BIRTH CONTROL

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Intrauterine devices or IUDs

IUDs are used by hundreds of millions of women in the world. Most women, though not all, can use them, and they are 96 percent effective in preventing pregnancy. Before a woman is fitted with an IUD she must have a thorough examination. There are several types of IUD, and the one chosen depends upon the results of this examination. IUDs must be fitted by qualified people. IUDs can be left in place for a year or two - sometimes longer. A woman should attempt to take one out or reinsert it: that is a job for a trained person. IUDs are easily removed if the woman wants to try and have a baby. IUDs produce some slightly inflamed tissues; the inflammation prevents a fertilized egg from implanting itself. Some people, though, believe that IUDs cause the Fallopian tubes to contract slightly, speeding the passage of eggs through the tube and thus making it more difficult for sperm to fertilize them.

Advantages of IUDs

Disadvantages of IUDs

Sometimes the uterus will not accept an IUD; it may be expelled shortly after insertion, or it may come out at the first menstrual flow after it has been fitted; between five and ten percent of women (they tend to be younger ones) expel their IUDs after first insertion there is a risk of infection of the uterus, Fallopian tubes and ovaries an IUD can migrate through the uterine wall there is an increased risk of a Fallopian tube (ectopic) pregnancy. Most women can have IUDs fitted safely and successfully, but there are certain circumstances in which a woman should not have one. If she is already pregnant, fitting an IUD can be very dangerous as it is likely to lead to miscarriage. An IUD should not be fitted if the woman has any uterine or vaginal disease, anemia or poor blood-clotting. It may be unwise to fit an lUD if she has a tipped or prolapsed uterus. All these are things that physicians and nurse practitioners normally check for.

Types of IUD

Five types of IUD are the Copper 7 and T, the SAFT Coil, the Lippes Loop and the Progestasert.

The Copper 7 and the Copper T, both of which are made of plastic wound with copper wire, continually release small amounts of copper into the woman's uterus. The effect of the copper is to keep the lining of the uterus inflamed and so make it impossible for the lining to accept a fertilized egg. The amount of copper released is minute - certainly less than you would normally have in your body from the foods you eat. There is no evidence whatsoever that this extremely small addition of copper is in any way harmful; in fact, it doesn't even show up in blood samples. Copper 7s and Copper Ts need replacing about every three years because the copper runs out after that time. Your physician will advise you about replacement. The SAFT Coil and the Lippes Loop are both made of plastic and also inflame the lining of the uterus, but in a different way: by their presence alone. Their shape and their presence alone are to cause inflammation. Both these forms of IUD can stay in place permanently. An IUD comes in straightened form inside an inserter tube. The tube is passed through the vagina and cervix until the IUD can be released. The Progestasert releases extremely small quantity of progestin that affect the lining of the uterus, making it unsuitable plantation of a fertilized ovum. Progestaserts need replacing after a year.

Q: "How do you get an lUD?"

A: "An lUD must be fitted by a physician or other qualified person like a nurse practitioner or physician's assistant. After examining you and evaluating your medical history, the clinician will suggest the type of lUD that is right for your uterus size, for your pregnancy history and for your future pregnancy plans. Your possible allergy to copper will be an important aspect of the choice. It must be pointed out here that many physicians have their own preferences among the various lUDs available, and so they may urge you to have a particular kind of lUD because they are very familiar with it, having used it successfully on a large number of their other patients."

Q: "How is an lUD put in the uterus? Does it hurt?"

A: "A clinician gently guides a special lUD inserter tube through the vagina and cervix into the uterus. The lUD is in a straightened out position inside the inserter tube. When the tube is in the right position, the clinician releases the IUD, which returns to its original form inside the uterus. The inserter tube is then withdrawn and the thread or threads attached to the end of the lUD are trimmed so they hang through the cervix into the back of the vagina. The threads should be felt regularly to check that the lUD is still there and in its proper position. If the thread cannot be felt or seems to have lengthened or moved forward noticeably, your clinician must be contacted immediately. An IUD can be inserted in a few minutes. Sometimes it is painful, sometimes not. Your clinician may give you a simple and safe local anesthetic (in the cervical area) to prevent pain. If you don't have an anesthetic you may want to take ordinary pain killers afterwards. Some women have cramping of the uterus and some bleeding for a few days or even a week or two after insertion. If pain is severe and bleeding heavy, you must contact your clinician immediately. An lUD can be inserted at any time during the menstrual cycle, but most clinicians prefer to insert it during menstruation since the cervix expands at that time, making placement easier and less painful."

Q. "What happens if you get pregnant with the IUD still in place?"

A: "It rarely happens, though we don't yet know why it happens at all. If it does one of the following is likely to take place: about half the time a miscarriage will occur within the first few weeks of the pregnancy; strong cramps, and bleeding like a heavy period are signs that this has happened; the symptoms are more severe if the pregnancy has continued for a month or two; pregnancy with an IUD in place leads to strong possibilities of serious infection of the uterus; if an infection does exist, your IUD will be removed by your physician; a D&C or vacuum procedure will also be performed, which means that the pregnancy will have been terminated. If no miscarriage occurs and if no infection exists, your physician may try to remove the IUD without disturbing the pregnancy; although this is difficult to do, some physicians believe it is an important step to prevent the risk of miscarriage and infection later in the pregnancy; if the IUD cannot be removed this way, some physicians may still advise termination of the pregnancy because of the high risk of miscarriage and dangers of infection. Some physicians allow the IUD to remain in place, while carefully checking the mother and the pregnancy and permit the pregnancy to continue. There have been many births with an IUD in place resulting in no harm to mother or baby. If you should get pregnant with an lUD in place, consult your physician immediately and question her or him very closely."

Q. "How soon can you have a baby after the IUD is removed?"

A: "Right away, if you like, though some physicians advise women to wait a month or two before trying to get pregnant. This short period allows the uterine lining (endometrium) to return to its usual thickness and to function again as it did before the insertion of the lUD."

Q. "Can you have an IUD removed at any time?"

A: "Yes."


Pills (Oral contraceptives)

Since coming on the market in 1960 pills have become the most popular birth control method. Hundreds of millions of women throughout the world use them. Why? Because when taken as prescribed by a physician, oral contraceptives are 98 to 99 percent effective, they are easy to use, they do not interfere with lovemaking in any way, they are not expensive, they tend to cause a lighter and more regular menstrual flow and may control menstrual cramps.

This is how pills work. They contain synthetic hormones that are carried by the bloodstream throughout the body; they work particularly on the pituitary gland (the master gland), the brain, the ovaries, the uterus and cervix. The hormones that the body produces naturally tell the systems each month that it is time to release a new ovum from an ovary. But when a woman is pregnant the hormone balance in the body changes, and the instruction to release a new egg each month is canceled. Pills work in the same way. The hormones they contain convince the body's hormone system that the woman is already pregnant, so no new ovum is released. If no ovum is released, the woman cannot get pregnant. However, there will still be a menstrual flow each month because the uterus knows that there is no pregnancy and so it continues to shed its lining.

There are many different kinds of pills. They are of varying chemical strengths, and have different benefits and drawbacks. Which one is best for each woman has to be decided by her and her physician after a thorough medical evaluation, including a personal and family history, a Pap smear, breast and pelvic examination, a complete blood and urine analysis, and a blood pressure and weight check.

This very important examination can show that some women should never use birth control pills. For example, a history of blood clots or heart disease may be a reason to avoid the use of oral contraceptives; liver disease, cancer of the breast, uterus or cervix are also strong reasons to avoid estrogen-type pills. Smoking increases risks, particularly of phlebitis. Equally, if a woman should happen to be pregnant and not know it, such pills can be harmful. There are also other diseases or problems, like fibroids, abnormal vaginal bleeding, gall bladder diseases, mononucleosis, diabetes and hypertension, which may warrant the choice of another birth control method.

Although healthy adolescent girls and young women show no serious side effects if they take properly prescribed pills, it is common for physicians to advise going off pills from time to time and using another method. This is a safety precaution to minimize the risk of any complications later on. Women sometimes derive incidental benefits from using the pills. For example, pills tend to decrease cramps around the time of menstruation, reduce the number of days of the menstrual flow and decrease the amount of blood loss. Premenstrual tension and depression may also be relieved by oral contraceptives, and they can sometimes control acne too.

If you get any of these symptoms, see your doctor:

Q. "Can you get pregnant if you miss taking one or more pills?"

A: "Yes, it is possible. However, you can take several steps which will avoid the possibility of a pregnancy if you miss a pill on a certain day: if you miss a pill one day, take two pills the next - take the one you missed and the regular one for that day and then continue your regular one-pill-a-day schedule; if you miss taking pills two days in a row, take two pills each day until you catch up, then continue your regular schedule of one pill a day; but, when you miss two pills in succession be sure to use another method of birth control along with the regular pills until your next period; if you miss taking pills three or more days in a row stop using your pills and use another method of birth control until you have your menstrual flow; then begin using your new pack of pills regularly, and continue to use your backup birth control method for at least two weeks.

It helps to take your pills at the same time each day, so that your body will become accustomed to the regular addition of hormones. If you miss your period contact your clinic or physician immediately; do not wait to see if the next one is on time.

Q. "One of my friends takes pills for 21 days, another takes pills for 28 days. What's the difference?"

A: "Pills usually come in 2 1 -day packs, but 28-day packs of pills are also prescribed by physicians. Each pill in the 2 1 -day pack contains hormones, while in the 28-day pack only the first 21 pills contain hormones; the remaining seven pills contain iron or sugar and iron. Regardless of the pills used, menstruation usually occurs during the seven non-hormone days, and usually begins two to three days after the last hormone pill has been taken. When you start taking pills do you get immediate protection?" "Yes, if you begin taking them immediately after your period. No, if you start any time after that in your cycle. If you start at any time other than immediately after your period you must use a backup method until you start on your second pack of pills."

Q: "What is the mini pill?"

A: "Mini pills are taken every day, contain no estrogen and only low amounts of progestin. Progestin is a manufactured hormone resembling the natural hormone progesterone, which is produced by the ovaries after ovulation. The advantage of mini pills is that they contain lower doses of hormone and therefore interfere less with the total system. They have been on the market since 1973. The mini pill does not always prevent an ovum from being released - in fact it does so less than 50 percent of the time. The mini pill has several different effects. It makes cervical mucous thick and sticky, so that it is more difficult for sperm to pass through to the Fallopian tubes. The progestin in mini pills also stops the lining of the uterus (the endometrium) developing properly, and some people believe the Fallopian tubes contract more rapidly under the influence of progestin, thereby interfering with the normal movement of the egg down the Fallopian tube. The mini pill has a high (97 percent) actual effectiveness rate, but it must be taken every day without fall. If a pill is missed one day a backup method of birth control must be used. Mini pill users seem to have less breast tenderness, but can have irregular periods and spotting; they also have less nausea, headache and leg pain than other oral contraceptive users. A complete medical evaluation and prescription must be obtained before using the mini pill."

Q. "Is the mini pill the same as the morning-after pill?"

A: "No. The morning-after pill is an emergency method of preventing pregnancy after having unprotected intercourse (even once) around the time of ovulation. There is no substitute for planning. Planning the night before will avoid morning-after problems, and if an oral contraceptive is needed, saying "No" is the safest and most effective one. Saying no to intercourse does not, of course, rule out other satisfying sexual activities."


Vaginal Spermicides

Vaginal spermicides are sperm-killing products that are placed in the vagina before intercourse. They come in various forms:

1 Foam 2 Cream 3 Jelly 4 Tablets 5 Suppositories

All vaginal spermicides are placed high in the vagina around the cervical area. They are designed to prevent pregnancy in two ways: first, and most important, they contain a safe chemical (spermicide) that kills sperm before it can reach an ovum; second, they spread around the cervical area to create a barrier that prevents sperm from entering the cervix.
Foam, cream and jelly are all placed in the vagina with a special applicator that comes with the product. Spermicidal tablets and suppositories are placed in the vagina by hand.
Vaginal spermicides alone are not as effective as oral contraceptive pills, the IUD, diaphragm or condom, but they do provide varying degrees of protection against pregnancy if they are used properly each time of intercourse. The effectiveness of each of the five types of vaginal spermicide will be discussed in the sections that follow.

Vaginal spermicides have no proven health risks or medical side effects. They are easily purchased from a pharmacy or clinic without a doctor's prescription. They are convenient to use, especially for women who have sexual intercourse infrequently.

1 CONTRACEPTIVE FOAM

When it is properly placed, high in the vagina, foam works as a contraceptive because it contains spermicide that kills sperm on contact. Also it coats the surface of the cervix and acts as a barrier preventing sperm from reaching an ovum and causing a pregnancy. Contraceptive foam can be purchased without a doctor's prescription in a pharmacy or family planning clinic. Foam is packaged in aerosol cans and comes with a special applicator. After use, the plastic applicator should be washed with warm water. The can of foam must be shaken vigorously to mix the chemical and the bubbles. The applicator that comes with the foam is then filled with foam (the instructions show how), the applicator is placed high in the vagina and the foam is released around the cervix. This is done lying down, to prevent the foam from gravitating out of the vagina. Two applications of foam provide added protection. Foam must be placed in the vagina before sexual intercourse, but no longer than 30 minutes before, and must be left in for six to eight hours after. When intercourse occurs several times in any given period, another application of foam must be placed in the vagina each time before intercourse.

How effective is foam? Foam is the most effective vaginal spermicide. Some studies show that foam can be 97 percent effective if properly used, but on average the figure is about 85 percent. Using foam and a condom together increases the protection against pregnancy to the level of pills, the IUD and the diaphragm. When foam fails as a contraceptive, it is generally because it has been used improperly. It may fail if the applicator is not inserted deep enough in the vagina, or if more foam is not added each time when having sex two or more times within a short period; it may also fail if the foam is applied more than 30 minutes before having intercourse.

Once in a while the foam does not kill the sperm or remain on the cervix as it should. This is a product failure, but it occurs rarely.

Q "I heard that foam irritates the vagina and penis. Is that true?"

A: "It can be. Sometimes the chemicals in the foam cause irritation. Changing brands may be enough to solve the problem. If that doesn't work, and the irritation or discomfort continues, change to another method of birth control. Such irritation is not dangerous and carries no serious medical risk. When you buy spermicidal foam at a pharmacy be sure that the can is marked 'contraceptive' and comes with an applicator. Many stores place vaginal deodorants and sprays on the same shelves with contraceptive foams and jellies."

Q: "What about oral sex and foam?"

A: "Have oral sex first then insert the foam."

Q. "Should I douche after I use the foam?"

A: "No, definitely not. Doctors do not advise douching except for specific medical conditions. If you use a douche, you will probably negate the sperm-killing effect of the foam. After six to eight hours but not before, you can wash in and around the vagina if you wish. Foam does not drip and is not as messy as contraceptive jelly or cream: there is no actual need to clean up. It is a matter of personal preference."

2 and 3  CONTRACEPTIVE CREAM AND CONTRACEPTIVE JELLY

Both contraceptive cream and contraceptive jelly prevent pregnancy in the same way when properly placed high in the vagina each time before intercourse: they cover the opening of the cervix, acting as a barrier, and they kill sperm on contact. Cream or jelly can be purchased without a doctor's prescription at a pharmacy, family planning clinic or in some supermarkets. Be sure to buy the contraceptive cream or jelly that can be used alone for pregnancy prevention: some are safe only if they are used with a condom. Contraceptive cream and contraceptive jelly are packaged in tubes like toothpaste and come with an applicator to ensure proper use each time you have intercourse. The tube of cream or jelly and the applicator have threads so they can be screwed together to ensure that the applicator is filled correctly. Prior to intercourse, but no sooner than 15 minutes before, the applicator filled with either cream or jelly is inserted deeply penetrated in the vagina and the contents released to spread over the cervical area. The woman should be lying down. The cream or jelly will act as a barrier preventing sperm from moving into the cervix, and the spermicide it contains will kill any sperm that come in contact with it.

Two applications of the cream or jelly give added protection. When having intercourse more than once in a short period of time a new application of cream or jelly must be added each time before intercourse begins. The cream or jelly must be left in place six to eight hours after intercourse. When the cream or jelly disperses, becomes gooey and starts to drip, only the outside part, the lips of the vagina, should be washed.

How effective are creams and jellies? Contraceptive creams are more effective than contraceptive jellies - studies show contraceptive creams when properly used to be approximately 93 percent effective and contraceptive jellies to be 77 percent effective. Although these rates are not as high as foam alone, or a diaphragm and cream or jelly, or a condom and foam, using contraceptive cream or jelly alone is certainly better than no method at all. When contraceptive cream or jelly fails to prevent pregnancy, it is usually the user's fault. Common mistakes are: not releasing the cream or jelly from the applicator deep enough in the vagina, and walking around immediately after insertion. Not allowing the cream or jelly to remain in place for six to eight hours is another. Applying the cream or jelly too far ahead of intercourse has been known to lead to pregnancy, and not using a new application of cream or jelly before each time of intercourse, however recently the last application was made, has had the same effect.

Q. "My wife doesn't like contraceptive jelly. She says it gets too watery. Is that true?"

A: "Yes. Contraceptive jelly becomes very watery at body temperature and tends to drip and get a bit messy. For this reason, some women prefer to use a contraceptive cream or foam, both of which drip less."

Q. "Which contraceptive cream or jelly is the best?"

A: "As long as the cream or jelly is spermicidal and can be used alone, the different brands are very much alike and must meet the same government standards. People choose according to cost, odor and the feeling of the foam or jelly in the vagina."

Q "Can any contraceptive cream or jelly cause an irritation?"

A: "Yes. Some women and some men have found certain brands of cream or jelly to be irritating to the vagina or to the penis. The remedy is usually to change brands, but if the irritation continues you may have to change your method of birth control."

4 CONTRACEPTIVE TABLETS

A contraceptive tablet is placed by hand high in the vagina five to ten minutes before having intercourse. Body heat causes the tablet to foam up. The tablet contains a spermicide and the foam creates a barrier around the cervix, making it difficult for sperm to pass into the uterus. Contraceptive tablets can be purchased without a doctor's prescription at a drugstore, family planning clinic or at some supermarkets. Be certain these are tablets that are inserted in the vagina by hand and are contraceptives. Each time before sexual intercourse, while lying down, a contraceptive tablet is placed deep in the vagina as close to the cervix as possible. The tablet must be left in place six to eight hours after intercourse before washing the vagina.

How effective are they? There are no large-scale studies of the effectiveness of contraceptive tablets. Failure rates are reported from five to 39 percent, but no one figure has been agreed upon by authorities as the average. Tablets may fail for any of these reasons: sometimes a tablet does not foam up; sometimes the woman does not wait until the tablet has foamed up, or alternatively she may wait so long after the tablet has foamed that it no longer provides protection.

5 CONTRACEPTIVE VAGINAL SUPPOSITORIES

When a contraceptive suppository is properly placed by hand deep in the vagina, body heat causes it to melt and release a spermicide that kills sperm on contact. The spermicidal action prevents pregnancy but does not harm the tissue of the vagina. The contents of the suppository as they melt also form a physical barrier across the cervix, impeding the passage of sperm. Suppositories can be purchased without a doctor's prescription at a family planning clinic, pharmacy or in some supermarkets. When buying suppositories in a drugstore or market, be sure they are for birth control and not for hygiene or constipation. They will be marked "Contraceptive Suppositories." Contraceptive vaginal suppositories come in packages with each suppository in a separate slot for easy removal. Some suppositories are wrapped in a foil which must be completely removed before the device can be inserted properly in the vagina. There are instructions in each package for proper use. Suppositories are placed by hand deep in the vagina three to 15 minutes before intercourse; it takes a few minutes for them to melt completely. It is important to insert a new suppository each time before intercourse, and not to wash the vagina for at least six to eight hours after. Vaginal suppositories are supposed to be in the same effectiveness range as contraceptive foam (85 to 97 percent).

When vaginal suppositories fail to prevent pregnancy, it will be through not inserting the suppository high enough in the vagina; intercourse before the suppository has melted completely; having intercourse too long after the suppository has been put in; or failing to use another suppository when trying many sex positions in a short time. If a man cannot ejaculate or can only ejaculate with dfficulty with retarded ejaculation he may need sex therapy or professional help to enable him to come normally.


General Issues Around Contraception

Artificial Methods of Birth Control

Birth Control Index