lubricant is sometimes needed while inserting the device or during intercourse. (It is not made of latex, so oil lubricants will not harm it.)
  • During intercourse, the woman checks to be sure that the outer ring is lying flat against her labia and then guides her partner's penis into the ring.

The female condom should be removed in the following circumstances:

  • If it tears during insertion or use
  • If the outer ring is pushed inside
  • If it bunches up inside the vagina

Advantages of the Female Condom. The female condom is an effective barrier to viruses, including HIV, and other sexually transmitted organisms, particularly since it covers a large area, including external genitals. However, it does not completely protect against sexually transmitted diseases.

  • The standard female condom is made of polyurethane, which is thin and soft but at the same time stronger than the latex male condoms. Polyurethane is not damaged by lubricating oils, as latex is and is also less likely to cause an allergic reaction. It transmits body heat better than latex, providing a more "natural" sensation.
  • The man does not have to withdraw his penis immediately after ejaculation, as is the case with the male condom, but can, if he wishes, withdraw after he has lost his erection.

Disadvantages and Complications of the Female Condom. Compliance rates are low for many reasons. About 25% of women have difficulty on the first attempt at self-insertion. The inner ring may be uncomfortable for some women (in which case it can be removed). Some couples complain that the female condom is unpleasant to look at and can be noisy during intercourse. Without sufficient lubrication, it can also be pushed out of place by the penis. Using more lubricant can help keep the female condom in place and reduce the noise. Female condoms are also expensive, and some women wash them out and reuse them to save money. (In such cases, they should be disinfected first and then washed carefully.) Repeated washings can increase the risk for damage and holes.

Diaphragm

The diaphragm is a small dome-shaped latex cup with a flexible ring that fits over the cervix. The cup acts as a physical barrier against the entry of sperm into the uterus. A diaphragm is usually used along with a spermicide, although whether spermicide is necessary is an issue of some debate.

The diaphragm
The diaphragm is a flexible rubber cup that is filled with spermicide and self-inserted over the cervix prior to intercourse. The device is left in place several hours after intercourse. The diaphragm is a prescribed device fitted by a health care professional and is more expensive than other barrier methods, such as condoms.

Diaphragms come in different sizes and require a fitting by a trained health care provider. Some women will need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 pounds or more. As a general rule, diaphragms should be replaced every 1 - 2 years.

Although the diaphragm has a relatively high failure rate, even with perfect use, it is considered a good choice for women whose health or lifestyle prevents them from using more effective hormonal contraceptives. Certain conditions of the vagina and uterus, a history of toxic shock syndrome, or a history of recurrent urinary tract infections, may disqualify a woman from using the device. The diaphragm should not be used if either partner is allergic to latex or spermicides.

Using and Inserting the Diaphragm. The diaphragm can be placed in the vagina up to 1 hour before intercourse. The following are general guidelines for insertion:

  • Before or after each use, the woman should hold the diaphragm up to the light and fill it with water to check for holes, tears, or leaks.
  • A small amount of spermicide (about 1 tablespoon) is usually placed inside the cup, and some is smeared around the lip of the cup.
  • The device is then folded in half and inserted into the vagina by hand or with the assistance of a plastic inserter.
  • The diaphragm should fit over the cervix, blocking entry to the womb.
  • If more than 6 hours pass before repeat intercourse occurs, the diaphragm is left in place and extra spermicide is inserted into the vagina using an applicator.
  • The diaphragm must remain in the vagina for 6 - 8 hours after the final act of intercourse, and can safely stay there up to 24 hours after insertion.
  • The diaphragm should be washed with soap and warm water after each use and then dried and stored in its original container, which should be kept in a cool dry place.

Advantages of the Diaphragm. The diaphragm can be carried in a purse, can be inserted up to an hour before intercourse begins, and usually (although not always) cannot be felt by either partner. It does not interfere with a woman’s hormones.

Disadvantages and Complications of the Diaphragm. Some disadvantages or complications are as follows:

  • Failure rates are high, about 16% with typical use.
  • Some women dislike having to insert the device every time intercourse occurs or have trouble mastering the insertion and removal process.
  • The diaphragm can be dislodged during sex.
  • Frequent urinary tract infections and vaginal infections are a problem for some women. This difficulty can sometimes be resolved by a refitting, by urinating before inserting the device, or by urinating after intercourse.
  • Some women may have allergic reactions to the latex or spermicides.
  • Although rare, cases of toxic shock syndrome have been reported among diaphragm users. To be safe, the diaphragm should not stay in place for more than 24 hours and should not be used during menstrual periods. (For pregnancy protection, however, the diaphragm should stay in place for 6 - 8 hours after intercourse.)
  • The diaphragm does not protect against sexually transmitted diseases.

Cervical Cap

The cervical cap (FemCap) is a thimble-shaped latex cup that fits over the cervix. It is always used with a spermicidal cream or gel. It is similar to a diaphragm, but smaller, and is available in only four sizes. The cap is sold by prescription and requires a pelvic examination, Pap test, and fitting by a health care provider.

Insertion and Use of the Cervical Cap. After a small amount of spermicide is placed in the cap, the device is inserted by hand. As in diaphragm use, instruction and practice is required. The cap must be kept in the vagina for 8 hours after the final act of intercourse. Caps wear out and should be replaced every 1 - 2 years. A refitting may also be needed when a woman experiences certain changes in her health or physical status.

Cervical cap

Click the icon to see an image of a cervical cap.

Candidacy for the Cervical Cap. Because of the restricted range of available sizes, about 1 in 5 women will not be able to be fitted for the cap. The cap is not widely used, and some women, particularly those who live in sparsely populated areas, may not have access to health care professionals who are trained in fitting this device. Other conditions that can preclude cap use include:

  • An abnormal Pap test
  • A history of toxic shock syndrome
  • A sexually transmitted or reproductive tract infection
  • Inflammation of the cervix
  • The cap has little value for women who have had children, because the stretching of the vagina and cervix makes a proper fit more difficult and failure rates are high.

Advantages of the Cervical Cap. Among women who have never given birth, the cap's failure rate is similar to that of the diaphragm. The cap in general is also similar to the diaphragm in terms of cost, ease of use, and also the potential for latex or spermicidal allergies. But unlike the diaphragm, the cap can safely remain in the vagina for up to 48 hours (twice the time limit for a diaphragm), so it can be inserted well in advance of intercourse. The cap is rarely associated with urinary tract infections.

Disadvantages of the Cervical Cap. The following are disadvantages of the cervical cap:

  • May be difficult to insert
  • May be pushed out of place during sex
  • Cannot be used during menstruation
  • High failure rates (32% typical use) for women who have given birth

Lea’s Shield. Approved in 2002, Lea’s shield is similar to a cervical cap but contains an air valve that helps it stick to the vaginal walls and allow for the passage of cervical mucus. Unlike cervical caps, it is available in only one size and does not need to be fitted. Lea’s shield is made of silicone, and its cup-shaped bowl completely surrounds the cervix without resting on it. The shield is as effective as the diaphragm and cap when used with spermicide. Its advantages are:

  • One size fits all
  • Can be left for 48 hours after intercourse
  • Reusable for 6 months

The Sponge

The sponge is a disposable form of barrier contraception. It is made of soft polyurethane foam coated with spermicide, is round in shape, and fits over the cervix like a diaphragm, but is smaller and easily portable. The Today sponge is the only brand of contraceptive sponge available in the United States.

The Today sponge originally came on the U.S. market in 1983, but was withdrawn in1994 because of problems at the company's manufacturing facility. In 2009, after several failed attempts, the Today sponge was relaunched and is now available in drugstore chains throughout the United States.

Use and Insertion. To use the sponge, the woman first wets it with water, then inserts it into the vagina with a finger, using a nylon cord loop attachment. It can be inserted up to 6 hours before intercourse and should be left in place for at least 6 hours following intercourse. The sponge provides protection for up to 12 hours. It should not be left in for more than 30 hours from time of insertion.

The sponge should not be used during menstruation, after childbirth, miscarriage, or termination of pregnancy, or by women with a history of toxic shock syndrome.

Advantages and Disadvantages. The sponge is easy to use, is not felt during intercourse, and can be inserted up to 6 hours before intercourse. However, because it contains the spermicide nonoxynol-9, it does not protect against sexually transmitted diseases and may increase the risk for vaginal irritation and transmission of HIV. [See Spermicides section.]

Fertility Awareness Methods

Fertility awareness methods, also called natural family planning, do not use drugs, physical devices, or surgery to prevent pregnancy. Instead, these cycle-based methods rely on tracking the changes in the body that signal fertility. A woman is only fertile during part of her menstrual cycle. By monitoring certain changes in her body, a woman can more or less predict the fertile phase and abstain from sexual intercourse during that time. She can also use barrier methods if they are not prohibited by religious beliefs.

Fertility awareness methods include:

  • Temperature
  • Cervical mucus (ovulation)
  • Calendar
  • Symptothermal

Temperature Method. To determine the most likely time of ovulation and therefore the time of fertility, a woman is instructed to take her body temperature, called her basal body temperature. This is the body's temperature as it rises and falls in accord with hormonal fluctuations.

  • Each morning before rising, the woman takes her temperature with a specialized basal body thermometer and marks the result on a graph-paper chart.
  • She also notes the days of menstruation and sexual activity.
  • The so-called "fertile window" is 6 days long. It starts 5 days before ovulation and ends the day of ovulation.
  • The chances for fertility are considered to be highest between days 10 - 17 in the menstrual cycle (with day 1 being the first day of the period and ovulation occurring about 2 weeks later). However, not all women are fertile within that period of time. Women who have a longer or shorter menstrual cycle may have different time periods of fertility.
  • Immediately after ovulation, the body temperature increases sharply in about 80% of cases. (Some women can be ovulating normally yet not show this temperature pattern.)

By studying the temperature patterns over a few months, couples can begin to anticipate ovulation and plan their sexual activity accordingly. To avoid losing spontaneity, couples should try to avoid becoming fixated on the chart in scheduling their sexual activity.

Cervical Mucus Method. The cervical mucus method (also called the ovulation method) requires a woman to take a sample (by hand) of her cervical mucus every day for a least a month and to record its quantity, appearance, feel, and to note other physical signs connected with the reproductive system. Cervical mucus changes in predictable ways over the course of each menstrual cycle:

  • Six days before ovulation, mucus is affected by estrogen and becomes clear and elastic. Ovulation is likely to occur the last day that mucus has these properties.
  • Right after ovulation, mucus is affected by progesterone and is thick, sticky, and opaque.

Once a woman's individual pattern is understood, analyzing cervical mucus can provide a highly accurate guide to fertility.

Calendar Method. The calendar (rhythm method) is considered the least reliable of fertility awareness methods. Women who have very irregular periods may have even less success with this method. In the calendar method, the woman first keeps a record of her menstrual periods for about 6 - 12 months. She then subtracts 18 days from the shortest and 11 days from the longest of the previous menstrual cycles. For example, if a woman's shortest cycle was 26 days and her longest cycle was 30 days, she must abstain from intercourse from day 8 through day 19 of each cycle.

Symptothermal Method. This method combines the temperature, cervical mucus, and calendar methods and is considered the most effective fertility awareness method. In addition, the woman tracks symptoms that may identify her fertile period. These symptoms include changes in the shape of the cervix, breast tenderness, and cramping pain.

Candidacy for Fertility Awareness Methods

Because of the high risk for pregnancy, fertility awareness methods are recommended only for those whose strong religious beliefs prohibit standard contraceptive methods. Couples who are not guided by religious authority, but who simply want a more natural sexual life, may use a barrier contraceptive during the fertile phase and no contraception during the rest of the cycle. However, they should understand the risk of pregnancy will be higher with this method. To be effective against pregnancy, cycle-based methods require not only training, commitment, discipline, and perseverance, but also the cooperation of the male partner. Cycle-based methods are not recommended for women unless they are in a stable, monogamous relationship, and can count on their partner's willing participation.

Fertility-based awareness methods do not protect against sexually transmitted diseases.

Emergency Contraception

Emergency contraception is available to prevent pregnancy in situations such as:

  • After sexual assault
  • After consensual intercourse in which contraception is not used
  • When contraception is used but fails (for instance, when a condom breaks or a diaphragm dislodges)

Emergency contraception is administered as a pill or, less commonly, as an IUD. Emergency contraception should not be used as a substitute for regular routine contraception.

Emergency Contraceptive Pills

The emergency contraceptive pill (ECP) is also called the “morning-after” pill. The emergency contraceptive pill is not the same thing as the "abortion pill." These pills should not be taken by a woman who is pregnant.

There are two types of “morning-after” pills:

  • One type uses the progestin levonorgestrel to prevent either fertilization or the implantation of a fertilized egg in the uterine lining.
  • The other type uses the antiprogestin drug ulipristal, which appears to inhibit or delay ovulation.

Levonorgestrel “Morning-After” Pill. Emergency contraceptive pills that use leveonorgestrel are available under the names Plan B One-Step, Plan B, or Next Choice: Depending on the brand, they are available as either one or two pills:

  • Single pill (Plan B One-Step). Approved in 2009, Plan B One-Step is a single tablet that contains 1.5 mg of levonorgestrel.
  • Two pills (Plan B, Next Choice). Plan B is taken as two doses that each contain 0.75 mg of levonorgestrel. Next Choice is the generic version of Plan B. Both pills can be taken at the same time or as two separate doses 12 hours apart.
  • The levonorgestrel morning-after pill can be taken up to 3 days (72 hours) after unprotected sex. The pill is most effective the sooner it is taken. It is most effective within the first 24 hours after unprotected sex.

All of the above pills are available over-the-counter (without a prescription) to women 17 years and older. Women younger than 17 years need a prescription from a doctor.

The FDA warns consumers that the above products are the only over-the-counter emergency contraceptives approved in the United States. In recent months, fake non-prescription morning-after pills (such as “Evital”) have been circulating in the market. These phony products may not be safe or effective for preventing pregnancy.

Side effects of Plan B One-Step, Plan B, and Next Choice may include:

  • Nausea and vomiting
  • Lower abdominal pain
  • Headaches
  • Dizziness and fatigue
  • Breast tenderness
  • Fluid retention
  • Changes in the timing or flow of the woman's next menstrual period including a period that is heavier or lighter than normal

Ulipristal “Morning-After” Pill. In 2010, the FDA approved ella, a new type of morning-after pill that contains the antiprogestin drug ulipristal acetate. Ella can be taken up to 5 days (120 hours) after unprotected intercourse and works just as well on the first day as the fifth day. Side effects are similar to those of levonorgestrel emergency contraceptive pills. Ella is available only by prescription.

Emergency Contraceptive IUD

An alternative emergency contraceptive is insertion of a copper-releasing intrauterine device (IUD) within 5 days (120 hours) of unprotected intercourse. It can be removed after the woman's next period, or left in place to provide ongoing contraception. The copper IUD reduces the risk of pregnancy by 99.9% and is effective in protecting women from unintended pregnancy for at least 10 years.

Female Sterilization

Female surgical sterilization (also called tubal sterilization, tubal ligation, and tubal occlusion) is a low-risk, highly effective one-time procedure that offers lifelong protection against pregnancy. Female sterilization is the second most widely-used form of contraception in the United States (oral contraceptives are the first).

Basics of Female Sterilization

Female surgical sterilization procedures block the fallopian tubes and thereby prevent sperm from reaching and fertilizing the eggs. The ovaries continue to function normally, but the eggs they release break up and are harmlessly absorbed by the body. Tubal sterilization is performed in a hospital or outpatient clinic under local or general anesthesia.

Uterus
The uterus is a hollow muscular organ located in the female pelvis behind the bladder and in front of the rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

Sterilization does not cause menopause. Menstruation continues as before, with usually very little difference in length, regularity, flow, or cramping. Sterilization does not offer protection against sexually transmitted diseases.

Tubal ligation

Click the icon to see an image of tubal ligation.

Specific Tubal Sterilization Techniques

Laparoscopy. Laparoscopy is the most common surgical approach for tubal sterilization:

  • The procedure begins with a tiny incision in the abdomen in or near the navel. The surgeon inserts a narrow viewing scope called a laparoscope through the incision.
  • A second small incision is made just above the pubic hairline, and a probe is inserted.
  • Once the tubes are found, the surgeon closes them using different methods: clips, tubal rings, or electrocoagulation (using an electric current to cauterize and destroy a portion of the tube).
  • Laparoscopy usually takes 20 - 30 minutes and causes minimal scarring. The patient is often able to go home the same day and can resume intercourse as soon as she feels ready.
Tubal ligation - series

Click the icon to see an illustrated series detailing tubal ligation.

Minilaparotomy. Minilaparotomy does not use a viewing instrument and requires an abdominal incision, but it is small -- about 2 inches long. The tubes are tied and cut. Generally speaking, minilaparotomy is preferred for women who choose to be sterilized right after childbirth, while laparoscopy is preferred at other times. Minilaparotomy usually takes about 30 minutes to perform. Women who undergo minilaparotomy typically need a few days to recover and can resume intercourse after consulting their doctor.

Essure. The Essure method uses a small spiral-like device to block the fallopian tube. Unlike tubal ligation, the Essure procedure does not require incisions or general anesthesia. It can be performed in a doctor’s office and takes about 45 minutes. A specially trained doctor uses a viewing instrument called a hysteroscope to insert the device through the vagina and into the uterus, and then up into the fallopian tube. Once the device is in place, it expands inside the fallopian tubes. During the next 3 months, scar tissue forms around the device and blocks the tubes. This results in permanent sterilization.

Candidacy for Female Sterilization

Before undergoing sterilization, a woman must be sure that she no longer wants to bear children and will not want to bear children in the future, even if the circumstances of her life change drastically. She must also be aware of the many effective contraceptive choices available. Possible reasons for choosing female sterilization procedures over reversible forms of contraception include:

  • Not wanting children and being unable to use other methods of contraception
  • Health problems that make pregnancy unsafe
  • Genetic disorders

If married, both partners should completely agree that they no longer want to have children and should also have ruled out vasectomy for the man. Vasectomy is a simple procedure that has a lower failure rate than female surgical sterilization, carries fewer risks, and is less expensive. [For more information, see In-Depth Report #37: Vasectomy.]

Even if all these factors are present, a woman must consider her options carefully before proceeding. Women at highest risk for regretting sterilization include:

  • Women who are younger at the time of sterilization
  • Women who had the procedure immediately after a vaginal delivery
  • Women who had the procedure within 7 years of having their youngest child
  • Women in lower income groups

If a woman changes her mind and wants to become pregnant, a reversal procedure is available, but it is very difficult to perform and requires an experienced surgeon. Subsequent pregnancy rates after reversal depend on the surgeon’s skill, the age of the woman, and, to a lesser degree, her weight and the length of time between the tubal ligation and the reversal procedure. Not all insurance carriers cover the cost of reversal.

Advantages of Female Sterilization

Women who choose sterilization no longer need to worry about pregnancy or cope with the distractions and possible side effects of contraceptives. Sterilization does not impair sexual desire or pleasure, and many people say that it actually enhances sex by removing the fear of unwanted pregnancy.

Disadvantages and Complications of Female Sterilization

  • Failure is rare, less than 1%, but can occur. More than half of these pregnancies are ectopic, which require surgical treatment.
  • After any of the procedures, a woman may feel tired, dizzy, nauseous, bloated, or gassy, and may have minor abdominal and shoulder pain. Usually these symptoms go away in 1 - 3 days.
  • Serious complications from female surgical sterilization are uncommon and are most likely to occur with abdominal procedures. These rare complications include bleeding, infection, or reaction to the anesthetic.

Resources

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Review Date: 11/7/2011
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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