Throughout this series on women’s reproductive care, we often identify women as people with biologically-female anatomy, such as a uterus, a vagina, and ovaries. However, we acknowledge that people with this anatomy identify as other genders, that having this anatomy does not necessarily mean a person is a woman, nor is it a prerequisite for being a woman.
If you look at any pamphlet with information on a hormone-based birth control – the Nexplanon implant, the Kyleena IUD, Junel birth control pills, the NuvaRing vaginal ring – you will likely see the same thing: photos of attractive young women with perfect hair and makeup smiling and laughing while sitting on a park bench, going for a run, embracing their partner, picking up their young child, or talking with their doctor. They paint an exciting, pretty picture of a woman’s life on a particular brand of birth control.
However, finding the right hormone-based contraception is not always easy or pretty. Sometimes there are unwanted side effects, sometimes there are complications, sometimes there are risks. Many women have to try multiple different brands and methods before finding one that works. Despite this trial and error, properly-used contraception often allows for many freedoms which its user may not have otherwise had. Just think – a life with regular periods, well-managed menstrual pain, or sex with less fear of pregnancy! Given the immense benefits of contraception, finding and maintaining the right one is a worthwhile journey.
What is Contraception?
Contraception, also known as birth control, are medications, medical devices, procedures, or behaviors designed to prevent pregnancy. Over the course of their lifetime, nearly every woman will use some form of birth control. Currently, there are about 18 different categories of contraception (13 medications/devices, 3 behaviors, and 2 non-reversible procedures). For the purposes of this article, we will focus on the reversible medications and medical devices aimed at preventing pregnancy.
Contraception is not a modern invention, in fact, people have searched for effective contraceptive options for thousands of years. In ancient Egypt, women were said to have put honey or acacia leaves inside their vaginas to prevent pregnancy – interestingly, some of these materials were later found to have spermicidal properties! Many cultures throughout time used pessaries, or devices placed at the top of the vagina, to prevent conception. It was not until 1960, when the FDA approved the first birth control pill, that contraception decoupled from the sex act became a viable option for women wishing to prevent pregnancy and take greater control of their reproductive lives.
Why is Preventing Unplanned Pregnancy Important?
Although unintended pregnancies are not necessarily a bad thing, overall, protecting against unintended or unwanted pregnancies is a crucial pillar of public health.
According to the CDC, an estimated 45% of pregnancies in the U.S. are unplanned. These pregnancies are associated with an increased risk of problems for the mother and infant, because the mother may unknowingly continue unhealthy behaviors or delay prenatal care. In short, unintended conception can lead to a higher-risk pregnancy and potentially jeopardize the mother or fetus.
In addition, unplanned pregnancies disproportionately affect vulnerable members of our society who may be less equipped to take on the rigors of pregnancy and child-rearing. According to the CDC, unintended pregnancy rates are highest among women aged 18 to 24, women earning low incomes (<100% of federal poverty level), and women who have not yet completed high school. Unwanted pregnancies also can prevent women from pursuing educational or professional paths in order to provide childcare, can contribute to financial burdens for women who are already financially-strained, and can further endanger women who are in abusive relationships. The reality is that unplanned pregnancies can compound challenging life circumstances and make socioeconomic mobility and financial empowerment more difficult for women. In all, preventing unplanned pregnancies is a very good idea, both from an individual and public health perspective.
It goes without saying that asking people to abstain from sex in order to prevent pregnancy is an unrealistic option. While there are many reasons why people choose to abstain from sex, the choice to engage in sex or not should always be a personal, individual decision. Asking or requiring someone who is able to consent and wishes to engage in sex to abstain denies them a fundamental part of their humanity. Relying upon abstinence to prevent pregnancy is not a feasible or appropriate option for many people.
Exploring Highly-Effective Contraception
According to a CDC survey conducted from 2015 – 2017, about 65% of the 72.2 million women aged 15 – 49 in the U.S. are currently using contraception, the most popular options among them being female sterilization (such as tubal ligation) – 18.6%, oral contraceptive pills – 12.6%, long-acting reversible contraceptives (such as the implant or IUDs) – 10.3%, and traditional condoms – 8.7%.
There are many, many contraceptive options to choose from, however, not all modern contraception was created equal. In general, medications (such as birth control pills or the Depo-Provera shot) and long-acting reversible contraception (such as IUDs and implants) tend to be more effective at preventing pregnancy than other methods. Barrier methods (such as condoms, diaphragms, and cervical caps) are known to be significantly less effective. Although many forms of contraception could be very effective in theory, user error lowers their practical efficacy. For example, a person may forget to take a birth control pill or accidentally use an expired condom, which could lead to an unintended pregnancy.
According to Planned Parenthood, the practical efficacy of different contraceptive medications and devices are as follows: the implant – 99%, IUD – 99%, the shot – 94%, vaginal ring – 91%, the patch – 91%, birth control pills – 91%, condoms – 85%, internal condoms – 79%, diaphragms – 88%, the sponge – 76-88%, spermicide – 72-86%, cervical cap – 71-86%. So while only 1 in 100 women who use IUDs as their primary form of birth control will become pregnant, 15 in 100 women who use condoms as their birth control will become pregnant.
*** It is also important to mention that condoms and internal condoms are the only form of contraception that protect against sexually transmitted diseases and infections (STD/STIs). All other forms, including birth control pills, provide no protection against STD/STIs whatsoever. This is because STDs/STIs are spread through fluid exchange or skin-to-skin contact, so there needs to be a physical barrier in place to protect against transmission. ***
Discussing Side Effects and Risks
Most hormone-based contraception comes with a similar range of potential side effects, such as: changes in menstrual bleeding, irregular bleeding, or spotting between periods; changes in menstrual cramping or pain; breast tenderness, headaches, nausea, changes in energy levels, or changes in vaginal moisture. Less common side effects include depressed mood or changes in sex drive. According to Planned Parenthood, these side effects will often go away within 2-3 months after beginning use. In other words, if you believe a particular form of hormone-based contraception will work for you but are experiencing side effects, it may be worthwhile to see if this changes after a few months of use.
Of course, there are notable exceptions when side effects evolve into risks and any birth control should be stopped immediately. In general, these include rare but serious blood clots, strokes, cancers, and depression.
Jennifer Rubin, MD, a board-certified internist and pediatrician, explains how she screens for risk factors in patients before prescribing hormone-based birth control:
As physicians, we look for risk factors for contraindications [reasons for a person not to receive a certain treatment] or relative contraindications to hormonal birth control. We ask about any personal or family history of clotting disorders, as we know hormone-based birth control can further increase this risk. Separately, we know tobacco use with birth control pills further increases [clotting] risk, so we always need to ensure that this piece of social history is known and accurate. For people with classical migraines, also known as migraines with aura, there is a slight, but statistically significant increase in risk for stroke, which would prompt us to recommend a different mode of contraception. Lastly, we will look for a family history of hormone-driven cancers, specifically breast or ovarian cancers. A history of these cancers prompts us to recommend conversations with the family’s oncologist to discuss potential increased risk. Each of these risk factors change our conversations and guide us to recommend non-hormone based birth control.
In other words, a trained physician will explore potential risk factors before prescribing birth control in the first place, minimizing the risk of any serious complications.
Aside from physician-confirmed complications associated with contraception, women should be wary of other claims involving severe complications arising from a particular type of birth control, as these testimonials are often meant to shock rather than to inform.
A particular form of birth control that is largely misrepresented are IUDs, or intrauterine devices, that are placed inside the uterus to prevent conception. A YouTube search on IUDs will return terrifying results about serious complications arising from IUD use, such as debilitating pain or infertility. However, many of these testimonials are rooted in misinformation and consequently misrepresent the large majority of women who have IUDs without any problems. Dr. Rubin explains:
While I do not place or consent patients for IUDs myself, many of my patients have IUDs. IUDs are considered safe and effective so long as the patient has been appropriately screened for contraindications, and the provider placing the IUD is properly trained in the procedure and follows through with the appropriate monitoring. Yes, there are rare situations where things can go awry with IUDs…lost strings, infections, expulsion of the IUD with resultant high risk pregnancy, and uterine perforation requiring surgical intervention. In theory, there could be damage to the uterus or to the fallopian tube [from a problem with an IUD], which has the potential to cause fertility issues. However, while things can always happen, IUDs are usually quite safe, very effective, and remarkably convenient. I have many, many, many patients who have IUDs and love them because they get them placed and forget about them.
As Dr. Rubin just demonstrated, a physician can lead you through all of the potential risks of a certain contraception and give you their informed opinion about your best next steps. Overall, bringing up your concerns regarding contraception with a trained physician who listens to you and answers your questions is the best way to get trustworthy information.
Wait a Minute – Why is This All on Women?
Throughout this discussion, one fact has been so glaringly obvious it may have been hard to see at all – these hormonal contraceptive options are available only to people with biologically-female anatomy! Although having many birth control options is important so that women can decide when to have children or not, the lack of well-developed male birth control has served to reinforce the gender divide where women are primarily responsible for becoming, or not becoming, pregnant.
Currently, the birth control options available to men are withdrawal, condoms, and vasectomies, and each come with significant limitations. Although it is a popular option, withdrawal is not considered to be a reliable form of birth control, with an efficacy of only 78%. This is because a person may have difficulty withdrawing their penis if approaching ejaculation or mistime an ejaculation entirely. In addition, withdrawal does not protect against pre-ejaculate fluids that precede ejaculation, which can contain small amounts of viable sperm and thus can cause pregnancy.
On the other hand, while condoms are a great option for protecting against STD/STIs, they are not highly-effective at preventing pregnancy (15 in 100 women will become pregnant if only using condoms).
Lastly, vasectomies are a sterilization method where a man’s vas deferens is cut or blocked so that sperm can no longer enter the seminal fluid and conception cannot take place. These procedures are highly effective at preventing pregnancy, but they are also permanent and under-utilized. Men are not advised to undergo a vasectomy unless they are done with having children or never want to have children, a decision which is usually made in middle age or later. This can leave decades after the onset of sexual activity where an unintended pregnancy is a risk for men who have sex with women. In addition, only 6% of U.S. men will ever undergo a surgical sterilization, compared to 16% of women who undergo tubal ligation, a more invasive surgery with longer healing times that produces the same results.* This discrepancy in surgical sterilization between women and men only underscores the greater reproductive and contraceptive burden which women are expected to bear.
Even with the glaring lack of effective male birth control, research on male oral contraceptive pills (OCPs) has progressed slowly at best. In all likelihood, men will not have an available OCP for years.
One OCP undergoing research is dimethandrolone undecanoate (DMAU), a once-daily pill that suppresses two male hormones and simultaneously decreases the production of sperm without causing symptoms associated with low testosterone. Although clinical trials indicated initial success with the medication, further research has faced obstacle after obstacle.
According to Logan Nickels, PhD, the research director for the Male Contraceptive Initiative, “studies on a male pill started decades ago, but there were lots of hurdles… A lot of the stalling of these early studies was caused by an inability to find a pharmaceutical partner to help finance the research. Lots of pharmaceutical companies in the early 2000s didn’t want to get involved with new birth control methods because they were concerned about litigation.”
So while pharmaceutical companies remain wary of potential side effects of male birth control, many of these risks and symptoms mirror the ones women have endured for decades. For example, Tolulope Bakare, MD, the Director of Male Reproductive Health at UT Southwestern Medical Center, explains that “we’ll need to discover [male birth control’s] long-term effects on the body… We don’t know yet whether DMAU can cause depression issues or increase the risk of blood clots like the female birth control pill, or whether it might damage the liver, kidneys, or other organs that help break down the drug.” The side effects reported for DMAU were acne, headaches, mild erectile dysfunction, reduced sex drive, tiredness, and weight gain of 5 lbs or less. Many of these side effects are more or less the same as those caused by female hormonal birth control. In other words, pharmaceutical companies expect women to shoulder these effects but stop male OCP research in its tracks for producing the same side effects.
So why are women expected to face these side effects and risks, but these same risks are stalling research on male oral contraceptives? The answer is most likely rooted in a gender bias that continues to pervade reproductive care in the U.S. Because women have the organs that actually grow, birth, and feed infants, and have historically been the main infant caregivers, they are expected to bear reproductive responsibility much more heavily than men.
Not only is this discrepancy between women and men’s birth control unfair from a gender-equality perspective, but it is also unfair and impractical from a logistical perspective. According to Power To Decide, many women live in “contraceptive deserts,” or “counties in which there is not reasonable access to a health center offering the full range of contraceptive methods.” An estimated 637,340 women in North Carolina, and 19 million women nationwide, live in these contraceptive deserts.
In addition, the cost of contraception can be a major obstacle for women of lower-income. A month-long pack of birth control can cost $150, or $1,800 per year. An IUD alone can cost $1,300, plus the additional cost it requires for a physician to insert it. According to the 2018 North Carolina Pregnancy Risk Assessment Monitoring System Survey, 7.2% of women in North Carolina do not use contraception simply because they cannot afford it. While many insurance plans greatly reduce the cost of contraception, not all women are covered by medical insurance. In fact, Medicaid, the medical insurance which is meant to cover people earning low-incomes, is only available to North Carolina adults who are elderly, blind, pregnant, living with a Social Security-certified disability, or living with dependent children, according to the North Carolina Justice Center. Shockingly, this leaves out most child-free women and men from being protected under Medicaid coverage. In other words, women earning low-incomes may not only struggle to cover the cost of birth control, but may struggle to be covered by medical insurance at all.
Why Contraception is Worth Your While
While we wait for the development of effective male birth control so that men can shoulder their fair share of reproductive responsibility, women must work with currently available contraceptive methods if they do not wish to become pregnant.
The good news is that physicians are ready and willing to work with women on their contraceptive options and find a method that best suits the individual person. Dr. Rubin is reassuring: “[Physicians] are here to work within everybody’s individual reality, which will be different from person to person… We want you to stay safe and choose the right form of birth control for you, one that works with whatever medical conditions or risk factors you may have.”
You have the right to expect that the doctor who prescribes your contraception listens to your concerns without judgement, assesses you for risk factors, answers your questions, and follows up with you about your satisfaction with your current method of birth control. If a doctor is not delivering care in these ways, you can find a different doctor who is a better fit for you.
The sheer number of modern contraceptive options may be overwhelming, but overall, more options give you a better chance of finding something that works well for you. For many women, contraception means freedom – freedom from heavy or irregular menstruation, freedom from severe acne, freedom from some debilitating symptoms of reproductive diseases, freedom to engage in sex without fearing unintended pregnancy. Contraception can be a powerful tool in a woman’s arsenal of self-care, and accordingly, we must fight for contraceptive education, access, and equality.
* Eisenberg, Michael L., Jillian T. Henderson, John K. Amory, James F. Smith, and Thomas J. Walsh. “Racial Differences in Vasectomy Utilization in the United States: Data From the National Survey of Family Growth.” Urology 74, no. 5 (2009): 1020–24. https://doi.org/10.1016/j.urology.2009.06.042.
Make Your Contraception Work For You!
- If you have not already, establish care with a Primary Care Physician (PCP), such as an Internist or a Family Medicine Physician, and an Obstetrician-Gynecologist (OB-GYN) who you trust. Once you establish this relationship, try to see the same doctor every time you visit – continuity is key to good care!
- You are never the “wrong age” to ask about contraception if you think it could help you.
- If you are sexually active or planning to become sexually active, never hesitate to tell your doctor. If someone is in the room with you, you can always ask to speak with the doctor privately. This is a completely natural and normal part of life that doctors discuss all the time.
- If you are interested in beginning contraception or changing your current contraception, begin a conversation with your doctor. You may get a more thorough response if these conversations are scheduled as a separate appointment from your annual physical.
- Be sure to voice any preferences you have for which type of birth control you would like to take. Don’t think you can keep to a pill schedule? Tell them! Can’t stand shots? Tell them! Don’t like the idea of an implant in your arm? Tell them!
- Ask your doctor if you are at risk for any serious complications or side effects from a certain type of contraception. Make sure you fully understand their answer and ask any questions if needed.
- If you are having side effects or complications from contraception that are concerning you or affecting your quality of life, tell your doctor. You have the right for a doctor to listen to you thoroughly and to be taken seriously!
- Besides abstinence, the best protection against unintended pregnancy is using two forms of contraception (one being a condom!), such as OCPs and condoms, an IUD and condoms, etc. Always keep condoms with you!
- If you are sexually active, get tested for STDs/STIs every 6 months. It is also a good idea to get tested before you become sexually active.
- If you are sexually active with multiple partners or do not know your partner’s or your own STD/STI status, be sure to use condoms each and every time you have sex.
- Watch this video on how to correctly use a condom!
- Follow correct condom hygiene: store condoms in a cool, dry, dark place; check the condom’s expiration date and the package for holes or tears before use; place the condom on an erect penis before sex; never use two condoms at the same time; remove the condom promptly while your partner still has an erection; use a new condom every time you have sex (even if these times happen close together); use a new condom if switching between different types of sex (such as from anal to vaginal).
- Check out the Physician-Approved resources if you have questions about contraception:
- Ask your partner(s) to split the cost of contraception with you. If you need any other contraceptive support, such as transportation to clinics, also consider asking your partner(s) for help with this. Although you may be the one taking the medication, contraception is absolutely a shared responsibility!
Next Week’s Article Topic: Sexually Transmitted Infections