The Modern Woman’s Ultimate Guide to Birth Control

The world of birth control (or contraception) is ever-changing and evolving. With more choices than ever, there’s bound to be an option that fits your needs. Tried pills before and couldn’t remember to take them? Then try something else! Don’t like hormones? There’s something for you too! And birth control isn’t just for preventing pregnancy. Here we’ll talk about the down and dirty of all the different types, just like I do with clients in my office every day. With this quick-reference guide, learn which method might be right for you.

First things first, some common myths about birth control debunked:

• You have to have a pelvic exam to get birth control—FALSE! Updated guidelines for women’s health state that unless you’re having symptoms that warrant a pelvic exam, it’s not necessary to have one just to get birth control
• You can’t get an IUD if you haven’t give birth before—FALSE! Women who have never been pregnant can benefit from getting an IUD.
• All birth control makes you gain weight—FALSE! Only one form of birth control has been linked to weight gain; we’ll review that later.
• If you’re on birth control for a long time, it can make it harder to get pregnant later when you stop—FALSE! With the exception of one type, once discontinued, your body has a relatively quick return of fertility.
• You have to see an OB/GYN to get birth control—FALSE! Your certified nurse-midwife can also prescribe it for you.

For the most part, birth control falls into 3 main categories, with a few sub-categories. This doesn’t include things like condoms, withdrawal, and fertility-based awareness methods, which we’ll touch on later.

Birth control basics

Just a quick review of a few things.

• Hormonal birth control contains the hormones estrogen and/or progestin (synthetic form of progesterone)
• Some hormonal birth control only contains progestin (not estrogen). Fun fact: birth control only needs to contain progestin to prevent pregnancy. Progestin is the hormone that tricks your body into thinking it’s already pregnant, which prevents your ovaries from ovulating and releasing an egg each month. Estrogen, the other hormone in most pill types of birth control, is included to decrease the annoying side effect of irregular spotting/bleeding that can sometimes occur with progestin-only types.
• It’s not medically necessary to have a period every month. Crazy, right? A lot of people have been taught that it’s healthy to have a period every month, and even needed for “cleansing”. However, birth control partially works by thinning the endometrial lining of your uterus (the part that sloughs off each time you have a period), which means there is no need for it to be shed at the end of a cycle. Hence, why some women don’t have periods while on continuous types of birth control.

The pills

Pills are the oldest and most well-known form of birth control. For many women, it’s what they’re used to and what works well for them. Pills are broken down further into 2 categories.

• Combined Oral Contraceptives (COCs)
• Progestin-only Pills (POPs)

COCs

COCs are by far the larger and more common group of birth control pills. They combine the hormones estrogen and progestin (hence, the name). There are so many different brands, that it’s impossible to list them all. However, just know that they are all basically the same, except for slight differences in recipe, or the amount of each hormone in each pill. Some brands have the same amounts of hormones in every pill (monophasic). Others are fancier and have varying amounts of hormones in each pill that mimic your natural hormone fluctuations, depending on what day of the month it is (biphasic or triphasic). Some are considered “low-dose”, and some are higher dose. If you’re just starting out, I usually recommend starting with a simple, low-dose, monophasic pill, and then troubleshooting from there if you don’t like it.

• PROS:
  • Cheap, hundreds of different brands to choose from
  • If taken continuously, can eliminate your monthly period
  • Low-dose options usually well-tolerated
• CONS:
  • Have to take a pill everyday
  • Can’t be taken by people with certain medical conditions
  • Not good to take while breastfeeding (can decrease milk supply)
  • Side effects of higher doses include nausea and breast tenderness

POPs

POPs, like the name suggests, only contain progestin (synthetic progesterone). Since they don’t have estrogen, they can be taken by people who, for medical reasons, aren’t able to take COCs. If you have high blood pressure, have a history of blood clots, or are breastfeeding, then POPs might be a better choice for you. However, there are 2 downsides to POPs. The first is that it isn’t very forgiving when it comes to timing. It MUST be taken at the same time every day to prevent pregnancy. The second is that many women report irregular bleeding and spotting while taking it.

• PROs:
  • Cheap
  • Can be taken by women who can’t take estrogen
  • Well-tolerated
• CONs:
  • Have to be taken at the same time everyday
  • Irregular spotting is a common side effect

Things that aren’t pills

There are 3 types of birth control that aren’t pills, but are also not LARCs.

• The patch
• The ring
• The shot

The patch

The patch is a small, square, adhesive patch that contains both estrogen and progestin. You place it on a clean area of skin and leave in place for 1 week. The next week you remove it and place a new one. Repeat this 3 weeks in a row. Week 4 is a patch-free week when you’ll have a period, then start over again the next month.

• PROs:
  • Don’t have to take a pill everyday, change it out once weekly
• CONs:
  • Contains higher doses of hormone, and may result in more side effects like nausea and breast tenderness

The ring

The ring (most commonly known as Nuvaring) contains both estrogen and progestin, and is inserted vaginally. It’s left in place for 3 weeks, then removed and discarded on week 4. You’ll have a period during week 4, then insert a new ring at the start of the next week. Some people are turned off by the thought of sticking something up there. But really? It’s your vagina, and you know it better than anyone else. Others are concerned about being able to feel it once it’s in there. But I can tell you that almost everyone who has used the ring report not even knowing it’s in there once it’s in the right place. And they love the convenience.

• PROs:
  • Don’t have to remember to take something everyday
  • Usually well-tolerated
• CONs:
  • Need to remember to take it out at week 3 and insert new one after week 4

The shot

The Depo Provera injection is a good option for people looking for a low-maintenance method that’s not considered a LARC. However, it can have a few side effects that some people find bothersome.

• PROs:
  • Progestin only, can be taken by women who can’t take estrogen
  • Only have to worry about it every 3 months (no pills everyday)
• CONs:
  • Requires an office visit every 3 months
  • Is the only form of birth control to be linked to weight gain
  • Once stopped, can take an unpredictable amount of time for fertility to return (in other words, don’t start on depo if you are planning to become pregnant in the near future)
  • Is not recommended for long-term use, due to risk for decreased bone density over time

The LARCs

LARCs stands for Long-acting Reversible Contraception, and are my most-recommended forms of birth control. They’re easy to use–one-time insertion at an office visit, and then nothing for years! They’re also usually well-tolerated, and once discontinued, there’s a quick return of fertility. Meaning if you get a 5-year IUD this year, then change your mind next year and want to get pregnant? No problem! Just have it pulled out, and voila! You can start trying to get pregnant right away.

• The IUDs
• The implant

The IUDs

There are 2 types of IUDs. Several different ones that contain progestin, and 1 IUD that has no hormone at all. All of them require a one-time office visit to have it inserted. Insertion can sound intimidating, but I promise it’s not as bad as some may have you believe. Your provider uses a speculum to visualize your cervix, then gently inserts the IUD through your cervix so that it sits just inside the lower part of your uterus. You may feel some cramping for a few minutes after insertion, but taking a dose of NSAIDS (like ibuprofen) before/after the procedure can help. You may experience some irregular bleeding/spotting for a few weeks-months after insertion while your uterus gets used to its new resident.

Progestin IUDs

Progestin IUDs include brands like Mirena, Skyla, Kyleena, and Liletta, and only contain progestin. Once inserted, than can last anywhere from 3-7 years, depending on the brand. They’re a great choice if you have heavy periods, as most women who get them experience much lighter, shorter periods. In fact, about 50% of women who choose a Mirena IUD stop having periods altogether after the first year of use

• PROs
  • Once inserted, last for years
  • Lighter or no periods
  • Quick return of fertility once removed
• CONs
  • Irregular spotting is common side effect for a period of time after insertion

Copper IUD

There is one type of IUD (Paragard) that contains no hormone at all, and instead uses copper as its active ingredient to prevent pregnancy. It’s also the longest-lasting birth control, at 10 years of protection after insertion. However, if you have heavy periods, it’s probably not the right choice for you, as it can actually cause heavier bleeding during periods. If you’re looking to avoid hormones, don’t have heavy periods to start with, and want long-lasting protection, then a Paragard might be a good fit.

• PROs
  • No hormones
  • Lasts for 10 years
  • Quick return of fertility once removed
• CONs
  • Can cause heavier bleeding with periods

The Implant

The contraceptive subdermal implant (or Nexplanon), is a progestin-only device that’s inserted just under the skin on the inside of your upper arm. Once inserted, it lasts for 3 years. Don’t let the word “implant” scare you. It’s 4cm in length, only 2mm in diameter, and is barely noticeable once it’s in the right place. The worst part about insertion is the small injection of local anesthetic used just before insertion, which does burn for about 30 seconds. After that, you just feel pressure, and the whole procedure takes about 5-10 minutes tops. After 3 years (or sooner, if you want), your provider can remove it using local anesthetic and a minuscule incision—small enough to not need a stitch.

• PROs
  • Lasts for 3 years
  • No estrogen
  • Easy to place, minimal discomfort
  • Quick return of fertility once removed
• CONs
  • Irregular spotting can be side effect

Troubleshooting your birth control

Sometimes, you might start a birth control and then decide you don’t really like it. When starting any new type of birth control, there will be a period of adjustment when any side effects (like nausea, irregular spotting, etc) may be more noticeable, but then will improve over time. If it’s nothing too severe, a good rule of thumb is to try to stick it out for 3 months, and then reassess how you’re feeling. Any side effects that are still present after 3 months of use are likely to stay for good. And before you throw in the towel and quit taking it, talk to you provider about any annoying side effects; chances are they can help you troubleshoot what’s bothering you and what changes you might need to make.

• Nausea? Usually means too much estrogen. Try a lower-dose pill.
• Breast tenderness? Decrease the estrogen.
• Irregular bleeding? Usually means you need more estrogen. If using progesterone-only, try something with estrogen. If using a COC, increase the estrogen dose.

The ACHES rule

Like any medication, birth control use does carry its own risks. Used properly, it can be safe, effective, and freeing for many people; but knowing what warning signs to look out for is important. The most serious adverse event associated with hormonal birth control is the increased risk for a blood clot, which could lead to dangerous complications. This risk is increased in certain groups; be sure to tell your healthcare provider if you have a history of a blood clot, you smoke, get migraines with aura, have seizures, or are over the age of 35. Remembering the acronym “ACHES” can help you recognize a serious complication.

• A– abdominal pain
• C-chest pain
• H-headache
• E-eye pain or sudden visual changes
• S-severe leg pain

With all of these symptoms, we’re talking about severe pain that doesn’t resolve with normal comfort measures (like resting or taking a Tylenol). If you experience any of the ACHES symptoms, stop taking your birth control and seek medical attention right away.

The “other” methods

• Condoms
  • It’s always a good idea to use condoms, especially in new relationships or if you and/or your partner have other partners. Besides helping to prevent pregnancy, they protect you from sexually transmitted infections (STIs), which are not fun to mess around with.
• Withdrawal (or the “pull-out” method)
  • Before you laugh, withdrawal is actually used effectively by a lot more people than you may realize. Withdrawal is the practice of the male partner “pulling out” from the female partner before ejaculating, to decrease chance of pregnancy. While you may feel comfortable spinning the roulette wheel, I don’t recommend using withdrawal as your only form of birth control. Even those with impeccable timing can have a few swimmers sneak by unnoticed, and remember—it only takes one!
• Fertility awareness
  • There are several varieties of these methods, and can include tracking your cycle days, monitoring your temperature and cervical mucus, and much more. This is an entire category in itself, and way too much to cover here. If you’re interested in learning more, I encourage you to ask your provider about more details.

I hope this helps sort out any confusion you may have about choosing a birth control! If you still have questions, or are ready to try out a new form of birth control, come see the midwives for a visit!

Dr. Lauren