AN OVERVIEW OF THE MOST HIGHLY EFFECTIVE METHODS

LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM (MIRENA)

This is as effective in preventing pregnancy as a tubal sterilization and has the advantage of no need for surgery. It lasts for 5 years. It is a small device that is easily placed inside the uterus. It contains a hormone called progestin much like the progesterone a woman's ovaries produce each month. This hormone causes the mucus of the cervix to thicken so that sperm cannot reach the egg. It also causes the lining of blood in the uterus to shrink and lessen. It is over 99% effective and there is no accidental misuse of this method.

Advantages

  • It is the most effective reversible method ever developed.
  • It is as effective as sterilization but is readily reversible.
  • It prevents ectopic pregnancies and pelvic inflammation.
  • It decreases menstrual cramping and dramatically decreases menstrual blood loss. Sometimes women will not bleed at all, which is safe and not harmful. In fact you will be less likely to become anemic.
  • It may be used by postmenopausal women to take estrogen therapy to protect the inside of the uterus from developing endometrial cancer.
  • Once it is removed (by gently pulling on the fine string against the cervix), fertility rapidly returns (if you are still able to get pregnant -- i.e., not menopausal).
Disadvantages
  • The menstrual pattern will change. There may be some days of spotting or bleeding that are not on schedule for a while. This is not a health risk but if a woman doesn't know about this, she may get worried.
  • It does not provide protection from sexually transmitted infections (STIs).

STERILIZATION

Sterilization is an operation or device (Essure) that blocks the tubes that pass a woman's egg to her uterus. After the procedure, the egg will have no way to get to the uterus. Sterilization should be considered permanent. You should be certain you do not want to deliver more children under any circumstances before undergoing the surgery.

Advantages

  • It is extremely effective and permanent.
  • It is a fairly simple operation or procedure.
  • There is no need to use a contraceptive method at the time of sex.
Disadvantages
  • It requires surgery and anesthesia.
  • There are pre- and post-operative tests.
  • There is some pain or discomfort for several days.
  • It is not 100% effective. The failure rate is as high as 1% to 5% in the first 10 years after the operation.
  • Should a pregnancy occur, there is an increased chance that it will be an ectopic pregnancy, which occurs outside of the uterus. This is an emergency and a possible life-threatening situation.
  • Regret, or being sorry that you chose the sterilization, is greater if you are under age 25 years when the surgery is done, if you divorce or remarry, if a child dies, or if you have just had a baby or an abortion.
  • It does not provide protection from STIs.

ORAL CONTRACEPTIVES

Oral contraceptives (OCs) contain two hormones, an estrogen and a progestin, or may only contain a progestin. They work by stopping the egg from being released by the ovary (ovulation). It also makes the blood lining inside the uterus lessen. If taken correctly and consistently, only three women in 1,000 will become pregnant. But typical couples who use OCs report skipping, missing, or being late in starting a new pack, so about 8% will experience an accidental pregnancy.

Advantages

  • It decreases risk for cancer of the ovary and cancer of the lining inside of the uterus (endometrial cancer).
  • It lowers the chance of having non-cancerous breast masses, ovarian cysts, ectopic pregnancy, and pelvic inflammation.
  • It decreases menstrual cramps and the amount of blood each month.
  • Mild acne may improve.
  • Some OCs can be taken continuously so that there are less "pill periods" a year.
Disadvantages
  • It must be taken every day.
  • It sometimes causes mild nausea or spotting of blood for the first few cycles of use.
  • It may cause mild headaches, mood changes, or changes in sex drive.
  • It changes the menstrual flow. This is not dangerous but if you do not know that this is okay you might get worried.
  • Serious complications like blood clots may occur but are very rare.
  • It does not provide protection from STIs.

INJECTION -- (DEPO-PROVERA)

This provides a hormone much like the progesterone the ovaries make. It stops the release of the egg (like OCs); it thickens the mucus in the cervix and provides other contraceptive effects. It must be given as an injection every 3 months. Only three in 1,000 women will become accidentally pregnant in the first year of use.

Advantages

  • "Hands-free" method -- no daily dose and nothing needs to be used during sex to prevent pregnancy.
  • It is highly effective if the woman receives her injections right on time.
  • It helps to decrease menstrual blood loss and anemia as well as cramps and pre-menstrual syndrome.
  • It is a very private method. No one has to know you are using it.
  • It is okay for breast-feeding women to use.
  • It may improve symptoms caused by a condition called endometriosis.
Disadvantages
  • It may cause very irregular bleeding, but it is usually very light and is not dangerous.
  • You may gain weight. To avoid weight gain, you should watch your calories and not overeat, and get regular brisk exercise.
  • You must return to your health care provider every 3 months for the next injection.
  • It may lower estrogen hormone levels and this can cause some bone loss. To avoid this, you should get regular weight-bearing exercise, eat a balanced diet, and take extra calcium to protect your bones.
  • If you do not like the side effects from the injection, you will have to wait until it wears off in 3 months.
  • It may take up to 10 months for normal fertility to return.
  • It does not provide protection from STIs.

VAGINAL RING (NUVARING)

This is a hormone-releasing ring that is put into the vagina for 3 weeks, followed by 1 week with no ring inside the vagina. The hormones are absorbed through the skin of the vagina. It prevents pregnancy like the other hormonal methods by preventing ovulation and changing the cervical mucus so the sperm cannot pass as easily, and it changes the inside of the lining of the uterus. It is very effective; about eight out of 1,000 women using the ring will accidentally become pregnant.

Advantages

  • It is nearly "hands-free" and only has to be inserted and removed once every 3 weeks.
  • It is highly effective in preventing pregnancy.
  • Like the other hormonal methods, monthly bleeding will probably be lighter and shorter and there will be fewer cramps.
Disadvantages
  • You may not like to insert a contraceptive into the vagina.
  • You may be worried you will not be able to insert it correctly or be able to remove it easily.
  • It may be felt during sex, but it can be temporarily removed for a short amount of time.
  • It may cuase the same side effects as other hormonal methods.
  • It does not provide protection from STIs.

TRANSDERMAL PATCH (ORTHO EVRA)

This is a patch that is applied to the skin, and the hormones are released through the skin. A new patch has to be applied every 7 days for 3 weeks in a row followed by 1 week with no patch. It prevents pregnancy like the other hormonal methods by preventing ovulation, changing the cervical mucus, and changing the lining of the uterus. In typical use, eight out of 1,000 women accidentally become pregnant while using the patch.

Advantages

  • It is nearly "hands-free" and only needs to be changed every 7 days for 3 weeks.
  • It is highly effective in preventing pregnancy.
  • Like the other hormonal methods, the monthly bleeding will probably be lighter and shorter and there will be fewer cramps.
Disadvantages
  • The patch peels off in about 2% of cases, especially if women place it where they have used fatted soaps, lotions, or oils under or over the patch.
  • Some women (20% develop a mild skin irritation at the site of the patch application.
  • If you weigh more than 194 pounds, the patch may be slightly less effective.
  • There are some temporary side effects such as breakthrough bleeding and spotting, and other symptoms when first getting used to the patch (similar to OCs).
  • There is a higher steady state of hormones due to the continuous absorption, so a woman will be exposed to more estrogen-related risks over the 3 weeks of patch use compared to OCs. Estrogen may increase the chance of developing blood clots in the veins, but this is a very rare occurrence with most women.
  • It does not provide any protection from STIs.

COPPER T IUD (PARAGARD)

This is a small device that is placed inside the uterus. The vertical and horizontal arms of this IUD are wrapped with copper, which is slowly released into the uterine space. The copper stops the sperm from making their way up through the uterus and into the fallopian tubes. It reduces the ability of the sperm to fertilize the egg. It also prevents the egg from successfully implanting in the lining of the uterus if fertilization has occurred. Less than 1% of women will experience an accidental pregnancy in the first year of use.

Advantages

  • It is effective for up to 12 years.
  • It is highly effective in preventing pregnancy.
  • It is convenient, safe, and private.
  • It can be used by women who cannot or do not want to use estrogen.
  • It can be used by breast-feeding women, and can be inserted immediately following the delivery of a baby or immediately after a pregnancy termination.
  • It is easily removed by a health care provider by a gentle tug on the fine string that is attached to the end of the device.
  • There is a rapid return to fertility after it is removed.
Disadvantages
  • There may be cramping, pain, or spotting during and after the insertion.
  • The number of bleeding days for the month may be longer and there may be more cramping than before.
  • It requires an office visit for insertion and removal by a health care provider that has been trained in the proper insertion technique.
  • It does not provide any protection from STIs

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Linda Dominguez, NP, is assistant medical director, Planned Parenthood, Albuquerque, NM; and clinician, Southwest Women's Health, Albuquerque.