Contraception: pick and mix?

I couldn’t help but wonder: Are women simply ‘indecisive’ about their contraception, or has there been some miscommunication?

Research shows that 70% of British women have tried the contraceptive pill, with around 3.5 million women currently using it (Fiennes, 2019). This accounts for nearly 90% of contraception use.

In recent years, other forms of contraception known as Long-Acting Reversible Contraception (LARCS) have become increasingly popular, such as the copper and hormonal coil. Alongside the popularity of natural planning apps like Natural Cycles, these shifts demonstrate that women are increasingly dissatisfied with their contraceptive options. 

I’ll refer to it as ‘pick and mix’; people often use contraception recommended to them by others, or what is represented in popular culture. Considering that 62% (of approx. 66 people who answered the blog’s Instagram quiz) said they were not given adequate contraception information when they were younger, there has been a clear education gap.

Here we’ll consider the benefits of contraception, address some of the myths, and look at the types and their effectiveness. I also wanted to include some of your personal experiences to socialise medical information, yet also highlight that everybody reacts differently to contraception. 

Whilst these words are subjective experiences, it is important to consider how some people have had some very negative experiences using contraception. Having this information can help with decision-making. Keep in mind that contraception is continually reviewed by healthcare professionals, and advice does change throughout time – for example, the original pill had 7 times the amount of hormones it does today. 

Condoms (external, internal) can also be considered contraception as they prevent pregnancy, although as they are single-use, and have no internal reproductive functions, so  we’ll skip these. Of course, barrier methods should always be used for sex with a new partner to reduce the risk of STI transmissions – see the demystifying STIs post for more convincing ;). They also have no hormones, so can be used for short-term contraception.

If you don’t have a regular partner, are committed to your sexual health and use condoms to best practice standards, there is no reason you need to go on longer/hormonal forms of contraception. It’s totally up to you! Knock yourself out with all the tropical, warming, ribbed, dotted, thin condoms you can find. Note that some of these, such as tropical condoms are only intended for oral sex.  You can also use dental dams for oral sex on vulvas, and make sure to check yourself for other STIs that condoms don’t protect against such as herpes, syphilis and genital warts, which can be passed through skin-to skin contact. 

What are the benefits of contraception?

1. The first and clearest benefit is that it protects against pregnancy – although it isn’t possible for any form of contraception to be 100% effective. In a year 80-90% of women will get pregnant with no contraception… (FPA, 2019)
2. Some can regulate your menstrual cycle (NHS, 2019) – a huge relief for some women
3. Can help with reproductive conditions such as PCOS, endometriosis (NHS, 2019) as well as in some cases of PMDD (premenstrual dysphoric disorder)
4. Being able to plan when you have sex more and an element of personal control (leading to more sexual freedom!)
5. Useful if you’re with longer-term sexual partners (less anxiety/stress!)

Myths around contraception

1. Affects fertility in the long-term
2. You don’t need to use condoms because you’re protected from pregnancy
3. It can or will give you cancer

Types 

If you want to see the timeline of when these all emerged, refer back to the history of sexual health post. I’ll start with the most common!

Ultimately, it is best to do your own research, consider your lifestyle or medical history, and then consult a healthcare professional. There are side effects to taking contraception, which are important to consider alongside the clear benefits of using it. 

The pill – taken daily 

• Can be combined: estrogen and progestin, which are synthetic hormones similar to what is naturally produced by the ovaries. The effect of them is similar to what the bodies hormones do during pregnancy – they prevent an egg from being released, thicken the mucus in the cervix (which connects the vagina to the uterus, opens during childbirth), and thin the uterus lining that usually thickens during the menstrual cycle (FPA, 2019) 
• Can also be progestin-only (also known as POP). This is mostly taken by people who can’t take estrogens: such as people who are smokers, at higher risk of blood clots/high blood pressure, family history of migraines, past or present breast cancer (NICE, 2019)
• Taken daily for 21 days with/without a 7-day break (new guidelines show this break is not needed)
• 99% effective, 91% with typical use (FPA, (2019) (so 9 in 100/year pregnant). Ideally take at the same time every day. If you begin taking it during your period, you’ll be immediately protected up to 5 days (ibid). Can make periods lighter, can improve acne (FPA, 2007)
• Have to be careful concerning diarrhoea/sickness – affects reliability 
• Not everyone can use it: see here for the list of conditions it is not compatible with. Usage declines with age (FPA, 2007). There can also be drug interactions if you’re on important medications that can stop you needing to take it
• It is also one of the most politically contested forms of contraception, especially given its insidious testing history on Puerto Rican women (Fiennes, 2019). Most people will try it, although the research is increasingly suggesting that there might be easier contraceptive options out there
• It can increase your risk of breast cancer, and longer-term, cervical cancer. However, it can decrease the risk of ovarian and womb cancer, amongst others. The risk goes away 10 years after usage (Cancer Research, 2020)
• Instagram users say: Cerazette (POP) ‘ruined my life’ and have had the coil for about 7 years and love it’
• POP: ‘made me feel zero emotions % gain weight but the combined pill has been good!
• ‘Fairly positive with the pill (Gedarel)
• Changed from ‘Marvelon instead of Microgynon!!!’
• ‘The pill worsened my mental health when I was younger!! Did start it young, however’ (research suggests for younger patients there is a significantly increased risk of clinical depression (Fiennes, 2019))
• ‘Quick weight gain and stretch marks, unrecognisable mental health’

The patch – Changed once a week for 3 weeks, then break/no break

• Looks like a nicotine patch
• Delivers the same hormones as the combined pill through the skin. Same effectiveness, similar effect on periods as the pill may be easier if you forget to take your pills every day
• Might not be as effective for people who weigh > 90 kg (FPA, 2019)
• Can’t be placed near the breasts, many people choose upper leg, arm, bum etc. (anywhere where it won’t get rustled about too much, needs to be moved to prevent skin irritation (ibid)) 
• Can be temporary side effects when beginning usage, spotting bleeds, and longer-term side-effects similar to the pill 
• You have to be really on it, like the pill, with putting them on at the same time every day

The vaginal ring – one provides contraception for a whole month

• Less popular than the combined pill
• Folded and inserted into the vagina, and pushed upwards towards the cervix (NuvaRing, 2020)
• Releases the same hormones as the combined pill, same effectiveness
• Avoids the diarrhoea/sickness issue of the pill as it stays in 
• More popular in the wider European continent (I’ve heard in places such as Italy, Spain)

Injection – Lasts for 13 weeks

• Progestin injection,  and works similarly in the body to the combined pill, POP and patch. There are combined injections but these are generally not offered in the UK
• 99% effective, 94% with typical use (6 in 100 pregnant/per year)
• Can thin bones, not greater longer-term; if you use it, you will be risk-assessed for osteoporosis every two years (FPA, 2019). Not recommended for < 25-year-olds whose bones are still growing
• Can take a year for fertility to return (ibid)
• Some people may put weight on, your periods are likely to change (most often stopping completely)
• It’s overprescribed use on certain communities such as black women in the UK and globally,  this has been protested throughout history 

Implant – lasts for 3 years!  

• Most effective – less than 1% failure rate (<1 in 1000 pregnant over 3 years)
• A small rod inserted under the skin in the upper arm (FPA, 2019), which releases progestin into the bloodstream
• Periods should be lighter
• Not compatible with enzyme-inducing medication such as for HIV, epilepsy, TB (ibid)
• You may get acne or, acne could get worse
• Earlier this decade, there was some controversy around incorrect insertion of the implant, which has been reported in a small but significant amount of users 
• Instagram users say: ‘My sister in law had the implant and it relocated in her body so she had a procedure to remove it’
• ‘I had a period that lasted over 8 weeks on the implant and it got stuck in my arm’
• ‘Extremely awful mood swings and low mood with the implant – when removed, back to normal’
• Another user told me her implant caused really irregular bleeding, and the inconsistency ‘caused pregnancy scares’
• ‘I have had the implant twice now, and I would recommend highly’

IUS (intrauterine system) – effective for 3 -5 years

• Hormones are localised, 99% effective (<1 user pregnant/year)
• Has a similar effect to the pill thickening cervical mucus and thinning the uterus lining, given that it releases progestin
• Periods meant to be lighter, although some spotting in the first few months, can be used whilst breastfeeding
• Speculum used when inserting, where it is opened ‘like an umbrella’ into the uterus  
• Strings – not ideal for Mooncup usage – ask your healthcare provider when you get this fitted 
• May not be suitable if you have any cervical or womb problems, pelvic inflamation, certain cancers, liver disease, or history of of unexplained bleeding after or during sex
• It can also in some cases be rejected or displaced by the womb, and there’s a small risk of ectopic pregnancy if it fails (NHS, 2018) 
• Possible to get an infection when it is first fitted (FPA, 2019)
• Instagram users say: ‘very negative experience of the Mirena coil’
• ‘Had excruciating periods before I got the Mirena! Would literally pass out or throw up’
• ‘It can be really good and REALLY REALLY BAD. Almost put me in A & E and I had to argue with Drs./Nurses to have it removed. The pain isn’t taken seriously enough’

IUD (intrauterine device) – lasts for 5 – 10 years

• The copper (and plastic) coil, non-hormonal
• The copper in it kills sperm and also changes cervical mucus to make sure sperm don’t reach an egg; it can also stop a fertilised egg from being implanted in the uterus (FPA,  2019)
• 99% effective (fewer than 2 pregnant in 100 over 5 years)
• Can be fitted as emergency contraception
• Some people cannot use it if they have uterus/cervix problems, unexplained bleeding between periods or a history of pelvic infections
• Periods can be longer, heavier/more painful at the beginning (FPA, 2019)
• Similar to the IUS, your body can reject it 
• Instagram users say: ‘No one tells you how incredibly painful it is to get a coil put in!!’
• ‘Increased rate of yeast infections’
• ‘The GP couldn’t get it in’

Caps/diaphragms 

• Are circular domes ‘made of thin, soft silicone that’s inserted into the vagina before sex. It covers the cervix so sperm can’t get into the womb (uterus) to fertilise an egg’ (NHS, 2017)
• When used properly with spermicide (a foam/cream/paste/gel containing chemicals that kills sperm), they have 92-96% effectiveness (ibid)
• You have to put them in before sex, and they can take time to learn how to use – because of this, their effectiveness goes down, and thus they have become less popular
• You also have to leave them in the vagina 6 hours after having sex
• Cystitis can be common, as well as spermicide irritation. They are still an option however, and better than the pull-out method… with its 22% human failure, is a lot less reliable than condoms
• Used to be very popular back in the day; not popularly discussed, although Carrie in SATC did use it! And Monica in friends

Situating women’s voices 

‘No one warned me about contraceptive periods’

‘I have always made positive experiences with condoms’

‘The morning after pill – when those emergencies come, it’s awful’

People who responded to the Instagram poll I did expressed their justified concerns that there is a lot of haziness concerning contraception, and they often felt unprepared concerning the effects of it.

Women have made a lot of ‘noise’ concerning their experiences: through #MyPillStory (mainly in the USA), and the Mad About The Pill investigation. These voices should be listened to in order to shape the future of contraception and the needs of users.

Depression and changed mood/personality, is often the most reported side effect, at least verbally and between women. Some studies were considered to be inconclusive or with a too-small data set: until 2016 when a Danish study found a slightly higher causal relationship between pill users and antidepressant usage, particularly with higher dosage progestin pills. This study was conducted on over 1 million women, over 13 years. 

Other side effects people may discuss from hormonal contraception are decreased sexual desire, although research suggests that whilst they may affect it, other factors such as age, and partner attraction could affect it more. Concerning research, it seems that it is hard to a) get a large enough sample size of women to inform scientific trends and b) to extrapolate effects directly caused by contraception as opposed to other lifestyle factors such as mental health, poor working/living conditions etc.

For some people, it might be worth tracking your natural menstrual cycle (which you can do here) to see where your natural fluctuations of weight gain, mood, feelings of lower desire etc., lie. If you get to know this, it might be that you can prepare more for the side effects of contraception, and highlight what was normal for you before taking a specific contraception. 

The future

Worryingly, many women might gaslight themselves concerning their symptoms, or may not have their pain taken seriously. Ultimately, there seems to be frustration around inadequate contraception education, and a yearning for more non-hormonal options.

From what I can ascertain, there are two main non-hormonal contraceptive futures. India’s Saheli non-hormonal pill (not licensed out of India or by the WHO) and labs in America are exploring ‘the use of polidocanol foam, currently used as a treatment for varicose veins, as a non-hormonal, non-surgical permanent contraceptive that, once inserted transcervically, blocks sperm from reaching an egg’ (Brooke, 2019). The Natural Cycles App, which is receiving better testing throughout its uses, could be an option for those who want to track their fertility whilst testing their temperatures. It isn’t as reliable as other methods of contraception, but provides some hope. 

Male contraception could be an option, which could have more non-hormonal options than for female reproductive systems – given that ovulation doesn’t need to be prevented.

With 93% of the Instagram poll said they would feel more satisfied to try non-hormonal options in the future, we can only hope for more scientific innovation.

Feel free to let me know – what contraception do you like?

What might you consider in the future?

Blog illustration by the ever phenomenal Mayra Salazar, @mayra.tee on Instagram

Resources

Reading: 

• Which method of contraception is right for me? This website has a tool to compare contraceptives
• The pill side effects: opting for hormone-free contraception 
• Is Your Contraceptive Pill Causing You Depression, Anxiety and Panic Attacks? Debrief Exclusive Investigation 
• Myths and facts about… the contraceptive pill 
• OXFORDSHIRE SEXUAL HEALTH SER VICE – guide on alternative pill taking 
• Why Is It So Hard to Get a Diaphragm These Days?  
• The Contraceptive implant ‘controversy’ is just mud flinging | Lisa Hallgarten 
• Books I have been recommended but haven’t purchased due to personal bookshelf queues!: Hormonal by Eleanor Morgan, How the Pill Changes Everything by Sarah E Hill  

Listening: 

• Romantic Side Effects to Birth Control
• Contraception on Project Pleasure  

Watching:

• Sex, Explained: birth control on Netflix

References 

Brooke, E. (2019).  The bitter pill: why isn’t birth control better? (Accessed online: https://www.vox.com/the-goods/2019/6/25/18715504/birth-control-side-effects-pill-iud 14/05/2020)

Brochmann, N & Dahl, E. S. (2017). The Wonder Down Under: A user’s guide to the vagina. Great Britain: Yellow Kite

Cancer Research. (2020). Does the contraceptive pill increase cancer risk? (Accessed online: https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/hormones-and-cancer/does-the-contraceptive-pill-increase-cancer-risk#XXX1 13/05/2020)

Fiennes, N. (2019). Behind Closed Doors : Sex Education Transformed. London: Pluto Press.

FPA. (2007). Contraception Patterns of Use Factsheet. Files Webpage. (Accessed online: https://www.fpa.org.uk/sites/default/files/contraception-patterns-of-use-factsheet-november-2007.pdf 10/05/2020)

FPA. (2019). Which method of contraception is right for me? Contraception Webpage. (Accessed online: https://www.sexwise.fpa.org.uk/contraception/which-method-contraception-right-me 13/05/2020)

NHS. (2017). Contraceptive diaphragm or cap. Contraception Webpage. (Accessed online: https://www.nhs.uk/conditions/contraception/contraceptive-diaphragm-or-cap/ 14/05/2020)

NHS. (2018). Intrauterine system (IUS). Contraception Webpage. (Accessed online: https://www.nhs.uk/conditions/contraception/ius-intrauterine-system/ 14/05/2020)

NHS. (2019). What is contraception? Contraception Webpage. (Accessed online: https://www.nhs.uk/conditions/contraception/what-is-contraception/ 10/05/2020)

NICE. (2019). Contraceptives, hormonal. (Accessed online:  https://bnf.nice.org.uk/treatment-summary/contraceptives-hormonal.html 13/05/2020)

Nuva Ring. (2020). Inserting NuvaRing. NuvaRing website. (Accessed online: https://www.nuvaring.com/inserting-nuvaring/ 14/05/2020)