Thinking about Birth Control

Hopefully, the decision to have intercourse involves thinking about birth control. Some choose to abstain from intercourse to avoid the risk of pregnancy; others choose to abstain because they are not ready for intercourse, or because they prefer other forms of intimacy. If you have made the decision to have intercourse there are many methods of birth control available. It is important to remember that your contraception needs may change as your life style and individual needs change. Please think about your answers to the following questions as you decide which method of birth control is right for you at this time in your life.

• How important is the effectiveness of the method? Am I comfortable sharing this decision with my partner?

• What responsibility will my partner have in using the method? Am I comfortable sharing this responsibility with my partner?

• How easy will it be for me to comply with the instructions for use? What about privacy issues (parents, roommate, friends in the gym, insertion/removal etc)?

• Will it offer any protection against sexually transmitted infection?

• How does it work? How will it make me feel? Are there health benefits or risks?

• How will it affect my period? Am I comfortable with these changes?

• How soon can I become pregnant after discontinuing the method?

• How easy is it to obtain additional medication and how often do I have to see my health care provider? What about cost?

Once you have considered these questions, talk with your partner about your decision. Talking about intercourse and birth control issues may be difficult. Anticipate the issues of sexuality and talk about it before you are in the middle of a sexual encounter.

While contraception may be a primary focus of your discussion with your partner, it's also important to address issues of sexually transmitted infections (STI). If either you or your partner has ever had sexual contact with another person there is a risk of sexually transmitted infection.

Latex and polyurethane condoms provide the most protection against STI transmission, but they must be used with every act of intercourse and must be placed on the penis before any sexual contact occurs to effectively reduce this risk. Many couples decide to combine condom use and a hormonal method of birth control to provide STI protection and a high level of contraceptive effectiveness at the same time.

WHAT IF THE CONDOM BREAKS OR I HAVEN'T USED MY BIRTH CONTROL METHOD CORRECTLY OR I HAVE UNPROTECTED INTERCOURSE?
Correct and consistent use of your birth control method ensures the highest possible rate of effectiveness; however, condoms break, you may forget to take your pills or to change your patch or forget to get your shot on time. If this happens to you, or if you have unprotected intercourse, the risk of pregnancy may be reduced by immediately inserting two applicators of spermicide into the vagina. Emergency contraception pills are also appropriate in these instances. Call the Dial-A-Nurse (333-2700) for instructions or visit Women’s Health during walk-in hours..

HOW TO OBTAIN A METHOD OF BIRTH CONTROL
All methods with the exception of condoms, female condoms, spermicide and fertility awareness require a recent gynecological exam. Completing an on-line Birth Control Education Class is required if you have never used a hormonal method of contraception in the past.

WHAT DO EFFECTIVENESS RATES MEAN?
A range of effectiveness is listed for each method of birth control in this handout. The lower rating listed is the "typical effectiveness," which takes into account incorrect or inconsistent use within the first year of use.

The higher number is the "theoretical effectiveness" rate, which describes the method's effectiveness when used correctly at all times. Effectiveness statistics are difficult to evaluate because they vary widely depending on the design of the research study. The method with the highest effectiveness rating may or may not be the "best" method for you. The best method is the one you are informed about, comfortable with and will use consistently.

Method	Condoms - Latex, Polyurethane, Natural membrane
Effectiveness	85 - 98%
Availability	Available free of charge at McKinley Health Resource Centers; also available in drug stores, convenience centers, etc., at a low cost.
STI Protection	Latex and polyurethane condoms offer significant protection against STI transmission, but do not protect against all types of STI's; natural membrane condoms offer no protection against STI's.
Additional information	Most effective if put on before any genital contact; effectiveness improves when combined with vaginal spermicide. Latex condoms should not be used with oil-based lubricants (such as baby oil, Vaseline, suntan lotion). Condom breakage is usually related to lack of lubrication; use of additional water-based lubricants (Astroglide, K-Y jelly, etc.) may decrease breakage and increase sensation. Latex condoms are available in a wide range of colors, flavors and textures; brands and styles will vary in size. May break or come off (consider Emergency Contraception). Available in lubricated and non-lubricated styles; however, when lubricated with spermicide, the spermicide does not increase contraceptive effectiveness and is used primarily for lubrication. Avoid latex condoms if allergic to latex.

Method	Female Condom
Effectiveness	79 - 95%
Availability	Available at Planned Parenthood ($2.00 each) and at some drug stores.
STI Protection	Yes
Additional information	Thin, lubricated, polyurethane sheath which is inserted into vagina, held in place by a small flexible ring; a second ring forms the external open end of the sheath and remains outside the vagina; dimensions: 7.7 inches long/3.5 inch diameter. Can be inserted up to 8 hours prior to intercourse. Good if allergic to latex. Do not combine use of male and female condom because friction can cause breakage.

Method	Spermicide - Jelly, foam, cream, sponge
Effectiveness	71 - 82%
Availability	Spermicidal jelly is available at Health Resource Centers. Other spermicides can be obtained at drug stores & convenience stores.
STI Protection	No
Additional information	Recommended to be used with a condom. Most effective if inserted before any genital contact. Provides additional lubrication. Some consider messy to use. May cause irritation (especially those containing the ingredient, Nonoxynol-9; CDC guidelines express concern that vaginal/cervical irritation related to Nonoxynol-9 may increase risk of STI transmission. Currently there are no spermicides available that do not contain Nonoxyl-9). Today Sponge, effectiveness 84-91% (lower if a woman has had children).

Method	Fertility Awareness
Effectiveness	75 - 97%
Availability	Spermicidal jelly is available at Health Resource Centers. Other spermicides can be obtained at drug stores & convenience stores.
STI Protection	No
Additional information	Utilizes daily body temperature charts, sometimes combined with daily cervical mucus checks to predict ovulation which indicates risk of pregnancy. Requires instruction, high motivation and diligent record-keeping of fertility indicators. Increases awareness of changes in menstrual cycle. Requires use of back-up method or abstinence from intercourse during fertile part of cycle. Can be an "all natural" method. Stress, illness or vaginal infection can affect fertility indicators, which can result in pregnancy. Not the same as "Rhythm Method" which is not a reliable method of birth control.

Method	Diaphragm & Cervical Cap
Effectiveness	84 - 94%
Availability	Spermicidal jelly is available at Health Resource Centers. Other spermicides can be obtained at drug stores & convenience stores.
STI Protection	Partially - degree of protection not measurable
Additional information	Requires fitting by health care provider. Most effective if inserted before genital contact occurs and must be left in place for a designated time period after intercourse. Insertion and removal requires placing fingers inside vagina. Requires use of spermicide. Does not effect period cycles or fertility.

GENERAL INFORMATION ABOUT HORMONAL BIRTH CONTROL
"Hormonal birth control" refers to any method of birth control that contains estrogen and/or progestin. These are hormones similar to those produced by the ovaries naturally and are responsible for ovulation and the menstrual cycle. There are two categories of hormonal contraception: combined hormonal contraceptive agents and progestin-only contraceptive agents.

Combined Hormonal Contraception - contains both estrogen and progestin:

• Offers NO protection against STI's.

• Estrogen use increases the risk of abnormal blood clotting; therefore women with certain medical conditions are not good candidates for medications containing estrogen. Each person needs to be evaluated individually.

• Smoking increases the risk of abnormal blood clotting which can cause blood clots, stroke, heart attack, etc.

• All methods require prescriptions from a health care provider.

• Offers a very high effectiveness rating but to achieve this rating, the method must be used as directed.

• Fertility usually returns immediately upon discontinuation of use.

• May be prescribed as a treatment for medical conditions, other than contraception (cramps, irregular periods, prolonged menstrual bleeding, ovarian cysts, PMS, acne, etc.).

Method	Birth Control Pill Effectiveness
Effectiveness	92 - 97.7%
Additional information	Provides continuous contraceptive protection. Must be taken at the same time every day. Regulates menstrual cycle, decreases cramps and blood flow. May cause breakthrough bleeding, breast tenderness, nausea, weight gain/loss during the first few months.

Method	Transdermal Contraceptive System (Patch)
Effectiveness	92 - 97.7%
Additional information	2 cm. square beige patch worn externally. Patch applied weekly for three weeks provides continuous contraceptive protection; menses occurs during 4th week (no patch) - protection carries through this week. Breast tenderness may occur-especially in first month of use. May cause breakthrough bleeding and spotting and mild to moderate application site reactions. Body weight over 198 lbs. increases risk of pregnancy.

Method	NuvaRing® (Vaginal Ring)
Effectiveness	92 - 97.7%
Additional information	Soft flexible transparent ring approximately 2" diameter and cross-sectional diameter of 1/8" worn inside vagina. Absorption of hormones through the vaginal wall provides consistent blood hormone levels. Once per month insertion provides continuous month long contraceptive protection (ring is left in place 3 weeks and removed for 1 week; menses may occur during this off week). Does not interfere with intercourse; should not be felt by either partner. Insertion and removal requires placing fingers inside vagina. May increase normal vaginal discharge, increases normal bacteria in vagina to help reduce incidence of infection. Weight gain is minimal, minimal break through bleeding.

Progestin-Only Hormonal Contraception - contains only progestin:

• Offers NO protection against STI's.

• Provides an option for women who cannot use estrogen.

• All methods require prescriptions from a health care provider.

• Offer a very high effectiveness rating but to achieve this rating, the method must be used as directed.

• May be prescribed as a treatment for medical conditions other than contraception (cramps, ovarian cysts, etc.).

Method	Progestin-only Pills (Mini Pills)
Effectiveness	92 - 97.7%
Additional information	MUST be taken at the same time every day; back-up birth control necessary for 48 hours after a late pill. Other medications may cause changes in effectiveness. No long term effect on fertility. Effect on ovulation is unpredictable, therefore regularity of periods is unpredictable; may experience spotting or absence of periods.

Method	Depo Provera® (DMPA) Injections
Effectiveness	92 - 97.7%
Additional information	A shot every 12 weeks provides continuous contraceptive protection. May cause sporadic, unpredictable bleeding and spotting; heavier or lighter periods or no period at all may occur. Weight gain, breast tenderness, moodiness, vaginal dryness may occur; not recommended for women with history of severe depression. Long term use may cause decreased bone density - increased calcium intake recommended. DMPA may stay in the system up to 6-8 months after last injection; side effects may persist and return to normal menstrual cycles may be delayed. Fertility may not return to normal for 6-12 months after last injection.

Method	IUD/IVS (Intrauterine Devices/Systems) Mirena®, Paragard®)
Effectiveness	97 - 99.2% - No typical effectiveness rating available
STI Protection	No
Additional information	Provides continuous contraceptive protection; length of contraceptive protection varies with the device used (5 to 10 years). Mirena® contains a progestin-only hormone and offer benefits similar to other progestin-only methods; Paragard® contains copper, providing the 10-year effectiveness. Paragard® may cause heavier menstrual bleeding. Requires individual evaluation by health care provider prior to use. Not all women are good candidates for IUD/IVS. Fertility returns quickly after device is removed. Device must be paid for by the patient; insertion/removal is included in health service fee.

A NOTE ABOUT WITHDRAWAL, RHYTHM AND DOUCHING
Withdrawal is a method couples sometimes use. It can fail due to the presence of sperm in pre-ejaculatory fluid or the couple misjudging when the man should withdraw. This method requires a high level of trust and cooperation; couples may find it emotionally unsatisfying and pregnancy is more likely to occur. Withdrawing before ejaculation is better than using no method at all.

Couples, who use the rhythm ("safe time") method, abstain from intercourse (or use another form of birth control) during the fertile time in the woman's menstrual cycle (based on calendar dates alone). This method has a high failure rate because many factors affect ovulation and it is not possible to predict when ovulation will occur based solely on calendar dates.

Douching after intercourse is not an effective form of birth control because some sperm may reach a woman's uterus almost immediately after ejaculation. In addition, douching may push sperm toward the uterus and increase the likelihood of pregnancy.

WHERE TO GET MORE INFORMATION
If you're thinking about obtaining a method of birth control or want more information, there are several resources available at McKinley.

Women's Health Clinic - Appointments for prescription birth control, pelvic exams, STI testing and Pap tests are available. Obtain information about birth control, pregnancy, and related issues. To schedule an appointment in Women's Health, call 333-2700 (press 4 for Women's Health) or visit the McKinley Health Center web site for the on-line birth control education class. All exams are included in the health service fee. There may be a charge for some of the hormonal contraceptive options.

Health Resource Centers - Condoms, spermicide, and pregnancy test kits. All products are included in the health service fee.

Sexuality Education Coordinator - To schedule an appointment, please call McKinley Health Center's Health Education Unit at 333-2714. Appointments are available for individuals and couples to talk about sexuality issues.

References
R. Hatcher, G. Trussel, F. Stewart, et al. (2004). Contraceptive Technology, 18th Revised Edition, New York: Irvington Publishers, Inc.
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002; 51 (No. RR-6)

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