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Contraception.

Overview

What Is It?

Contraception refers to a woman's chosen form of birth control, including hormonal, barrier, chemical and natural methods. Choosing a birth control method is one of the most personal health care decisions a woman makes. In nearly four decades of childbearing years, your need for birth control will most likely change many times. But at each life stage, you can make informed decisions by learning about all your contraceptive options and selecting one or more that best fits your reproductive health needs, and changing it if and when you find it-s necessary to use a different option.

Why Do Unplanned Pregnancies Occur with Contraception?

Many women are not adequately protected from an unwanted pregnancy by their choice of birth control method. In fact, according to the 2002 National Survey of Family Growth, about half of all pregnancies are unplanned. Of these unplanned pregnancies, almost half of the women were using some form of birth control. Reasons for contraception failure include:

Inappropriate Use of Contraceptive

For example, not inserting a diaphragm the right way or not using enough spermicide. Myths or personal concerns about the risks and safety of certain birth control options also contribute to incorrect use of birth control. Women may use a particular method only occasionally, for example, thinking that less frequent use is safer than continuous use. Or they may stop using a particular method because of bothersome side effects.

Failure to Continue Use of the Contraceptive

For example, forgetting to take your birth control pills or not using a condom every time you have sex. Age-related changes can lead women to believe they no longer need to use contraception. For example, women nearing menopause may mistakenly think they are no longer fertile because their menstrual cycles are no longer regular. However, about 38 percent of pregnancies that occur in perimenopausal women are unintended. Although menopause does mark the end of a woman's childbearing years, you have not gone through menopause until 12 consecutive months without a period. You can get pregnant even if your periods are irregular.

Failure of the Contraceptive

In some cases the method itself fails, resulting in an unplanned pregnancy.

How to Choose the Right Birth Control Method

Today, American women have more contraceptive options to choose from than ever before. So you should be able to find one that works well for you and fits your lifestyle. Other things to consider before making a contraception choice:

* Find out how much the contraceptive costs. Do you have to pay for it all at once or can the cost be spread out over a year? Will your health insurance cover it?

* Ask yourself if you can realistically use this method. Are you sure you understand how to use it properly? Will this method embarrass you or your partner? Does it fit with your lifestyle?

* Find out how to use the method correctly and what to do if you forget to use it occasionally.

* Ask your health care professional about side effects. What should you expect? What should you do about them if they occur, and when should you expect them to stop?

* Will this method cause any unacceptable weight gain?

You can probably think of many more questions about birth control. Learn as much as you can about your options and make an informed decision about which method is the best and safest for you. Consider your needs and discuss them with your health care professional during your next medical appointment.

To get you started, here is some basic information about contraceptive options approved by the U.S. Food and Drug Administration (FDA), and resources you can use for more in-depth research. For a comparison of how effective each type of contraception is for preventing pregnancy, please see the chart, "Contraceptive Failure Rates" at the end of this entry.

Types of Contraceptive Options

The contraceptive options women may choose are:

Birth Control Pills

There are three types of BCPs on the market today: the combination pill, the mini-pill and the emergency contraceptive pill. The combination pill is the most widely prescribed. It contains two hormones: estrogen and progestin. It works by suppressing ovulation each month.

Learn more: Birth Control Pills

Long-Acting Hormonal Methods

Several options are available to women who want long-term, but not permanent, protection against pregnancy, including intrauterine devices, hormonal patches and vaginal rings. These options rely on estrogen-progestin or progestin alone to prevent ovulation.

Learn more: Long-Acting Hormonal Methods

Barrier Methods

Barrier methods are less effective than hormonal methods but cause fewer side effects and are associated with less risk. They include condoms, diaphragms, the contraceptive sponge and cervical caps

Learn more: Barrier Methods

Spermicides

Spermicides are nonprescription, nonhormonal chemical products (foam, cream, gel, suppository and film) containing the active ingredient nonoxynol-9 (N-9) or octoxynol-9 (O-9).

Learn more: Spermacides

Natural Family Planning

A calendar, body temperature and physical symptoms, such as the consistency of cervical mucus, are used to determine when ovulation is likely, and you avoid intercourse during this time.

Learn More: Natural Family Planning

Permanent Contraception

Female sterilization closes a woman's fallopian tubes by blocking, tying or cutting them so an egg cannot travel to the uterus.

Learn more: Permanent Contraception

The Effectiveness of Contraceptives

The statistics below represent the percentage of women who experienced unintended pregnancy during one year of using the contraceptive method indicated.
Method                                      Failure Rate

Permanent Contraception:(Sterilization)
Male Sterilization                          0.15%
Female Sterilization                        0.5%

Hormonal Methods:
Hormone Shot (Depo-Provera)                 Less than 1%
Combined Pill (Estrogen/Progestin)          2-3%
Minipill (Progestin only)                   3%
Three-month pill (Seasonale, Seasonique)    Less than 2%
Patch (Ortho Evra)                          Less than 1%
Ring (Nuva Ring)                            1%

Intrauterine Devices (IUDs):
Copper T                                    0.5%
Levonorgestrel releasing IUD                0.1%

Barrier Methods:
Male Latex Condom(*)                        14%
Diaphragm(**)                               5-20%
Cervical Cap (no previous births)(**)       15%
Cervical Cap (previous births)(**)          30%
Female Condom                               21%
Sponge                                      18-28%

Spermicide: (gel, foam,
suppository, film)                          26%

Natural Methods:
Withdrawal                                  18-20%
Natural Family Planning (calendar,
temperature, cervical mucus)                15-20%

No Method                                   85%

* used without spermicide

** used with spermicide


Birth Control Pills

Birth Control Pills (BCPs)

There are three types of BCPs on the market today: the combination pill, the mini-pill and the emergency contraceptive pill. The combination pill is the most widely prescribed. It contains two hormones: estrogen and progestin.It works by suppressing ovulation each month. Thinning the uterine lining and changing the consistency of the mucus in a woman's cervix, making it harder for sperm to move into contact with an egg.

All combination BCPs contain 20 to 50 mcg of estrogen, a lower dose (one-fourth or less) than the BCPs marketed 20 to 30 years ago. They come in different formulations. Some require taking a constant dose of both medications for 21 days followed by one week of placebo tablets. Others vary the dose of estrogen and/or progestin that a woman gets throughout her cycle or add five additional days (tablets) of estrogen at the end of the 21-day cycle.

In May 2007, the FDA approved Lybrel, the first continuous use birth control pill. It is a multiphasic pill (containing varying levels of estrogen and progestin designed to be taken at specific times throughout the entire pill- taking schedule) and comes in a 28-day pack. This product is designed to be taken continuously with no break in between pill packets, which means you won't have a period. However, you may have some spotting or breakthrough bleeding, particularly when you first start using Lybrel.

Seasonale, is a 91-day oral contraceptive regimen also designed to reduce the number of months you have a menstrual cycle. Tablets containing progestin and estrogen are taken for 12 weeks (84 days), followed by one week of placebo tablets. Therefore, the number of expected menstrual periods is reduced from once a month to about once every three months, or four times a year. It was approved in 2003. The FDA approved Seasonique, the "next generation" of Seasonale, in 2006. Seasonique is the same as Seasonale except with Seasonale, women take inactive pills during their four yearly periods and with Seasonique, they take a low dose of estrogen during their periods. Recently, Lo-Seasonique was approved by the FDA as well. It is similar to Seasonique but with lower doses of hormones.

If and when you decide to get pregnant and stop taking birth control pills, you may get pregnant immediately-there are no long-term effects on your fertility from birth control pills.

Benefits

Birth control pills are now prescribed by health care professionals because of their long- and short-term health benefits for women. Birth control pills can:

* Regulate, shorten or eliminate a woman's menstrual cycle

* Decrease severe cramping and heavy bleeding

* Reduce anemia

* Reduce ovarian cancer risk. According to a 2008 review conducted by Collaborative Group on Epidemiological Studies of Ovarian Cancer, taking the pill for 15 years or more cuts a woman's risk of ovarian cancer by 58 percent; taking it for 10 to 14 years cuts risk by 44 percent; and taking the pill for one to four years cuts a woman's risk by 22 percent.

* May reduce colorectal cancer risk.

* Reduce the development of ovarian cysts

* Decrease benign breast disease

* Provide reliable birth control without affecting future ability to become pregnant

* Reduce the severity and incidence of pelvic inflammatory disease (PID)- infection primarily of the fallopian tubes and/or the female reproductive tract

* Protect against ectopic pregnancy (pregnancy outside the uterus, in the fallopian tubes)

* Reduce the risk of uterine (endometrial) cancer. Studies find that oral contraceptives protect against this disease by providing the progestins needed to oppose the stimulation of the uterine lining caused by estrogen. The risk is lowest in women who have taken the pill for a long time, and it appears to continue for at least 10 years after a woman has stopped taking the pill.

* Minimize perimenopausal symptoms, such as irregular menstrual bleeding

* Reduce acne

* Treat the emotional and physical symptoms of premenstrual dysphoric disorder (PMDD), a severe form of PMS. Only one combination OC, called YAZ, has been approved by the FDA for use as an oral contraceptive and as a treatment for the emotional and physical symptoms of PMDD (as well as a treatment for moderate acne). It contains the progestin drospirenone and ethinyl estradiol, a form of estrogen.

Risks

Women with certain health conditions may not be able to use birth control pills. These include:

* Heart disease or stroke

* Liver disease

* Blood clots in the deep veins or lung

* Breast cancer

* Severe or uncontrolled diabetes. The estrogen in birth control pills may increase glucose levels and decrease the body's insulin response, while the progestin in the pills may encourage overproduction of insulin. Use of birth control pills by diabetic women should be limited to those who do not smoke, are younger than 35 and are otherwise healthy with no evidence of persistent high blood pressure, kidney disease, vision problems or other vascular disease.

* Smokers 35 or older. Women age 35 or older who smoke and take birth control pills have a significantly higher risk of ischemic stroke.

* Certain types of migraine headaches. Women who take birth control pills and have a history of migraines have an increased risk of stroke compared to nonusers with a history of migraine. Your risk is greatest if you have migraines with "aura"-blurred vision, temporary loss of vision or seeing flashing lights or zigzag lines. As a result, the World Health Organization (WHO) has concluded that for women of any age who have migraines with aura and women over age 35 who get migraines (with or without aura), the risks of BCPs usually outweigh the benefits.

* Severe hypertension. BCP users with a history of high blood pressure faced a substantially higher relative risk of ischemic stroke (blood clot in the brain) than nonusers with no such history. Oral contraceptives have been associated with a small, but significant increase in ischemic stroke risk in many, but not all, studies. This was a particular concern with early birth control pills that contained higher doses of estrogen, but newer BCPs containing less estrogen are associated with a lower risk of stroke than high-dose pills. In otherwise healthy young women (nonsmokers without persistent high blood pressure), the risk is low.

* Smoking cigarettes while taking BCPs dramatically increases risks of heart attack for women over age 35. Smoking is far more dangerous to a woman's health than taking birth control pills, but the combination of oral contraceptive pill use and smoking has a greater effect on heart attack risk than the simple addition of the two factors.

* Some women worry that BCPs may increase their risk for cancer, particularly breast cancer. However, research on the association between breast cancer risk and birth control pill use is conflicting. In general, studies have not shown a link. Birth control pills may increase breast cancer risk in women with the BRCA1 mutation and possibly in women with the BRCA2 mutation. Discuss the risks and benefits of birth control pills with your health care professional.

* There is some evidence that long-term use of BCPs may increase the risk of cancer of the cervix (the narrow, lower portion of the uterus). There is also some evidence that BCPs may increase the risk of certain benign (noncancerous) liver tumors.

Possible side effects

Nausea, breast tenderness and bleeding are the most common side effects of all BCPs. Most side effects decrease or disappear after three months of continuous use. Switching to another BCP formulation can also relieve side effects.

A serious issue often overlooked by both health care professionals and women is that interactions with other medications can reduce the effectiveness of BCPs. Medications known to interact with BCPs are rifampin (an antibiotic) and some anticonvulsants. If you take these drugs regularly but are still interested in using BCPs as your birth control method, talk with your health care professional.

The "Mini Pill"

A second BCP option is referred to as the "mini-pill." One pill, which contains only progestin, is taken every day. These pills work by preventing ovulation and reducing and thickening cervical mucus to prevent sperm from reaching the egg. They also keep the uterine lining from thickening, which prevents a fertilized egg from implanting in the uterus. However, with progestin-only birth control pills, ovulation isn't consistently suppressed, so the actions on cervical mucus and the endometrium are the critical factors. They may not be as effective as combined BCPs. Progestin-only pills must be taken exactly on time, every day.

However, the progestin-only pill is often an option if you want to use oral contraception but can't take estrogen. If you are breastfeeding or experience uncomfortable side effects from estrogen, such as headaches, this could be the best option for you.

Protection against ectopic pregnancy is not as strong with the mini-pill as it is with combination BCPs. The main side effect from mini-pills is menstrual irregularity; you may not have any bleeding for months or you may have some spotting between periods. As with combined BCPs, the mini-pill does not protect you from sexually transmitted diseases, so condoms are necessary if you or your partner is at risk.

Emergency Contraception

This type of contraception is designed to prevent pregnancy after unprotected sex (when standard contraceptives fail or no method was used). Emergency contraceptive pills (ECPs) are not intended to be used regularly as a contraceptive. There are four FDA-approved emergency contraception pills in the United States: Plan B One-Step, Plan B (which is being phased out) and Next Choice, all of which contain the progestin levonorgestrel, and ulipristal acetate tablets, sold under the brand name "ella."

Approved by the FDA in August 2010 and expected on the U.S. market in late 2010, ella can prevent pregnancy when taken orally within five days (120 hours) after unprotected sex. It is a progesterone agonist/antagonist whose likely main effect is to inhibit or delay ovulation. ella cuts the chances of becoming pregnant by about two-thirds for at least 120 hours after unprotected sex, studies have shown.

Plan B One-Step should be taken within 72 hours of unprotected sex. Recent research shows that the levonorgestrel pills may be effective up to 120 hours after unprotected sex but are more effective the sooner they are taken. Plan B and Next Choice work similarly to Plan B One-Step, but consist of a two-dose regimen, with the first dose taken within 72 hours of unprotected sex and the second 12 hours later. Newer studies indicate that both pills may be taken together as soon as possible after unprotected sex.

Women 17 and over can buy the levonorgestrel emergency contraceptive pills without a prescription. They must ask for them at the pharmacy counter and show proof of age. Younger girls are required to have a prescription. ella will be available only by prescription, but women could keep a supply at home.

If you are too young to obtain emergency contraceptive pills over the counter, call 1-888-NOT-2-LATE or 1-800-230-PLAN to locate a health care professional who can help you. These numbers also provide information on which pharmacies sell emergency contraceptives because not all pharmacies carry them.

In addition, certain regular oral contraceptive pill packs can be used for emergency contraception if you take several pills at the same time (the exact quantity depends on the brand), but make sure you check with your health care professional for proper dosage and timing.

To learn more about how ECPs work and how to get them, ask your health care professional or pharmacist. Or visit the Internet site for emergency contraception operated by the Association of Reproductive Health Professionals and the Office of Population Research at Princeton University (ec.princeton.edu).

Side Effects and Risks

Emergency contraceptive pills should not be used regularly as birth control because they can disrupt your menstrual cycle. They are also not 100 percent effective and can cause side effects such as nausea and vomiting, headaches, breast tenderness, dizziness and bloating. Medication may be prescribed with ECPs to minimize nausea and vomiting.

Because ECPs are intended for use only as their name implies-during an emergency when other contraceptives failed or were not used-women who might otherwise not be able to take BCPs on a regular basis may be able to use ECPs. Discuss your options with a health care professional.

And if you waited longer than 72 hours after unprotected sex, you have another option. An IUD can be inserted by a health care professional up to 120 hours (five days) after unprotected sex and should prevent a fertilized egg from implanting in most cases. The same precautions apply for using an IUD as an emergency contraceptive as for choosing it as a birth control method: If you are at risk for sexually transmitted diseases (if you have multiple sexual partners) or if you have a recent history of pelvic inflammatory disease, you aren't a good candidate for this type of emergency contraception.

Long-Acting Hormonal Methods

Long-Acting Hormonal Methods

Several options are available to women who want long-term, but not permanent, protection against pregnancy. These options rely on estrogen-progestin or progestin alone to prevent ovulation. They include: Progestin shots (Depo- Provera (DMPA), or the low-dose form, Depo-Subq-Provera)

This method provides pregnancy protection for up to three months. A health care professional injects the medication into your buttocks or upper arm muscle. You will need to return to your health care professional's office every three months for another injection to continue protection. This option may bring some changes in menstrual bleeding. Early on, you may experience spotting. Later, many women stop having periods all together. It is OK not to have a period when using progestin shots. With this birth control method, the uterine lining doesn't grow thick enough to shed and cause menstruation. Progestin shots have been shown to reduce the risk of uterine (endometrial) cancer and prevent anemia and pelvic inflammatory disease. Side effects may include bloating/weight gain, headaches, depression, loss of interest in sex and hair loss, and it usually takes 12 weeks before the effects of the shot disappear. Recent studies show a link between Depo-Provera and a loss of bone density, which can lead to an increased risk of osteoporosis. The bone density may not return completely after discontinuing Depo-Provera. Because this bone density loss is greater with long-term use, talk to your health care professional about another method of birth control after two years on Depo-Provera.

Intrauterine Devices (IUD)

The IUD is a plastic, T-shaped device that is inserted by a health care professional into the uterus. One type of IUD, the ParaGard IUD, is a T-shaped piece of soft flexible plastic wrapped in copper that can be kept in place for up to 10 years. However, you shouldn't use the ParaGard IUD if you have any risk factors for pelvic inflammatory disease (PID) or have a recent history of pelvic inflammatory disease or experience heavy menstrual bleeding because a copper IUD can increase heavy bleeding.

Mirena (levonorgestrel intrauterine system) is another type of IUD, which can be kept in place for up to five years. During that time, it slowly releases a low dose of levonorgestrel, the same progestin found in many birth control pills. The levonorgestrel thickens cervical mucous, preventing sperm from reaching an egg. It also helps reduce cramping and bleeding. The U.S. Food and Drug Administration recently approved the IUD Mirena to treat heavy menstrual bleeding in women who use intrauterine contraception as their method of pregnancy prevention.

Once it's removed, pregnancy becomes possible almost immediately. You shouldn't use the Mirena IUD if you have a history of pelvic inflammatory disease (PID) unless you have had a subsequent normal pregnancy.

Although experts do not completely understand how the IUD prevents pregnancy, they believe the device works this way: It causes just enough tissue disturbances in the uterus to create an unfriendly environment for sperm. Few, if any, sperm can make it through the uterus to the fallopian tubes, so fertilization can't occur. The progestin in the progestin-releasing IUD thickens the cervical mucus and blocks sperm. The copper released by the copper-coil IUD also helps repel sperm.

Some women are reluctant to use IUDs because of the damaging effects caused by the Dalkon Shield, an IUD popular in the 1970s. That IUD was withdrawn from the market in 1975. Newer IUDs are constructed differently and are considered safe and effective for women with low risk of sexually transmitted diseases.

* Benefits. IUDs are highly effective in preventing pregnancy; they also provide some protection against ectopic pregnancies. Once the IUD is inserted, it requires no care other than checking the strings attached to the IUD to ensure that it remains in place. The strings are fine threads that hang into the cervix and can be felt from the vagina.

* Side effects. The most common side effects associated with ParaGard IUD use are cramping and heavy bleeding. Women using the Mirena IUD may initially have irregular periods/bleeding. After a few months, you may experience lighter periods or no periods at all.

Use of all IUDs has been associated with an increased incidence of pelvic inflammatory disease (PID), so women who have a recent history of PID or who are at high risk for contracting STDs should not use the IUD. Cramping, pain and heavy bleeding associated with IUD use in some women is most common at the time of insertion. Menstrual-related symptoms and discomfort may subside after several months.

Vaginal Contraceptive Ring

One of the newest contraceptives on the market, NuvaRing, is available by prescription only and consists of a soft, flexible, transparent ring that measures approximately two- inches in diameter. It contains a combination of estrogen and progestin hormones (ethinyl estradiol and levonorgestrel). It is inserted into the vagina like a tampon, where the hormones are slowly released on a continual basis. You need to insert a new ring each month for continuous contraception. You can insert the ring yourself into your vagina, where it should remain for three weeks. Then you remove the ring for one week, during which time you have your period.

* Benefits. NuvaRing only needs to be inserted once a month, making it a convenient form of birth control. And, like oral contraceptives, NuvaRing is highly effective when used according to the labeling. For every 100 women using NuvaRing for an entire year, only one will become pregnant.

* Side effects. Side effects of the NuvaRing may include vaginal discharge, vaginitis and irritation. Like oral contraceptives, NuvaRing may increase the risk of blood clots, heart attack and stroke. Women who use NuvaRing are strongly advised not to smoke, as it may increase the risk of heart-related side effects.

Skin Patch

The contraceptive Ortho Evra is a transdermal (through the skin) patch approved by the FDA in 2001 that contains ethinyl estradiol and the progesterone norelgestromin.

The one-and-three-quarter-inch patch is applied to the skin (abdomen, buttocks or upper torso, but not breasts) where it slowly releases hormones for a week. It must be replaced every week. After three weeks (and three new patches) you have one week that is patch-free, during which you get your period.

* Benefits. The Ortho Evra patch is 99 percent effective in preventing pregnancy when used correctly. It also removes the problem of having to remember to take a pill every day or insert a device before intercourse.

* Side effects and warnings. In clinical trials, the patch was less effective in women weighing more than 198 pounds. Also, some women experienced breast symptoms, headache, a reaction at the application site, nausea and emotional changes. Other risks are similar to those from using birth control pills, including an increased risk of blood clots, heart attack and stroke. Women who use Ortho Evra are strongly advised not to smoke, as it may increase the risk of heart-related side effects.

In 2005, the FDA updated the labels on Ortho Evra, stating that the birth control patch delivers a higher dose of estrogen than the birth control pill and therefore may increase the risk of blood clots and other serious side effects. Women taking or considering the birth control patch should talk to their health care professional about these risks.

Barrier Methods

Barrier Methods

Barrier methods are less effective than hormonal methods but cause fewer side effects and are associated with less risk. The effectiveness of barrier forms of contraception can be increased when used with spermicide.

The male condom

The condom is a sheath made of latex or polyurethane that is placed on the penis just prior to intercourse to prevent sperm from entering the uterus. Latex condoms, when used consistently and correctly, provide the best available means of reducing the risk of transmission of many sexually transmitted diseases (STDs), including gonorrhea, chlamydia, HIV and trichomoniasis. Condoms also can reduce the risk of genital herpes, syphilis, chancroid and human papillomavirus infection, but only when the infected areas are covered or protected by the condom, according to the Centers for Disease Control and Prevention. Condoms made of lambskin, however, do not offer such protection because they have microscopic holes that may stop sperm but are large enough to allow viruses to pass through.

The FDA approved the female condom in 1993. It is a soft, thin, polyurethane sheath with two flexible rings, one that contains the closed end of the sheath and is inserted into the vagina. The other ring stays outside the vagina.

Diaphragms and cervical caps

These barrier contraceptives require a prescription and initial fitting by a health care professional. The diaphragm is a soft rubber dome with a flexible rim that covers the cervix. The cervical cap fits snugly on the surface of the cervix. Both devices block sperm from entering the uterus but should be used along with a spermicide.

Both the diaphragm and the cervical cap can be inserted up to six hours before intercourse and should remain in place for six to eight hours after intercourse. You must remove a diaphragm after this period of time but you can leave a cervical cap in place for up to 48 hours.

These devices are easy to insert and remove for most women, although some women can't use the cervical cap because they have an irregularly shaped cervix. Proper fit of either device is important. If you choose one of these options, see your health care professional once a year to have it replaced. Pregnancy and childbirth can change how these devices fit. You should also carefully examine your diaphragm or cervical cap before each use to be sure it is not punctured or torn.

Benefits. One benefit of the barrier method is availability: Condoms and spermicides can be purchased over the counter (without a prescription).

Side effects. Some women and men experience allergic reactions to certain spermicides or to rubber or latex used in condoms, diaphragms or cervical caps. Consult with a health care professional if you develop any symptoms after using contraception. Symptoms might include:

* Rash

* Respiratory distress

* Swelling

* Hay fever-type reactions such as itchy, swollen eyes, runny nose and sneezing

* Asthma-type symptoms such as chest tightness, wheezing, coughing and shortness of breath

Diaphragm and spermicide use has been associated with an increased risk of urinary tract infections (UTI) and yeast infections. Emptying your bladder immediately after intercourse and removing the diaphragm after six hours may decrease your chances of developing a UTI.

The Contraceptive Sponge

The vaginal sponge (Today), which had been withdrawn from the market, won FDA reapproval in April 2005. The one-gram sponge is available over the counter, is 72 to 82 percent effective in preventing pregnancy and contains the spermicide nonoxynol-9. It may be more effective in women who haven't given birth. When moistened with water and placed in the vagina, it releases the spermicide and begins working right away and for the next 24 hours (and it can be used repeatedly within this timeframe). The sponge should be left in place for at least six hours after intercourse. Don't leave it in place for more than 30 hours.

Spermicides

Spermicides

Spermicides are nonprescription, nonhormonal chemical products containing the active ingredient nonoxynol-9 (N-9) or octoxynol-9 (O-9). They can be used alone or in combination with other barrier contraceptives. Spermicides are available as foam, cream, gel, suppository and film, and, when used with other barrier contraceptives, are more effective than either method used alone.

The FDA recommended changes to condom labels in late 2005. The proposed labels will state that using latex condoms can reduce-but not eliminate-the risk of pregnancy and the transmission of HIV and other STDs. The proposals also address latex condoms containing the spermicide nonoxynol-9, which, according to the FDA, may irritate the vagina or rectum and increase the chances of contracting HIV from an infected partner. The proposals also note that condoms leave some male genital skin exposed, which could permit transmission of human papillomavirus (HPV) or other STDs. These proposed changes have not yet been approved. A draft of the proposals is posted on the FDA's Web site at http://www.fda.gov/cdrh/comp/guidance/1548.pdf

Natural Family Planning

Natural Family Planning

Couples using this method identify a woman's most fertile period by tracking her menstrual cycle. A calendar, body temperature and physical symptoms, such as the consistency of cervical mucus, are used to determine when ovulation is likely, and you avoid intercourse during this time.

Benefits and risks. The most obvious benefit to natural family planning is that no artificial devices or hormones are used to prevent pregnancy. Little to no cost is involved. But, experts say, while these methods can work, a couple needs to be extremely motivated to use them effectively and accurately to prevent pregnancy.

Permanent Contraception

Permanent Contraception

Permanent contraception is the most common type of contraception overall, and it is a particularly common choice for women age 35 and older. Female sterilization closes a woman's fallopian tubes by blocking, tying or cutting them so an egg cannot travel to the uterus. There are two primary forms of female sterilization: a fairly new nonsurgical implant system (sold under the brand names Essure and Adiana), and the traditional tubal ligation procedure (done via laparoscopy or minilaparotomy), often called "getting your tubes tied."

* Nonsurgical permanent birth control

Sometimes called fallopian tube occlusion, the nonsurgical permanent contraception procedure can be performed in your doctor's office with local anesthesia. The Essure and Adiana procedures differ somewhat. The Essure system uses specially designed spring-like coils called micro inserts, while Adiana first delivers a low level of radiofrequency energy to a small section of each fallopian tube before a tiny insert, about the size of a grain of rice, is inserted where the energy was applied. In both procedures, your doctor uses a special instrument called a hysteroscope to place the insert through your vagina and cervix into the opening of your fallopian tube in your uterus. There is no incision. Within three months, the insert causes your body to form a tissue barrier that prevents sperm from reaching the egg. During this three-month period, you need to use another form of birth control. After three months, you have to return to your doctor's office for a special x-ray to make sure your tubes are completely blocked. In clinical studies, most women reported little to no pain and were able to return to their normal activities in a day or two.

* Tubal ligation

With this type of sterilization procedure, your fallopian tubes are blocked with a ring or burned or clipped shut. This procedure is typically performed under general anesthesia in a hospital. It can be done via a laparoscopy or a minilaparotomy.

* Laparoscopy: The surgeon makes a small incision through the abdomen and inserts a special instrument called a laparoscope to view the pelvic region and tubes. He or she then closes the tubes using clips, tubal rings or electrocoagulation (using an electric current to cauterize and destroy a portion of the tube). The patient can usually go home the same day and resume intercourse as soon as it's comfortable. Risks include pain, bleeding, infection and other postsurgical complications, as well as an ectopic, or tubal, pregnancy.

* Minilaparotomy. During a minilaparotomy, the surgeon makes a small incision (about two inches long) and ties and cuts the tubes without the use of a viewing instrument. In general, minilaparotomy is a good choice for women who undergo sterilization right after childbirth. Patients usually need a few days to recover and can resume intercourse after consulting with their doctors.

* Vasectomy

Male sterilization is called a vasectomy. This procedure is performed in the doctor's office. The scrotum is numbed with an anesthetic, so the doctor can make a small incision to access the vas deferens, the tubes through which sperm travels from the testicle to the penis. The doctor then seals, ties or cuts the vas deferens. Following a vasectomy, a man continues to ejaculate, but the fluid does not contain sperm. Temporary swelling and pain are common side effects of surgery. A newer approach to this procedure can reduce swelling and bleeding.

Benefits and risks

Sterilization is a highly effective way to permanently prevent pregnancy-it's considered more than 99 percent effective, meaning less than one woman in 100 will get pregnant after having a sterilization procedure. Surgery for female sterilization is more complex and carries greater risk than surgery to sterilize men, and recovery takes longer. Reversing sterilization in men and women is extremely difficult, however, and often unsuccessful. There is a small possibility of getting pregnant after sterilization; some evidence suggests that women who are younger when they are sterilized have a higher risk of getting pregnant.

Couples who are not sure about sterilization but want to postpone having children for at least five to 10 years should first consider using long-acting contraceptive methods such as IUDs or hormonal shots or implants before choosing sterilization.

Facts to Know

* Many women do not get the protection they expect from their birth control methods because they do not use the methods correctly

* Of women using birth control, nearly half experience unplanned pregnancies.

* Birth control pills, also called oral contraceptives, are now available in a variety of low-dose options that are safe and effective for most healthy women. Birth control pills include combination pills, which contain estrogen and progestin, and a "mini-pill" option that does not contain estrogen.

* Oral contraceptives (OCs) may reduce the risk of ovarian and uterine cancers and provide other health benefits such as regulating menstrual cycles; one brand of OCs has been shown to be effective for treating symptoms associated with premenstrual syndrome.

* When used consistently and correctly, condoms offer the best available means of reducing the risk of infection from the following STDs: gonorrhea, chlamydia and trichomoniasis. Condoms can also reduce the risk of genital herpes, syphilis, chancroid and HPV infection, but only when the infected areas are covered or protected by the condom.

* Women who have medical or religious concerns about artificial birth control methods can use fertility awareness methods, sometimes called natural family planning. These methods require that couples be motivated and adhere to a schedule that avoids sex when a woman is ovulating and most likely to be fertile.

* Nearly half of 15- to 19-year-olds have had intercourse. A sexually active teenager who doesn't use contraception has a 90 percent chance of becoming pregnant within one year. Studies show that teens who talk to their parents about sex, pregnancy, birth control and sexually transmitted diseases are less likely to become sexually active at an early age and more likely to use protection when they do have sex.

* Sterilization is the most popular form of birth control in the United States. It is considered a permanent form of birth control.

* It can be helpful to review your contraceptive options as you age to make sure your current birth control method continues to fit your lifestyle and reproductive health needs.

Questions to Ask

Review the following Questions to Ask about contraception so you're prepared to discuss this important health issue with your health care professional.

* How effective is this contraceptive option, and how do I use it correctly? What are its risks and benefits for me?

* (For implantable contraceptives): Do you have experience in inserting the implant? Will it hurt me? After it's inserted, will it be visible?

* What is the difference between the old and new IUDs? Are the new IUDs really safer to use?

* Should I consider the pill? What are its advantages and disadvantages?

* What is the difference between barrier devices like the diaphragm and cervical cap and the vaginal ring? What is the ring and how does it work?

* Does this contraception option protect me from AIDS or other sexually transmitted diseases?

* If I want to consider permanent contraception, what are my options?

Questions To Ask Yourself

* How important is it to you and your partner that you do not become pregnant at this time?

* What is the likelihood that you and your partner will be able to follow the requirements of the contraceptive method you choose?

* Do you take medication or have a medical condition that might make some contraceptives a poor choice for you?

* Do you smoke?

* How often do you have intercourse?

* How old are you? Do you have children, or do you want to have children some day?

* Will your health insurance pay for your contraceptive choice? If not, can you afford it long term?

Key Q&A

* What do I do if I miss a day of taking my birth control pills?

The pills you have to worry most about missing are the ones right before and right after the seven placebo pills in your pack. Known as the pill-free interval, the placebos are designed to be taken the week you have your period to help you stay in the rhythm of taking a pill every day. If you start a new pack late or take longer than seven days "pill free," you might ovulate and could become pregnant. Read the package insert that came with your pills; it will explain what to do about missed pills. Or call your health care professional. In the meantime, use backup contraception just to be safe. In general, if you miss a pill, take it as soon as you remember and then continue taking one pill each day as prescribed (depending on when you missed your pill, you may take two pills on the same day). If you miss two or more pills in the first week of your pill cycle and you have unprotected intercourse during this week, consider using emergency contraception. Don't worry if you miss pills in the fourth and final week of a 28-day pack; those pills are placebo only.

* I've heard that I can't get pregnant while I'm breastfeeding. Does that mean I don't need a contraceptive?

The lactational amenorrhea method (LAM) refers to the natural cessation of a woman's menstrual period while she is breastfeeding. Ovulation doesn't occur at this time, so birth control is automatic. LAM is only effective in preventing pregnancy if the mother is breastfeeding exclusively; her baby is less than six months old; and the mother's periods have not yet returned. If a woman starts to get her period again, it's a pretty good indication that she's ovulating and able to get pregnant. But, in general, even though breastfeeding does provide some contraceptive protection, it is not a completely reliable form of contraception. There are several birth control options that are safe for breastfeeding women and their babies, so why take chances? Here are your options:

* The mini-pill is a progestin-only pill that usually has no negative impact on milk production (combination pills can dry up milk) and may even provide a little boost in milk volume. You can start this pill right after delivery under the guidance of your health care professional.

* Nonhormonal contraception methods such as barrier devices and copper IUDs are preferred in women who are nursing because they don't contain hormones that could affect milk supply or pass through the milk. If hormonal methods are the only option, progestin-only birth control is preferred in women who are breastfeeding.

* Barrier methods such as condoms and spermicides have no impact on breastfeeding and may be helpful in overcoming vaginal dryness caused by breastfeeding (use lubricated condoms). They can be used immediately postpartum. If you want to use a diaphragm or cervical cap, wait until after your sixth postpartum week; diaphragms and cervical caps need to be fitted after you completely heal, and it's not advisable to use them until you've stopped bleeding.

* You can have an IUD inserted between six and eight weeks postpartum.

* I've been taking birth control pills for several years. Do I need to give my body a rest and stop taking them for a while?

There is no scientific evidence that taking oral contraceptives does any long- term harm to your endocrine system, which regulates hormones.

* My partner hates to use condoms because he says they make sex less pleasurable. Is there anything else I can do to protect myself from STDs?

You could try the female condom, which has a looser fit. There are also male condoms designed to enhance pleasure, which are sold over the counter.

You might try a few things to make condom use more fun. How about unrolling it onto your partner's penis yourself?

Condoms sometimes help men maintain an erection; tell your partner you want to use a condom so sex will last longer. If all else fails, refuse to have sex with him if he doesn't use a condom or find other ways to enjoy each other sexually. (Keep in mind that avoiding penis-vagina contact is the only way to stay safe from pregnancy, but other sexual acts, such as oral sex, still put you at risk for some STDs.)

* How do I keep a condom from slipping?

First, check during sex that the condom is still where it should be. Second, make sure your partner knows to withdraw soon after ejaculation, before the penis gets smaller. And third, while he is withdrawing, he should hold the rim of the condom.

* I've heard that birth control pills cause cancer, but I've also heard they can protect against cancer. Which is true?

Studies find a slightly higher risk of breast cancer in women who take birth control pills. There is also evidence, however, that use of birth control pills decreases the incidence of uterine, ovarian and possibly colorectal cancer. The longer a woman uses the pill, the more her risk of developing these cancers is reduced. Discuss the risks and benefits of birth control pills with your health care professional.

BCPs may also protect against developing breast and ovarian cysts.

* I've had all the children I want, but I'm not ready for sterilization. I've been considering the IUD. Is it safe?

Yes. The fears surrounding intrauterine devices (IUDs) stem mainly from problems with the Dalkon Shield, an IUD introduced in the 1970s. The construction of the Dalkon Shield increased the risk of bacterial infections, which resulted in pelvic inflammatory disease for many women. Today's IUDs are constructed differently and are safe and highly effective. IUDs are not good options for women at risk for contracting sexually transmitted infections, however.

* I am 16 years old and would like to use birth control pills. The problem is that I smoke cigarettes. My mom used to smoke and was told she couldn't use them. Can I?

In women younger than 35, the benefits of birth control pills appear to outweigh the risks, even in heavy smokers, unless there is a family history of blood clots. However, smoking puts you at risk for numerous serious health problems, including cancer and heart disease, so you should talk to your health care professional about ways to help you kick the habit.

Organizations and Support

For information and support on Contraception, please see the recommended organizations, books and Spanish-language resources listed below.

Organizations

American College of Obstetricians and Gynecologists (ACOG)

Website: http://www.acog.org

Address: 409 12th Street, SW

P.O. Box 96920

Washington, DC 20090

Phone: 202-638-5577

Email: resources@acog.org

American Social Health Association (ASHA)

Website: http://www.ashastd.org

Address: P.O. Box 13827

Research Triangle Park, NC 27709

Hotline: 1-800-227-8922

Phone: 919-361-8400

Email: info@ashastd.org

American Society for Reproductive Medicine (ASRM)

Website: http://www.asrm.org

Address: 1209 Montgomery Highway

Birmingham, AL 35216

Phone: 205-978-5000

Email: asrm@asrm.org

ASHA's STI Resource Center Hotline

Website: http://www.ashastd.org/herpes/herpes_hotline.cfm

Address: American Social Health Association

P.O. Box 13827

Research Triangle Park, NC 27709

Hotline: 1-800-227-8922

Phone: 919-361-8400

AWARE Foundation

Website: http://www.awarefoundation.org

Address: 834 Chestnut Street, Suite 400

Philadelphia, PA 19107

Phone: 215-955-9847

CDC National Prevention Information Network

Website: http://www.cdcnpin.org

Address: P.O. Box 6003

Rockville, MD 20849

Hotline: 1-800-458-5231

Phone: 404-679-3860

Email: info@cdcnpin.org

Emergency Contraception Hotline

Website: http://ec.princeton.edu

Address: Office of Population Research

Princeton University, Wallace Hall

Princeton, NJ 08544

Hotline: 1-888-NOT-2-LATE (1-888-668-2528)

Guttmacher Institute

Website: http://www.guttmacher.org

Address: 1301 Connecticut Avenue NW, Suite 700

Washington, DC 20036

Hotline: 1-877-823-0262

Phone: 202-296-4012

Email: info@guttmacher.org

International Women's Health Coalition (IWHC)

Website: http://www.iwhc.org

Address: 333 Seventh Avenue, 6th floor

New York, NY 10001

Phone: 212-979-8500

Email: info@iwhc.org

National Abortion and Reproductive Rights Action League (NARAL)

Website: http://www.naral.org

Address: 1156 15th Street, NW, Suite 700

Washington, DC 20005

Phone: 202-973-3000

National Abortion Federation

Website: http://www.prochoice.org

Address: 1660 L Street, NW, Suite 450

Washington, DC 20036

Hotline: 1-800-772-9100

Phone: 202-667-5881

Email: naf@prochoice.org

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention

Website: http://www.cdc.gov/nchhstp

Address: Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

Hotline: 1-800-CDC-INFO (1-800-232-4636)

Email: cdcinfo@cdc.gov

National Women's Health Network (NWHN)

Website: http://www.nwhn.org

Address: 1413 K Street, NW, 4th floor

Washington, DC 20005

Hotline: 202-682-2646

Phone: 202-682-2640

Email: nwhn@nwhn.org

Planned Parenthood Federation of America

Website: http://www.plannedparenthood.org

Address: 434 West 33rd Street

New York, NY 10001

Hotline: 1-800-230-PLAN (1-800-230-7526)

Phone: 212-541-7800

Sexuality Information and Education Council of the United States (SIECUS)

Website: http://www.siecus.org

Address: 90 John Street, Suite 704

New York, NY 10038

Phone: 212-819-9770

Books

A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge

of Your Health

by William H. Parker, Rachel L. Parker

All About Birth Control: A Complete Guide

by Jon Knowles

Sex Ed

by Miriam Stoppard

Sexual Health Questions You Have...Answers You Need

by Michael V. Reitano, Charles Ebel

The Whole Truth About Contraception: A Guide to Safe and Effective Choices

by MD, MPH Beverly Winikoff, Suzanne Wymelenberg

The Yale Guide to Women's Reproductive Health: From Menarche to Menopause

by Mary Jane Minkin, Carol V. Wright

Spanish-language Resources

Association of Reproductive Health Professionals

Website: http://www.arhp.org/Publications-and-Resources/Patient-

Resources/printed-materials/Facts-About-EC-SP

Address: ARHP-East

1901 L Street, NW, Suite 300

Washington, DC 20036

Phone: 202-466-3825

Email: arhp@arhp.org

Center for Young Women's Health

Website: http://www.youngwomenshealth.org/spcontra.html

Address: Center for Young Women's Health

333 Longwood Avenue, 5th Floor

Boston, MA 02115

Phone: 617-355-2994

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"Plan B One-Step." Plan B One-Step.com. July 2009. http://planbonestep.com/. Accessed July 2009.

"Get Emergency Contraception Now." Office of Population Research at Princeton University and the Association of Reproductive Health Professionals. August 12, 2009. http://ec.princeton.edu. Accessed August 2009.

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