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In This Report

•	Highlights
•	Introduction
•	Oral Contraception
•	Implant Contraception
•	Injected Contraception
•	Intrauterine Devices (IUDs)...
•	Spermicidal and Barrier Con...
•	Natural Family Planning Met...
•	Emergency Contraception
•	Female Sterilization
•	Resources
•	References

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Birth control options for women

Highlights

Drug Approvals

• Plan B (August 2006). Emergency contraception is now available without a prescription for women 18 years and older.
• Implanon (July 2006). The first implantable contraceptive since Norplant was withdrawn from the U.S. market in 2002.
• Seasonique (May 2006). A follow-up to the extended-use oral contraceptive Seasonale, Seasonique eliminates the hormone-free interval with 84 days of levonorgestrel and estradiol, followed by 4 days of very low-dose estradiol.
• Yaz (March 2006). A lower-dose version of the oral contraceptive Yasmin, Yaz uses 24 days of drospirenone and estradiol followed by 4 days of placebo pills.
• Loestrin 24 Fe (February 2006). Another new 28-day oral contraceptive, with 24 days of norethindrone and estradiol followed by 4 days of iron supplement pills.

Drug Warning

The contraceptive skin patch Ortho Evra exposes women to about 60% more estrogen than most birth control pills. Higher levels of estrogen may increase the risk for blood clots in some women. In 2005, the FDA advised women that they should ask their doctors whether the patch is right for them.

New Trends in Contraception

• Continuous dosing oral contraceptives. Several forms of 91-day oral contraceptives are now available. These contraceptives reduce the number of menstrual periods from once a month to 4 times a year.
• The return of the implant. Implanon is a new implanted contraceptive that hopefully will cause fewer complications than Norplant. (However, some doctors think it’s too early to know if Implanon is safe.) Unlike Norplant, Implanon uses one rod instead of six, and a different form of progestin. The rod can stay in place up to 3 years, and must be inserted and removed by a trained health care provider.
• Nonsurgical sterilization. The Essure procedure is much less invasive than tubal ligation. But, women should make sure an experienced doctor performs it.

Introduction

Contraceptives are devices 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. Contraceptives are not modern inventions. The first prescription for a contraceptive device described a tampon barrier device and was written on papyrus in 1550 BC.

Contraceptive Options

Choosing the appropriate contraceptive varies from individual to individual. Contraceptive options include:

• Hormonal contraceptives (oral contraceptives, skin patch, vaginal ring, implant, injection)
• Intrauterine devices (IUDs), which contain either a hormone or copper
• Barrier devices with or without spermicides (diaphragm, cervical cap, sponge, condom)
• Natural family planning methods (basal body temperature, cervical mucus, symptothermal)
• Female sterilization (tubal ligation, Essure)

The pill works in several ways to prevent pregnancy. The pill suppresses ovulation so that an egg is not released from the ovaries, and 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

Research has shown that the four most effective standard female contraceptives are surgical sterilization, the IUD, implants, and injections. They all have an estimated failure rate of less than 1% 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 used without spermicide is 14% with typical use and 3% 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.

Access to Contraceptives

Birth control is a controversial subject. In recent years, there has been a growing movement in the United States to restrict a woman's access to contraceptives. In addition to the political battles over non-prescription access to emergency contraception (Plan B), 18 states (as of 2006) are considering legislation that would allow pharmacists to refuse to dispense medications due to moral or religious objections. There have been hundreds of reports of pharmacists refusing to fill birth control prescriptions. In response to this trend, several members of Congress introduced in April 2005 the Access to Legal Pharmaceuticals Act, which would override any state legislation. The bill would require that pharmacies fill birth control prescriptions and would protect women’s legal right to purchase such products.

Oral Contraception

Oral contraceptives (OCs) 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 are equally effective with typical use, the combined pill is more effective with perfect use, and most women choose this form.

Some women, however, 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 OC combined brands now use lower estrogen doses than previous brands and are proving to be safe and effective while providing a better quality of life than earlier OCs.

For all OC 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. Former pill users who want to bear children usually regain fertility in 3 - 6 months, but they may regain it even sooner.

Click the icon to see an image of a blood clot.

Combination Estrogen-Progestin Contraceptive Pills

Oral contraceptives that contain both estrogen and progestin are the more common type of OC. At least 10 million American women and 100 million women worldwide use combination OCs. When they were first marketed in the early 1960s, OCs contained as much as 5 times the amount of estrogen and up to 10 times the amount of progestins 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 to be high dose, 30 - 35 micrograms are considered average dose, and 20 micrograms or less is low-dose. (The high doses found in current OCs are still much lower than earlier forms of the pill.) Experts 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.
• Drospirenone is used in Yasmin and Yaz. (Yaz contains a lower dose of estrogen than Yasmin.) Because drospirenone increases blood levels of potassium, women should not use Yasmin or Yaz if they have kidney, liver, or adrenal diseases.
• Levonorgestrel is used in Seasonale and Seasonique, as well as many other oral and non-oral contraceptives.
• Norethindrone is used in Loestrin and Loestrin 24 Fe (which adds iron supplements to the placebo pills).
• Norgestrel is used in various generic and brand contraceptives.

Many types of medications and supplements (Tylenol, anti-seizure drugs, antibiotics, vitamin C, St. John’s wort) can interact with progestin and reduce its effectiveness. Make sure your doctor is aware of any drugs, vitamins, and herbal supplements that you take.

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.

OCs 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). Monophasic pills contain the same amount of hormones in each dose. Biphasic and triphasic pills contain different dosages of hormones within the pill packs. Because monophasic pills have a consistent amount of hormones, they tend to cause fewer hormone-fluctuating side effects than biphasic or triphasic pills. Several 2006 reviews found little difference in effectiveness between these three types of oral contraceptives. Many experts recommend monophasic pills as the best first-choice for birth control pills.

Continuous-Dosing Oral Contraceptives. With standard birth control pills, a woman gets her period a few days after completing the active pills in her pack. Continuous dosing, (also called extended use), oral contraceptives aim to reduce -- or even eliminate -- monthly periods. Seasonale, the first continuous use oral contraceptive, was approved in 2003. It contains 84 days of active pills followed by 7 days of inactive pills. Seasonale produces a period about once every 3 months.

In 2006, the FDA approved Seasonique, a follow-up to Seasonale. Seasonique is also a 91-day pill cycle, but it includes 84 days of pills that contain levonorgestrel and estradiol, and 7 days of pills that contain only low-dose estradiol. As with Seasonale, women who take Seasonique have about 4 periods a year. The FDA is also reviewing Lybrel, which supplies a low-dose of hormones for 365 days a year. In clinical trials of Lybrel, some women stopped having periods altogether.

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.

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 2 pills as soon as you remember and then 2 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. One study found that women who miss 3 pills will probably still not ovulate, but nevertheless, they should take all necessary precautions to prevent pregnancy.

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

Progestin-only pill brands include:

• Levonorgestrel (Plan B)
• Norethindrone (Micronor, Avgestin, Norlutin, Nor-QD). (This progestin is made from male hormones, so may cause more male side effects than others.)
• Norgestrel (Ovrette)

Progestin-only pills, which only contain progestins, are always sold in 28-day packs and all the pills are active. (An exception is Plan B, which is emergency contraception.) Progestin-only pills must be taken at precisely the same time each day to maintain top 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 will experience even lighter periods than those taking combination pills. Some may not have periods at all. These hormones should not be used by premenopausal women in their 40s, since they pose a higher risk for adverse effects in this group.

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. OCs are among the most effective contraceptives. Failure rates are very low and are usually due to noncompliance. Some studies have suggested that women who are overweight may have a higher risk for failure. The risk for these women is also still very low, however.

OCs also have the following advantages:

• More sexual freedom. OCs do not interfere with intercourse, and in fact, many women report that sex is more pleasurable because they no longer have to worry about pregnancy.
• Reduce menorrhagia (heavy bleeding) and, therefore, reduce the risk for anemia.
• Reduction in dysmenorrhea (severe pain). High-dose OCs have been especially helpful, but they carry risks. Specific newer low-dose OCs that contain certain progestins, such as Yasmin (with drospirenone) and Mircette (with desogestrel), may reduce menstrual pain.
• Possible reduction in premenstrual syndrome with specific OCs, notably Yaz (which was approved for treating premenstrual dysphoric disorder -- premenstrual depression -- in 2006.) Some OCs, however, are associated with worse emotional changes. Monophasic OCs may have a more beneficial effect on mood than triphasic OCs.
• Reduction in endometriosis.

Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body causing pain and irregular bleeding.

• Reduction of ovarian cancer. OCs may reduce the risk of ovarian cancer by 30 - 50% (even in women with genetic risk factors). Progestin appears to be the protective factor by suppressing ovulation. Protection occurs after 5 years of use and persists for 10 - 20 years after stopping. Some experts believe that women at particular risk for ovarian cancer might consider oral contraceptives with the highest progestin dose.
• Reduction of endometrial (uterine) cancer. According to some studies, older OCs reduced the risk for endometrial cancer by half. More studies are needed on newer formulations, which have lower doses of estrogen, but it is generally believed that they, too, are protective.
• Possible protection against colon cancer. Duration of use does not seem to be associated with decreased risk, but protection appears stronger for women who have used oral contraceptives more recently.
• Possible protection against multiple sclerosis. Some studies have suggested that women who take oral contraceptives may be less likely to develop multiple sclerosis
• Acne improvement with low-dose OCs. (Some low-dose OCs, such as Ortho Tri-Cyclen, have been specifically approved for acne reduction, although most low-dose OCs reduce testosterone levels and so help reduce acne.)
• Possible protection against bone loss with low-dose OCs. The effect of OCs on bone density is unclear and may depend on the specific formulas and types of progestins used.

Disadvantages and Complications of Oral Contraceptives

Common Side Effects. Estrogen and progesterone have different side effects. Women on the combined pill may experience different effects from those on the progestin-only pill. Symptoms of serious problems include severe abdominal pain, chest pain, unusual headaches, visual disturbances, or severe pain or swelling in the legs. In spite of some concerns, combination OCs do not generally cause weight gain.

[For specific side effects of estrogen and progestin, See Box Hormones Used in Contraception.]

Serious Effects on Heart and Circulation. 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 or have a history of heart disease risk factors (such as high blood pressure) or cardiac events. Women who have certain metabolic disorders, such as polycystic ovary syndrome (PCOS), are also at higher risk for heart-related complications associated with these pills.

When birth control pills were first introduced, heart and circulatory risks were higher than they are now. Current brands of combination oral contraceptives contain much lower dosages of estrogen and are safer than those earlier pills. However, a 2005 review suggested that even low-dose combination birth control pills have some cardiovascular risks. Women should discuss their lifestyle and health history with their doctors to decide if birth control pills are a safe option. For women with heart disease risk factors, progestin-only (“mini-pill”) oral contraceptives may be safer than combination estrogen-progestin oral contraceptives.

Click the icon to see an image of stroke.

Breast Cancer. Studies have been conflicting about whether estrogen in oral contraception increases the chances for breast cancer, and if it does, which women are at risk. Some research supported a higher risk in women with a family history of breast cancer and who also used OCs before 1975, which contained high-dose estrogens and progestins. A reassuring 2002 study supported an earlier major study, with both finding no evidence that current OC use increases the risk for breast cancer. It also reported no higher risk in women who had taken OCs for 15 years of more or had taken them at young ages. Some issues remain unresolved. For example, the risk for women currently taking OCs around menopause (ages 45 - 64) is still unclear. OCs users with a family history of breast cancer or who carry the BRCA1 genetic mutation (although possibly not those with the BRCA2) may be at higher risk. Such women are at higher risk for breast cancer in any case.

Cervical Cancer. Numerous studies report a strong association between cervical cancer and long-term use of oral contraception (OC). The risk is highest (up to four times the risk of nonusers) in women infected with human papillomavirus (HPV) who have taken OCs for 10 years or more. (Women who are not infected with HPV have no significantly higher risk.) The reasons for this risk from OC use are not entirely clear. Some experts have suggested that the hormones in OCs might facilitate entry of the HPV virus into the genetic material of cervical cells. Certainly, women who use OCs are less likely to use a diaphragm, condoms, or other methods that offer some protection against sexually transmitted diseases, including HPV.

Click the icon to see an image of cervical cancer.

Other Complications. Other complications have been associated with the use of oral contraceptives:

• Taking oral contraceptives containing certain progestins (desogestrel in one study) may increase the risk for periodontal disease. Other types of progestins do not pose a risk for gum disease.
• There has been some debate over whether the progestin-only pill increases the risk for permanent type 2 diabetes in women who develop a temporary form of diabetes during pregnancy (called gestational diabetes). In any case, the low-dose combination pill does not appear to pose such a risk. Women with a history of gestational diabetes should discuss this controversy with their doctor.
• Some evidence suggests that oral contraceptives may reduce lung capacity during exercise. In fact, there have been a few reports of worsening of asthma with OCs, but this is an uncommon effect.
• The pill can affect the liver and, in rare cases, has 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. Oral contraceptives can interact with many other medications and herbal supplements.

Implant Contraception

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 FDA 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 is the main side effect. However, some doctors are concerned that Implanon may have some of the same risks as Norplant.

Injected Contraception

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. Like other progestin contraceptives, Depo-Provera prevents pregnancy by halting ovulation, thickening the cervical mucus, and stopping the implantation of fertilized eggs in the uterine lining.

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. The most serious side effect is loss of bone density (see Disadvantages ). Because of this complication, Depo-Provera should not be used for more 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 are not candidates for combination OCs, such as women smokers over age 35.

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. In November 2004, the FDA added a “black box” warning to the Depo-Provera label advising of this risk. The warning notes that the decline in bone density increases with duration of use and may not be completely reversible even after the drug is discontinued. Based on this information, the FDA recommends that Depo-Provera should not be used for longer than 2 years unless other birth control methods are inadequate. A 2005 study of young women (age 14 - 18 years) found that adolescents who stop taking Depo-Provera do regain bone density.
• The injections do not provide protection against sexually transmitted diseases. According to a 2004 study, women who take Depo-Provera have three times the risk of acquiring chlamydia and gonorrhea as women who do not use a hormonal contraceptive. The reason for this increased risk is unclear. The same study found that oral contraceptive use, in comparison to non-hormonal contraceptives, was not associated with increased risk.

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. Precisely how the IUD prevents pregnancy is a mystery. They may kill sperm or preven them from moving, which prevents fertilization from occurring. They may also stop a fertilized egg from implanting in the uterus. 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.

The intrauterine device shown uses copper as the active contraceptive, others use progesterone in a plastic device. IUDs are very effective at preventing pregnancy (less than 2% chance per year for the progesterone IUD, less than 1% chance per year for the copper IUD). 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.

IUD Forms

Two types of IUDs are available in the United States:

• Copper-Releasing (ParaGard) can remain in the uterus for up to 10 years.
• Progestin-Releasing (Mirena) can remain in the uterus for up to 5 years. Mirena is also known as a levonorgestrel-releasing intrauterine system, or LNG-IUS. The LNG-IUS is long-acting, safe, very effective in preventing heavy bleeding, and helps reduce cramps. In fact, some experts describe it as a nearly ideal contraceptive. It is also proving beneficial for women with menstrual disorders, (particularly heavy bleeding).

Inserting the IUD

With some exceptions, an IUD can be inserted at any time, except during pregnancy. 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.

Candidacy for the IUD

The IUD is often an excellent choice for women who do not anticipate future pregnancies, but who do not wish to be sterilized. Women who are unable to use hormonal contraceptives (for example, those with heart disease, epilepsy, migraines, hypertension, or liver disease) may be good candidates for the copper IUD.

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. Other women who may be poor candidates for the IUD are those with the following history or conditions:

• Current or recent history of pelvic infection
• Risk factors for sexually transmitted diseases (such as having multiple sexual partners)
• History of menstrual disorders. (Progestin-releasing IUDs may be an option for women with heavy or painful bleeding. They should avoid the copper-releasing IUDs, however.)
• Current pregnancy
• Abnormal Pap tests
• Cervical or uterine cancer
• A very large or very small uterus

Advantages of the Intrauterine Device

The IUD is one of the safest, least expensive, and most effective contraceptive devices available. In spite of its clear advantages and current safety record, only 1% of American women currently use the IUD. (Over 10% of European women have chosen the IUD.) This low use in America is mainly due to persisting and now unwarranted fears of serious infection. [See Infection below. ]

IUDs have the following advantages:

• The IUD is more effective than OCs at preventing pregnancy and it is reversible. Once it is removed, fertility returns. (In spite of outdated concerns, 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.

There are also additional advantages, depending on the specific IUD:

• 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.) Some studies suggest it might help avoid hysterectomy in 80% of cases. It may even be appropriate and protective for women with uterine fibroids.
• The copper-releasing IUDs do not have hormonal side effects and may help protect against endometrial (uterine) cancer.

Disadvantages and Complications of Specific Intrauterine Devices

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.

Menstrual Bleeding. Both 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.)

Menstrual difficulties can be so troublesome with either IUD that, according to one study, they were responsible for a removal rate of 5 - 15% within a year of insertion.

Infection. The current versions of IUD pose a slightly higher risk for pelvic inflammatory disease in the first month following insertion. The risk of PID in women without any symptoms of sexually transmitted infections, however, is the same in both IUD users and nonusers. An early IUD, the Dalkon Shield, which had a braided tail, was banned after reports of several deaths and a very high rate of infection. The newer types of IUDs are much safer and do not pose as high risk for infection. Still, some doctors may prescribe antibiotics as a precaution before insertion.

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

Expulsion. An estimated 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.

Effects on Pregnancy. None of the current IUDs increase the risk for infertility. In the very unlikely event that a woman conceives with an IUD in place, however, there is a higher risk of an ectopic pregnancy or miscarriage.

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, and the risk is higher or lower depending on the skill of the doctor.

Spermicidal and Barrier Contraception

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. [For a description of the male condom, see Box Male Condom.] Barrier devices are the only contraceptive methods that can help prevent sexually transmitted diseases (STDs).

Spermicides

Spermicides are sperm-killing substances available as foams, creams, or gels, 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, however, does not provide any additional protection against sexually-transmitted diseases. In fact, research indicates that frequent use can cause vaginal irritation and abrasions and actually increase the risk for HIV transmission in women. In addition, use of a spermicide with a barrier device doubles or triples the risk for a urinary tract infection in women, regardless of whether the device is a condom or diaphragm. Spermicides are no longer recommended with male condoms. (Non-spermicidial lubricated condoms are safe to use.) Some experts think they are not necessary for use with diaphragms, but this issue is still under debate.

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. Nor should they be used to prevent sexually transmitted diseases.

Diaphragm

The diaphragm, which is generally used with a spermicidal cream, foam, or gel, 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. The spermicide provides added chemical protection but, as stated above, some experts think they are not necessary for use with diaphragms.

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.

There are three basic rim designs:

• The Arcing Spring diaphragm applies strong pressure and easily flips into place. It is useful for women with weak vaginal muscles and for new users who are worried about incorrect placement.
• The Coil Spring Rim is useful for women with strong vaginal muscles.
• The Flat Spring Rim has a delicate rim and a gentle spring, and may be appropriate for women who have not had children.

Diaphragms come in different sizes and require a fitting by a trained health care provider. The health care provider also advises and prescribes the correct size of diaphragm for the user. 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 and can be used even when a woman is menstruating. 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 cannot be felt by either partner. It may protect against cervical gonorrhea, Chlamydia, and trichomoniasis, although more research is needed to confirm this. It does not provide protection against sexually-transmitted infections in areas other than the cervix.

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

• Failure rates are high, about 20% with typical use.
• Some women dislike having to insert the device every time intercourse occurs or have trouble mastering the insertion and removal process.
• Frequent urinary tract 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.
• Cases of toxic shock syndrome have been reported among diaphragm users, but it is very rare. To be safe, the diaphragm should not stay in place for more than 24 hours. (It is still important for pregnancy protection, however, to retain the diaphragm for 6 - 8 hours after intercourse.)
• It provides protection against sexually transmitted disease only in the cervix, and women should not rely on it for protection against HIV.

Cervical Cap

The cervical cap (Prentif, 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.

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 woman 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, at least with Prentif cervical cap, is similar to that of the diaphragm. (The FemCap appears to have a higher failure rate.) The cap in general is also similar to the diaphragm in terms of cost, ease of use, protection against STDs, 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, and no documented cases of toxic shock syndrome have been reported.

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

• Failure rate with any cap is high in women who have given birth (40%). In general, the FemCap has a higher risk for failure than either the diaphragm or the Prentif cap.
• Unlike the diaphragm, the cap cannot be used during menstruation.
• Use of the cervical cap (particularly the Prentif cap) poses a higher risk for abnormal cervical cell growth than with the diaphragm.

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.

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

The female condom may be the best option for women at risk for sexually transmitted diseases and who are not certain that their male partner will use a condom. There are virtually no obstacles against its use except a negative psychological perception. It is not completely fail-proof against pregnancy or sexually transmitted diseases.

Advantages of the Female Condom. In one study, 75% of the women preferred the female to the male condom. Many men also find it more appealing than the latex male condom. The female condom has a number of advantages over the male condom:

• The female condom is an effective barrier to viruses, including HIV, and other sexually transmitted organism, particularly since it covers a large area, including external genitals. However, there are few clinical studies at this time to determine its protection against sexually transmitted diseases. No contraceptive device is foolproof.
• The standard female condom is made of polyurethane, which is thin and soft but at the same time 40% 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, and possibly enhancing the pleasure of the sexual act.
• 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. Some women are distressed by 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. It is not known how many rewashings are safe.

The Sponge

The sponge (Today, Protectaid) is a disposable form of barrier contraception. It is made of soft polyurethane, is round in shape, and fits over the cervix like a diaphragm, but is smaller and easily portable. In 1994, the popular OTC contraceptive was taken off the U.S. market because of problems at the company's manufacturing facility. A new company has since acquired the rights to manufacture the sponge, and has been selling it in Canada and online since 2003. In April 2005, the FDA granted re-approval for the Today sponge to return to the U.S. market.

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 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. Because the sponge is not felt during intercourse and can be inserted up to 6 hours before intercourse, it encourages spontaneity. It appears to protect against cervical gonorrhea and Chlamydia.

Disadvantages. Failure rates (about 10%) are higher than with the diaphragm. There is a very small risk for toxic shock using the sponge, as there is for other barrier methods of contraception. The sponge may increase the risk for candidiasis (yeast infection). People who are allergic to spermicides should not use the sponge. The sponge does not protect against HIV or sexually transmitted diseases outside the cervix. The Today sponge contains 10 times the amount of the spermicide nonoxynol-9 than other products, and there is some evidence that this spermicide may increase the risk for HIV. The Protectaid sponge, available in Canada, contains a mix of three spermicides (nonoxynol-9, sodium cholate and benzal konium chloride).

Lea Shield

The Lea shield is made of silicone, and its cup-shaped bowl completely surrounds the cervix without resting on it. The shield does not need to be fitted, and 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

Natural Family Planning Methods

Natural family planning contraceptive methods do not use medication, physical devices, or surgery to prevent pregnancy. Instead, these cycle-based fertility awareness 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. The Catholic Church, for example, generally approves of most natural family planning methods.

Natural family planning methods include:

• Basal body temperature
• Cervical mucus
• Symptothermal
• Lactational amenorrhea
• Calendar

Basal Body 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, a 2000 study reported that only 30% of women were fertile within that period of time. In the study, women had a 10% chance of ovulating on each day between day 6 and 21. The researchers suggested that each woman track the length of her cycle, which in the general population of women actually runs 19 - 60 days. A long cycle, for example, suggests a delayed ovulation date.
• 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.

Symptothermal Method. This method uses both the basal body temperature and cervical mucus methods. 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.

Prolonged Breastfeeding (The Lactational Amenorrhea Method). Breastfeeding often delays the onset of ovulation and menstruation for about 6 months. A technique called the Lactational Amenorrhea Method (LAM) allows women to rely on breastfeeding for natural family planning. New mothers are candidates for LAM if their periods have not returned after delivery. They must be breastfeeding the baby on demand, day and night, without regularly substituting other liquids or foods in the baby's diet.

The risk for pregnancy with this method is less than 2% in the early months, although by 6 months after birth it increases to over 5%. The return of menstruation indicates the return of fertility. Bleeding or spotting during the first 56 days is not considered menstruation. After that, 2 or more consecutive days of bleeding are usually an indicator that periods have returned. Ovulation can occur before menstruation resumes, although it is less likely within 6 months of delivery (particularly if the mother is intensively breastfeeding).

Calendar Method. The calendar (rhythm method) is considered the least reliable of natural family planning methods, with an effectiveness rate of about 87%. 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.

Candidacy for Natural Family Planning

Because of the high risk for pregnancy, natural family planning 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, should use a barrier contraceptive during the fertile phase and no contraception during the rest of the cycle. 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.

Advantages of Natural Family Planning

Many couples, especially older ones, who have used these methods for a while and are strongly motivated, are able to successfully incorporate fertility awareness into their lives. For those with strong religious beliefs, natural family planning allows them to have a fulfilling sexual life yet still adhere to the rules of their church.

Disadvantages and Complications of Natural Family Planning

Couples who adopt a cycle-based approach to pregnancy avoidance must often abstain from sex or substitute other kinds of sexual intimacy for vaginal intercourse. Some couples find this self-denial and the need for vigilant tracking of the cycle difficult and stressful for the relationship. Failure rates are high with natural family planning. The risk for sexually transmitted diseases is also of particular concern, because such methods offer no protection against infection and religious beliefs usually preclude barrier protection.

Emergency Contraception

Emergency contraception is available to prevent pregnancy:

• 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)

Basics of Emergency Contraception

Emergency contraception, also called the “morning after pill,” uses the hormones found in birth control pills to prevent either fertilization or the implantation of a fertilized egg in the uterine lining. It is not the same thing as the "abortion pill" [See Mifepristone, below]. Emergency contraception is usually given as hormone pills within 72 hours of unprotected sex. Some of these pills (such as Plan B) contain only progestin. Other pills (such as Preven) contain a combination of estrogen and progestin. Emergency contraception is also sometimes prescribed as an intrauterine device (IUD), which is inserted within 5 days of unprotected sex.

In 2006, after a long political battle, the FDA approved the Plan B brand as the first over-the-counter emergency contraception. It is available without a prescription at pharmacies and health clinics for women over age 18. Women will need to present proof of age to purchase it. Girls younger than age 18 will still need to get a prescription from their doctors.

Specific Methods

Emergency Oral Contraception. There are two forms of emergency oral contraception:

• The Yuzpe method uses two doses of combined oral contraceptives containing estrogen and the progestin levonorgestrel. In the U.S., Preven is the standard brand used for the Yuzpe method. In general, this approach is effective in preventing pregnancies 75% of the time (although some studies report lower success rates).
• The other standard approach uses two doses of the progestin levonorgestrel, which includes Plan B. Studies indicate that this method causes less stomach distress and is more effective than the Yuzpe method. In one large study, levonorgestrel prevented pregnancy in 85% of women requiring emergency contraception.

With both methods, the woman takes her first pill or pills within 72 hours of intercourse and a second dose 12 hours later. The earlier they are taken, the more effective they are in preventing pregnancy. Some evidence suggests they may be effective up to 5 days after sex, although effectiveness is greater if used within 72 hours. Although these regimens are popularly called morning-after pills, they are actually the same oral contraceptives that users of OCs take regularly.

Side effects of emergency oral contraception methods include:

• Nausea and vomiting are common in both approaches, but particularly with Preven.
• Fatigue
• Headaches
• Dizziness
• Diarrhea
• Breast tenderness
• Fluid retention
• Changes in the timing or flow of the woman's next menstrual period. A 2006 study found that emergency contraceptive pills (such as Plan B) that contain levonorgestrel may alter the menstrual cycle and the length of periods.

Immediate side effects typically subside within 1 - 2 days of taking the second dose. Family planning experts warn that emergency pill use should not be treated as a substitute for regular contraception.

Copper-Releasing IUD. An alternative emergency contraception relies on insertion of a copper-releasing IUD within 6 days of 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%.

Mifepristone. Mifepristone is the drug used in Mifeprex (formerly called RU 486). This "abortion pill" blocks progesterone action so that the lining thins and deters implantation of the egg. Unlike emergency oral contraception, the combination of mifepristone and misoprostol can abort an existing pregnancy. A single dose of mifepristone used within 72 hours of unprotected sex can prevent pregnancy.

When used after pregnancy occurs, mifepristone is taken within 49 days of a woman's last period. The woman is given three pills containing mifepristone during her first doctor's visit, and then a second drug (misoprostol) 2 days later. Misoprostol causes uterine contractions that will expel the embryo. A third visit is needed to ensure the abortion is successful. Women who have ectopic or tubal pregnancies cannot take mifepristone. Side effects include pain, and use of the pills may also cause nausea and bleeding.

There have been four reported deaths from infection (sepsis) in women who took mifepristone and misoprostol for medical abortion. In 2005, the manufacturer of Mifeprex revised the drug's prescribing label. The new information advises women to immediately contact their doctors or go to an emergency room if they experience abdominal pain or discomfort, or general malaise (weakness, nausea, vomiting, or diarrhea), with or without fever, more than 24 hours after taking misoprostol.

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. About 700,000 women undergo this procedure each year in the United States.

Basics of Female Sterilization

Female surgical sterilization procedures block the fallopian tubes and thereby prevents 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.

The uterus is a hollow muscular organ located in the female pelvis between the bladder and 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. (One study suggested that women with a history of Cesarean section may experience slightly heavier bleeding.) Sterilization does not offer protection against sexually transmitted diseases.

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.

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 approximately 30 minutes to perform. Women who undergo minilaparotomy typically need a few days to recover and can resume intercourse after consulting their doctor.

Laparotomy. Laparotomy, a less common approach, requires an extensive 2- to 5-inch incision in the abdomen. It is considered major surgery and can require a hospital stay of a few days followed by recovery at home for several weeks. Resumption of intercourse depends on how quickly one is able to recover.

Culdoscopy. Culdoscopy involves inserting a scope through the vagina and into the pelvic cavity. Although it is less invasive than laparoscopy, a major 2002 analysis reported that it has a higher complication rate than either laparoscopy or minilaparotomy.

Essure. Approved in 2002, 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. [See In-Depth Report #37: Vasectomy.]

Even if all these factors are present, a woman must consider her options carefully before proceeding. Studies report that over time, 14 - 25% of women eventually regret this choice. Women at highest risk for regretting sterilization include:

• Women who are younger at the time of sterilization. In one long-term study, over 40% of women who had had tubal ligation between the ages of 18 - 24 regretted their choice. (Only about 4% of women over 35 had these regrets.)
• 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 are between 20 - 84%, depending on the surgical 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. There is some evidence it may help reduce the risk for ovarian cancer.

Disadvantages and Complications of Female Sterilization

• Failure is rare, but about 1 in 200 women become pregnant during the first year after sterilization, and failure rate can rise to 5% after 10 years. About a third 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. In general, there is more postoperative pain with the tubal ring than with electrocoagulation.
• Serious complications from female surgical sterilization are rare and are most likely to occur with abdominal procedures. They include bleeding, infection, or reaction to the anesthetic. On rare occasions the bowels or blood vessels are injured and require major surgical repair. The use of electrocoagulation poses a risk for burns in the small intestine and may increase the risk for menstrual disorders afterward.

Resources

• www.nichd.nih.gov -- National Institute of Child Health and Human Development
• www.plannedparenthood.org -- Planned Parenthood
• www.engenderhealth.org -- EngenderHealth
• ec.princeton.edu -- Emergency Contraception Website
• www.acog.org -- American College of Obstetricians and Gynecologists
• www.guttmacher.org -- The Alan Guttmacher Institute

References

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Baillargeon JP, McClish DK, Essah PA, Nestler JE. Association between the current use of low-dose oral contraceptives and cardiovascular arterial disease: a meta-analysis. J Clin Endocrinol Metab. 2005 Jul;90(7):3863-70.

Funk S, Miller MM, Mishell DR Jr, Archer DF, Poindexter A, Schmidt J, et al. Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel. Contraception. 2005 May;71(5):319-26.

Raymond EG, Goldberg A, Trussell J, Hays M, Roach E, Taylor D. Bleeding patterns after use of levonorgestrel emergency contraceptive pills. Contraception. 2006 Apr;73(4):376-81.

van Vliet HA, Grimes DA, Helmerhorst FM, Schulz KF. Biphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006 Jul 19;3:CD002032.

van Vliet HA, Grimes DA, Lopez LM, Schulz KF, Helmerhorst FM. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev. 2006 Jul 19;3:CD003553.

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