Family Planning 101



Hey girlfriends! Today, we are going to discuss various birth control options. During my time as a Certified Nurse Midwife, I have encountered numerous women who fear, dislike, or are confused about birth control. When I inquire about where those feelings stem from, I always hear a story about a family member or friend’s horrible experience. Some of these women have never tried birth control for themselves and some have with significant side effects. The first thing to realize is that all of our bodies are different. How I may respond to a certain method is not how you will respond. So I always encourage women who have never tried to at least find out for themselves, if they are a good candidate. For those who have had a personal unfortunate experience, many of them had only tried pills and weren’t aware of other options. Family planning methods vary in terms of the type of hormones they include (if they even have hormones at all) and how the hormones are introduced to the body. So the second thing to consider is that your body will react differently to each method. My job is to educate, provide options, and encourage each woman to pick the method that best works for her. I’m often asked what I think someone should do. This is impossible for me to know. Only you know your lifestyle, schedule, and specific needs so if equipped with knowledge, you are more than capable of making your own decision. Class is in session!


Combination Birth Control Pills



This is the method that most of my patients have heard about and tried in the past. When I first started birth control over 10 years ago, I was placed on this and honestly not even given another option. These are called combination pills because they contain a combination of two hormones: estrogen and progestin. Both of these hormones naturally occur in your body, but the introduction of more from birth control stops you from ovulating. No ovulation = no egg to be fertilized. Progestin also thickens cervical mucus so that it’s more difficult for sperm to enter. It’s important to note that different brands insert different amounts of hormones into their pills, so your dose may need to be adjusted based on side effects.


How to Use


You take the pill everyday around the same time with the last row of the pill pack or last few pills being placebo pills. During the placebo period, your body experiences withdrawal from the extra progestin, which stimulates an artificial period. For those who desire even less periods a year, you can use brands that contain placebo pills every 3 months. Some brands even include iron in their pills.


Pros


These are great at regulating your period and are often used for this very purpose. Your periods will be predictable and often shorter and lighter with fewer cramps. If you have a vacation or special event coming up, you can also avoid your period by skipping the placebo pills. We can all agree its super helpful knowing when your period is coming!


Cons


You have to take it everyday! I personally cannot remember to take pills everyday, so I really struggled on the pill. I recommend setting an alarm or placing it next to your vitamins or other medicines. Taking the pill incorrectly can actually increase your chances of getting pregnant than if you were on nothing.


Side Effects


· Mood swings

· Spotting

· Headaches

· Breast tenderness

· Nausea

· Changes in sex drive


The most serious side effect is developing blood clots that can cause a heart attack, stroke, or pulmonary embolism. This is life threatening! Smoking, being over 35 years old, having poorly controlled high blood pressure, a clotting disorder, or a history of clots increases your risk. Consider another method if you have these conditions. If you are not at increased risk, this method is safe for you.


Progestin Only Birth Control Pills


As the name suggests, these pills only have progestin in them. These are safer for the conditions I listed above as it’s the estrogen in the other pills that can lead to the development of blood clots. These pills and other progestin-only methods are also safe for breastfeeding since estrogen can reduce milk supply. Since the progestin is there, this method still thickens cervical mucus and thins the lining of the uterus. However, ovulation is only suppressed sometimes, so it can still occur. You can take the combination pills a few hours later, but this one you must take at the same time. I tell my patients that they really have to be strict when taking these pills as they are not as effective as the combination pills. These are not utilized to regulate periods because ovulation can occur whenever (there are no placebo pills). Side effects are similar to the ones I listed above but occur less frequently.


The Patch



The patch is placed on your body and releases both estrogen and progestin through the skin into your bloodstream. It’s important to note that this method is less effective in women who weigh more than 198 lbs. So it wouldn’t be a good method for me personally. The patch also exposes you to about 60% more estrogen than a regular pill. Generally, it works the same as the pill except for how you administer the hormones.


How To Use


Place one patch on your upper outer arm, stomach, butt, or back once a week for three weeks. Each time you should place the patch on a different site. During the fourth week, do not place a patch and this is when you will receive your period.


Pros


The patch causes regular, predictable periods. You have to remember this method less than the pills; once a week instead of every day. I suggest labeling your calendar each week as “on, on, on, off.”


Cons


This method is visible and could detach from the skin. You could also experience a reaction at the site of placement.


Side Effects


· Similar to pill – see above

· Skin reaction


NuvaRing



This method is a clear ring filled with the hormones estrogen and progestin that is inserted in the vagina. Again, works similar to the pill in terms of how it affects the body, but is administered differently.


How To Use


Insert the ring inside your vagina all the way back for 3 weeks continuously. At the beginning of the 4th week, remove the ring and leave it out for 1 week; this is when your period will occur.


Pros


Only have to remember twice a month; when you put it in and take it out. Periods are predictable.


Cons


You have to be comfortable inserting and removing yourself. It can be felt during sex. If placed incorrectly, it can be uncomfortable.


Side Effects


· Similar to pill – see above

· Increased vaginal infections


Depo Shot


Now we are moving on to other progestin-only methods. The shot is one of them and administered once every 3 months. This is a safer method if you are at increased risk for blood clots or breastfeeding.


How To Use


Your healthcare provider will either have the injections already in the office or they will prescribe it for you to pick up at the pharmacy. If it’s prescribed, bring the medicine with you when you go for your appointment. Healthcare personnel will inject the shot for you and tell you when to return for the next one. It is not advised to administer the shot to yourself at home.


Pros


This is a long acting birth control method that only has to be remembered 4 times a year! It is less prone to user error and therefore more effective.


Cons


Irregular bleeding is common with this method. Some women will have no periods at all while others bleed every day. There is no way to tell how your periods will be until you try it. This method can also lead to a loss of bone mineral density, which increases your risk for osteoporosis. I always advise my patients to take daily calcium and vitamin D supplements and to switch to another method after 2 years of continuous use. Returning to fertility also takes longer with the shot as it can take 10 months or more to ovulate regularly again.


Side Effects


· Irregular bleeding

· Weight gain (more prevalent than other methods)

· Loss in bone mineral density

· Mood swings

· Decreased libido

· Headaches

· Cramping

· Longer return to fertility


Nexplanon (Implant)



This progestin-only method is long acting and one of the devices that can be inserted into the body. It is a flexible plastic rod similar to the size of a matchstick that is inserted just under the skin of your non-dominant upper arm. The device can be felt if you press on it, but it does not bother you after initial insertion. Over the 3-year period that the rod is inserted, it releases a low, steady dose of progestin to thicken cervical mucus, thin the lining of the uterus, and occasionally suppress ovulation. You do not have to keep the implant in the full 3 years and can remove it before it expires. However, it’s recommended if you are looking for a long-term option. Similar to the patch, this method may also not be as effective in women with a BMI over 30.


How To Use


This birth control has to be inserted by a trained and licensed healthcare provider. After marking the appropriate site and setting up a sterile environment, the provider will prep your skin with an antiseptic in order to prevent infection. A local anesthetic (lidocaine) will be used to numb the skin. During this part, you will feel a stick and burning as the medicine is injected. An applicator with a needle is then inserted into the skin and a lever is pushed back which retracts the needle and places the rod. After successful placement is ensured, the arm will be bandaged for 24 hours. To remove, a small incision is made with a scalpel and the rod is pulled out using forceps.


Pros


You do not have to think about this method at all for 3 years! The implant and IUDs (discussed below) are as effective as being sterilized, but reversible. You can also get pregnant as soon as 7 days after removing, though it can take a few months for others.


Cons


It is a foreign object in your body. Though it is rare, the device can move to another part of the body and have to be removed through surgery or even be life threatening. It is important to check for placement at least every month. The rod can be felt easily through the skin.


Side Effects


· Irregular bleeding

· Decreased libido

· Headaches

· Mood swings

· Nausea

· Breast tenderness

· Weight gain

· Bruising at site of placement


Intrauterine Device (IUD)



Similar to the implant, the IUD is good for 3-10 years depending on the brand and is a T-shaped plastic rod placed in your uterus. Most contain progestin (Mirena, Skyla, Kyleena, Liletta) while one contains copper (ParaGard). The ones with progestin slowly release a steady dose of the hormone over the time period it’s indicated for. Since ovulation isn’t consistently suppressed, periods can still occur with this and other progestin-only methods. The copper IUD is the only method with no hormones. Since the copper results in inflammation, it is toxic to both sperm and eggs. IUDs can be used for all ages, even if you have never had a child. However, your risk for expulsion is greater if you haven't. It is recommended that insertion takes place during the period as your cervix is already dilated during this time. A small dose of a medicine called Cytotec can also be used to dilate the cervix for easier placement.


How To Use


A trained and licensed health care provider in an office setting places the device. Before starting, a bimanual pelvic exam is done to determine which way your uterus is facing. A speculum is placed in the vagina to visualize the cervix, which is then cleaned with an antiseptic agent. A sharp object called a tenaculum can be used to grasp the cervix so that it doesn’t slip away when your provider tries to insert the device. An instrument called a sound is then placed through the cervix up into the uterus to measure the length of your uterus. There are measurements on the applicator to ensure that the IUD does not go through the uterus. After measuring, the proper length is set and then the applicator is inserted through the cervix into the uterus. Once the applicator is properly placed, a lever is pulled down or stick inserted to push the IUD out of the applicator into the uterus with the arms expanded. The strings of the IUD are then cut short but not too short to where it cannot be removed later. Removing is simple as the strings are simply pulled on.


Pros


Longest acting birth control method that does not have to be remembered for years. The copper IUD is a great option for those who have horrible side effects from hormones.


Cons


It is a foreign object in your body that can go through the uterus and move to another part of the body. The IUD can be placed under ultrasound to ensure correct placement and then a follow up ultrasound in a month is always recommended to make sure it hasn’t moved. The copper IUD often causes heavier periods, more cramps, and spotting.


Side Effects


· Irregular bleeding

· Headaches

· Breast tenderness

· Mood changes

· Cramping/pelvic pain

· Increased risk to develop pelvic inflammatory disease (PID) if you have an untreated sexually transmitted infection (STI). Should have a pap smear and STI screening before placement.


Natural Family Planning


This method doesn’t require hormones or a device. If your periods are regular like clockwork, you can observe your body to determine when you are ovulating. This would not work for me as I have PCOS and therefore have unpredictable periods. Since conception occurs during the period of ovulation, you want to refrain from sex during this week or use condoms. Many women will use this if they do not want to introduce anything to their bodies.


How To Use


Study your cervical mucus daily. During ovulation, your mucus will be stretchy, clear, and slick like an uncooked egg white. You can also take your temperature daily before you get out of bed. Normally it will be between 97 and 98 degrees Fahrenheit. When you ovulate, your temperature will raise .5 – 1 degree, so it is necessary to record your temperatures in order to notice the difference.


Pros


No hormones/devices = no side effects. You can really learn your body with this method, and it can even be used to get pregnant; just have sex without a condom during ovulation.


Cons


Extremely ineffective if your periods are unpredictable. You have to be careful as stress, changes in diet or activity level, medications, and other factors can throw off your period.


Side Effects


None except for pregnancy if not used correctly.


No Insurance?


I was asked a good question about what to do if you do not have health insurance. I recommend starting with the health department or Planned Parenthood, as they will provide options on a sliding scale. Also, see if your office will let you do a payment plan for the implant or IUD. These can be between $800 - $1,000 but last for multiple years. You can also download coupons off of GoodRx to avoid paying full price at the pharmacy. I even pull up this website for my clients and search for the cheapest method at their particular pharmacy. A lot of brands will have discount cards for self pay patients on their website, so be sure to check.


I hope this guide provided useful information about the various birth control options and how they work. It can be confusing when presented with all these options during your short visit with your healthcare provider. I strongly recommend doing your research beforehand so that you are prepared with a few options and questions. Remember, knowledge is power. Protect your body and be strong.


xoxo, Global Midwife


Disclaimer: This is not medical advice, only education. Always check with your healthcare provider.

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