While about 60-70% of women in their reproductive age use contraception, approximately 99% of women in the United States have used contraception at some point in their life1. Needless to say, contraception plays a pivotal role in managing undesired pregnancies. It is estimated that about 50% of pregnancies in the United States are unintended. Contraception is necessary for this reason and hopefully with an increase in the awareness of other more effective forms of birth control, this number can be decreased in the next decade to come. In the past, the “birth control” pill was the main form of contraception used, but today there are many other options.
Factors that affect the decision making process include: personal preference, efficacy, and side effects/complications. The diagram below is a commonly used visual aide that shows the various methods of contraception used in the United States plotted in order of efficacy. The bottom tier is the least effective methods of contraception with a failure rate greater than 18%, when used properly. The middle tier is methods that are more effective than the bottom tier with a failure rate of 6-12%, when used properly. The top tier are the most effective approved forms of contraception that result in a failure rate less than 1%, when used/placed properly. Majority of patients have pre-conceived notions regarding birth control. These notions come from rumors in addition to legal commercials that can pretty much scare the pharmaceutical companies themselves out of using their own products. What everyone must realize is that birth control is a form of medicine/treatment. With every form of treatment, there are risks and benefits. It is the job of the practitioner to effectively counsel the patient on the various options and to weigh risks and benefits to better help patients make an informed decision.
The common misconception is the incidence of the stated risks associated with each form of contraception. In actuality, severe side effects are rare, amounting to less than 1% of women who experience these side effects. Birth control pills contain the hormones estrogen and progesterone with varying dosages. Exogenous hormones have been linked to an increased incidence of blood clots and cardiac disease, but these adverse effects are still exceedingly rare. What is not commonly known about birth control pills is that the continued use of them is associated with a decreased risk of ovarian cancer. According to a large 2008 research study that analyzed data from 45 different studies, with the continued use of birth control pills, there was a 50% decreased risk of ovarian cancer2. Birth control pills are an effective form of contraception when used appropriately, falling into the second tier of contraceptive methods on the diagram shown. “The pill” has been around for over 50 years, has been well studied and for some women is a great form of birth control. Despite the risks that may be associated with its use, the benefits should not be overlooked.
While there are patches, rings, injections, and barrier methods that are available as well, a focus on more modern versions of contraception is needed. Many women have myriad questions regarding these newer forms of contraception, so the focus here is to discuss what they are, what the risks are, and eradicate myths that are being perpetuated. The newer, more modern version of contraception is namely the implants. The intrauterine device (IUD) is a small 3cm T shaped device that is placed inside of the uterus to act as a locally acting contraceptive. It is placed vaginally using a speculum, similar as to when a woman gets a pap smear. It is a quick insertion that can cause crampy pain that usually a pain pill can help abate. This form of contraception also falls in the top tier in the efficacy diagram below. Studies have shown that the IUD is just as effective as permanent sterilization (getting “tubes tied”). Another benefit of this form of birth control is that once it is in place, a woman does not have to remember to take a pill every day or change a patch every week. There are 2 popular types of IUDs: Levonorgestrel-releasing IUD (brand names Mirena, Skyla, Liletta) and Copper IUD.
- Levonorgestrel-releasing IUD
- Mirena is one of the more popular devices that are about 3cm in size, T shaped and contains a progestin hormone that is released in small amounts daily. The hormone that is released acts in many ways to prevent pregnancy for 5 years in duration. One of the mechanisms is through thinning the lining of the uterus, thus making a non-suitable environment for a pregnancy to implant. Due to this effect on keeping a thin uterine lining, a main side effect from this device is lighter to no menstruation. Quite honestly, many women find this a “benefit” and not a negative “side effect”. A common misconception is that if a woman does not have a period, the lining or blood is building up inside the woman’s uterus. This is not true. Each month, due to hormonal changes, a woman’s uterine lining thickens to create a fluffy environment, conducive to implantation, in the event she gets pregnant. After the body gets the message that no pregnancy has taken place, the lining sheds in the form of bleeding, also known as a menstrual cycle. The hormone in this device keeps the lining thin, so there is no thickening of the lining and nothing to shed, essentially. Due to the hormonal effect in keeping the lining thin, this device has been shown to decrease the risk of endometrial cancer. In fact, in women with early stage, localized endometrial cancer, this is a commonly used method of treatment. The most severe side effect that women tend to seem most concerned about is the device perforating their uterus. Uterine perforation is when the device pokes a hole in the uterine muscle and is either stuck within the muscle or sometimes can be found outside of the uterus. This has been shown as a potential side effect, but the incidence is much lower than 1%. The most likely time for uterine perforation to occur is during the placement of the device. Another common fear that women have is that the device may fall out and result in a pregnancy. While this also is a possibility, the most likely time for this to occur is within the first month of placement. For these reasons stated above, it is common for practitioners to bring the woman back to his/her clinic to assess the placement of the device about 4-6 weeks later.
- Skyla IUD has the same progestin hormone as Mirena but with a smaller dose and is about 0.5cm smaller in size than the Mirena IUD. Skyla may seem more favorable in women that have never had any children vaginally. Skyla is only approved for use for 3 years prior to removing or exchanging the device.
- Copper IUD is similar to the other two devices mentioned, except it does not have any hormones. It is good for up to 10 years, which is a benefit to women who desire a very long acting, reliable, and reversible form of contraception. Main side effects associated with this device include irregular, heavy bleeding and pain.
Another type of implant, brand name Nexplanon, is the same type of hormone as the Mirena and Skyla IUD and is also released through a device. This device is a 3cm flexible rod that is placed just under the skin between the bicep muscles in a woman’s arm. It is placed similarly to an injection, with a larger needle, after the skin is numbed with an anesthetic. This is another long acting form of contraception, in that it is approved for 3 years. This, too, with the other types of implants listed above, fall into the top tier in the efficacy diagram. Again, being in the top tier of the diagram, means that it is among the most effective forms of birth control, with <1% failure rate and similar to getting one’s “tubes tied”. A common misconception with this form of birth control is that the device moves in the body and is difficult to find when it is time to remove it in 3 years. Significant migration (defined as >2cm) from the site the device was originally place is <1% and only 1 case to date has been reported of distant migration. Of note, this device can be seen on X-Ray and ultrasound in order to more easily locate the device if it does migrate.The modernization of birth control has not only given us more effective methods of contraception, but has given us a wider variety to choose from. There are risks and benefits associated with each type of contraception. Research the methods you may be interested in and consult with a physician for which type of birth control is best for you. It is better to educate ourselves with facts, rather than perpetuating the “contraception misconceptions”.