For some women, picking a method of birth control is like selecting a hairstyle or a signature fragrance: Once they settle on a choice, they go on automatic pilot. That’s unfortunate, say specialists in the field, because this is one decision that needs to be re-evaluated in light of new research, product developments and changes in your personal life.
Did you know:
– That the pill can lower your risk of ovarian cancer from 40 to 80 percent.
– That IUDs are now being inserted for a 10-year period and have been shown not to be a cause of pelvic inflammatory disease.
– That, unless you are in a stable, mutually monogamous relationship, protection against sexually transmitted diseases (STDs) is as important a reason for selecting a contraceptive method as convenience and effectiveness in preventing pregnancy.
At first glance, there would seem to be an abundance of methods to choose from. Contraceptive choices include the pill, the intrauterine device (IUD), the diaphragm, the Norplant surgical implant, Depo-Provera injections, condoms (including a female condom), the cervical cap, vaginal film and spermicidal cream, jelly or foam. For some women, tubal ligation and natural family planning also are options.
But actually that list isn’t as long as it seems, say the experts.
“Nothing is suitable for everyone all the time,” says Dr. Jeannie Rossoff, director of the Alan Guttmacher Institute in New York, a foundation for the study of contraceptive policy and technology. “What one woman finds yucky, another will find terrific.”
A survey by the Upjohn Co., maker of Depo-Provera, claims that 91 percent of American women feel there is a need for more contraceptive education.
“This research demonstrates the vital need for more education about birth control among women of all ages, races and income levels,” says Dr. Kathy Woodward, of the Department of Adolescent and Young Adult Medicine at Children’s Hospital in Washington.
“I think we’re a long way from having adequate choices,” says Amy Coen, chief executive officer of Planned Parenthood of Chicago, a medical provider of gynecological and family-planning services. “Women in other countries have many more products to choose from.”
Part of the problem, experts say, is that the Food and Drug Administration, which only began regulating birth control devices in 1976, has tightened standards for new products. Meanwhile, notes Coen, the federal government is pouring less money into research and development. The result? “We’re not seeing new methods of birth control, we’re seeing adaptations of already existing methods,” Coen says. Of the newest products on the market, “Norplant and Depo-Provera could be considered adaptation from the birth control pill, and the female condom could be considered an adaptation from the male condom,” she says.
And one readily available birth control device was discontinued last fall. Whitehall Robbins, of Madison, N.J., took the Today vaginal contraceptive sponge off the market because the company thought it would be too expensive to comply with newly revised FDA regulations on factory conditions.
“Neither the product itself nor its record of safety has been at issue,” noted company literature, adding that “the product was not the subject of a recall.”
Even with limited choices, however, women must weigh what’s important to them in a birth control method: protection from a sexually transmitted disease, freedom from side effects, spontaneity, cost and effectiveness in preventing unwanted pregnancy.
“Generally,” Rossoff says, “people prefer methods that are not linked to the timing of the sex act.”
According to the 1995 National Survey of Family Growth by the National Center for Health Statistics, in Hyattsville, Md., the most popular method of birth control is female sterilization (29.5 percent), followed by the pill (28.5) percent, male prophylactics (17.7 percent), vasectomy (12.5 percent), the diaphragm (2.8 percent), the IUD (1.4 percent) and all other methods (4.8 percent). The numbers total more than 100 percent because some women use more than one method.
A previous survey by the center ranked birth control devices according to reliability when used under ordinary conditions, such as forgetting to take the pill an average number of times. The survey counted what percentage of women became pregnant within one year using each method, comparing those rates to the 85 percent who became pregnant without practicing birth control. Ranked highest was the Norplant implant (.5 percent), tubal ligation (.5 percent), Depo-Provera injections (.4 percent), the IUD (4 percent), the pill (6 percent), condoms (16 percent), the diaphragm (18 percent), cervical cap (18 percent), abstinence (19 percent), withdrawal and vaginal sponges (each 24 percent) and spermicides (30 percent).
But those figures should be reviewed cautiously, says Dr. Ramona Slupik, of the department of gynecology at Northwestern University School of Medicine. “Studies of effectiveness vary, but all the studies suggest that the longer a woman uses a method, the greater the effectiveness.
“There’s a learning curve with all these methods,” says Slupik, who frequently lectures on contraception to professionals and the general public. “I’ve seen studies that cite an effectiveness rate of 98 percent for the diaphragm in married women who’ve been using it for more than a year and as low as 82 percent for new users. It really depends on your comfort level, conscientiousness and experience with these methods.”
Slupik says condoms should be combined with other methods of birth control to prevent the spread of STDs. “In the best of all possible worlds, I’d put everyone on condoms for STD protection and the pill for its non-contraceptive benefits,” she says. Slupik is excited about two new products not yet on the mass market: a polyurethane condom for men that is one-tenth the thickness of the latex prophylactics presently available, and RU486, which is being tested as a morning-after pill.
“It may not be better than what we presently have,” she says, “but women should have every device that’s available to them.”
Here’s a rundown on the newest and most popular birth control methods:
The pill
Still one of the most popular methods of birth control, the pill has been found to decrease the risk of ovarian cancer by 40 percent, Slupik says. “If you use the pill for as long as 10 years, you have an 80 percent drop in ovarian cancer.” The pill is effective as an anticarcinogen because it suppresses ovulation, which means cells are not as active, she says. “The protection persists for 15 years or more after the pill is discontinued” for reasons not all experts agree on.
More older women are using the pill because of this benefit, she says. “I see patients’ going on the pill simply because they want this protection.”
The pill also has been found to reduce cramping during menstrual periods, improve bone density and offer varying degrees of protection against pelvic inflammatory disease, endometrial cancer, ectopic pregnancy, acne and certain forms of arthritis.
Side effects such as nausea, breast tenderness and migraines are rarer than in earlier years because of the reduced amount of hormone-about one-sixth of what was in the original pill, says Slupik.
According to the American College of Obstetricians and Gynecologists in Washington, today’s pill comes in two formulations: a combination pill containing synthetic estrogen and progestin and a mini-pill that contains a small amount of synthetic progestin only. The combination pill suppresses normal ovulation, while the mini-pill acts on the uterus and fallopian tubes, decreasing cervical mucus to make fertilization of an egg and subsequent implantation in the uterus less likely.
No link has been established between breast cancer and oral contraceptives, says Slupik. In addition, the risk of heart attacks and strokes is negligible, she says.
There is a slight risk of contracting blood clots among women who are over 35 and are heavy smokers (half a pack or more a day), notes literature from the ob/gyn college.
“Timing and consistency in using the pill has been shown to be really important in enhancing its effectiveness,” says Slupik. Conception is possible within one to two months of going off the pill, she says.
IUD
The IUD, which is the most popular birth control method in Europe, has received an undeserved bad rap in this country, says Slupik, partly because of problems with the dangerous Dalkon Shield of the ’70s.
The Dalkon Shield, which was manufactured by A.H. Robins of Richmond, Va., was associated with the deaths of five women from spontaneous septic (involuntary) abortions that occurred with the device in place. Domestic sales of the device, which had a fundamentally different design from today’s IUDs, were suspended in 1974, and the company eventually filed for bankruptcy after being besiged with several hundred lawsuits claiming injuries that included pelvic inflammatory disease, birth defects and ectopic pregnancy.
The only two brands of IUDs marketed here today are the Paragard copper T380, by GynoPharma Inc., which can be inserted for 10 years, and the Progesterone T, by the Alza Corp., which must be removed annually.
IUDs are plastic devices that, when inserted in the uterus, prevent either fertilization or implantation of the egg. At one time they were thought to be a cause of pelvic inflammatory disease, although research has implicated STDs as the real culprit.
“We now know that the IUD will not cause PID or interfere with your fertility or increase the risk of ectopic pregnancy,” says Slupik. However, Slupik says that many physicians who practice defensive medicine because of the fear of malpractice litigation will not insert them in young women who have never given birth.
“If you’re 40 years old and you’re married and you know you don’t want to have kids, a doctor will generally feel pretty happy about putting in an IUD,” says Slupik.
Norplant
Norplant consists of six capsules of synthetic progestin that are surgically implanted beneath the skin on a woman’s arm. The cost of insertion is from $500 to $700, and the contraceptive effect lasts five years. Women can conceive as soon as the device is removed. Slupik and Rossoff describe this method as very safe, despite recent class action litigation arising from Norplants that were inserted improperly or removed with difficulty.
“It’s perfect for women who want long-term birth spacing or for women who’ve had failures with other methods of birth control,” says Slupik.
The Norplant can be removed in a 25-minute procedure that leaves a scar that is usually from a twelfth-of-an-inch to a quarter-of-an-inch long.
“If the health care professionals are properly trained and the Norplant has been inserted correctly-that is, as close as possible to the surface of the skin-they are not going to have problems,” says Slupik.
“Side effects with Norplant are common,” says Cindy Pearson, program director of the Women’s Health Network in Washington, D.C. “They range from minor disruption of the menstrual cycle to serious weight gain and depression. While for most doctors and many women this is acceptable, for some women they’re very disruptive of a normal life and make the method unacceptable.”
Pearson also maintains that some of the problems from Norplant stem from the device’s being implanted by people without proper training.
Depo-Provera
Depo-Provera, an injectible form of progestin, has been used by 15 million women worldwide. It is administered every three months, costing from $40 to $75 a shot. But its side effects will give many women pause. They include spotting, weight gain, depression and breast tenderness. More than half the women who use it will have irregular bleeding during the first year, Slupik says. On the plus side, many women who’ve used it for a year find their periods get lighter or disappear, she says.
Diaphragm
“I hardly fit any diaphragms anymore,” says Slupik. “It doesn’t protect against venereal warts, HIV or herpes. If you’re going to use a barrier method, choose one that protects you adequately.”
An improved version of the diaphragm called Lea’s Shield is scheduled for FDA approval in 1998. Studies have yet to begin on a disposable diaphragm that releases spermicide.
Female condom
The Reality condom has been on the market only since August, although it has been available to family-planning clinics for the last year and has been sold in 12 European countries for two years, says Holly Sherman, of the Female Health Co., in Chicago, which manufactures the female condom.
“It’s slowly catching on with my patients,” says Slupik, who estimates 1 to 2 percent of them are using it.
Coen confirms that it has been a steady seller at all six Chicago-area Planned Parenthood clinics. Even if its popularity is limited, says Coen, “if the women who use it like it, that’s all that counts.”
The condom is a long polyurethane sheath with one open ring and a closed ring that is anchored between the cervix and the vagina. The condoms cost about $3 a piece and are 40 times stronger than latex, says Sherman.
Carol, a 33-year-old married graphics designer, says she was a little intimidated by the device the first time she used it.
“It looked a little weird, and it’s bigger than I thought,” she says. She found it no trickier to use than a diaphragm and a lot more convenient because it was much easier to remove. She also was pleasantly surprised to find it didn’t limit sensation.
It was preferable to a male condom, she says, “because with those, there’s a tendency to wait until the last minute.” Nor did it interfere with her husband’s erection, which is a problem many men experience with using condoms, Slupik says.
Slupik confirms that her patients “think it looks funny.”
“But let’s face it,” she says. “Nine times out of 10, the lights are off anyway.”
