9 Contraceptive Methods

Since, in human beings, sex is a pleasurable activity which is frequently engaged in for its own sake and not solely for the purposes of reproduction, a couple who want to have sex and who do not want a child will need to use some form of contraception, i.e. they will need to find some way of stopping the male sperm meeting the female egg and fertilizing it.

Attempts to find some way of having sex without producing babies have a long history. Documents from Mesopotamia, 4000 years ago, record that a plug of dung was placed in the woman's vagina to stop conception. In Cleopatra's Egypt, small gold trinkets were inserted into the uterus of the courtesans as a form of early intra-uterine contraceptive device. At the same time, camel herders pushed pebbles into the wombs of the female camels so that they would not get pregnant on long caravan treks. More recently, in the eighteenth century in France, the renowned philanderer Casanova used a thin pig's bladder as an early condom or 'French letter'. Prior to this there were similar devices made from leather or gut. Finding a safe, effective and reliable contraceptive has proved a difficult task.

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Oral Contraceptives

The pill. It is not an overstatement to say that the development of the oral contraceptive pill in 1962 revolutionized modern life. For the first time there was an effective, safe, reliable, easy to use, reversible contraceptive that did not interfere with love-making and had no aesthetic drawbacks.

The pill works by suppressing ovulation. A woman's hormone level normally rises and falls during her monthly cycle and by so doing sets in train the various reproductive processes. A woman taking the pill maintains a more constant hormone level so her eggs are not released. The most commonly prescribed pills are taken for three of the four weeks. This allows the hormone level to drop during the fourth week causing a bleeding to start and allowing as natural a cycle as possible while preventing the release of the egg. If the woman stops taking the pill, her normal cycle should resume very quickly (sometimes immediately) and she is able to become pregnant.

In its early days there were some questions raised about the wisdom of long-term reliance on the pill, but a woman on today's pill is taking a hormone dose that is some 30 times less than the original. There is no doubt that it is safer to take the pill than to have just one pregnancy — a reasonable if not entirely logical basis of comparison.

Although the pill is very safe, there are some women who should not use it. Those who have had high blood pressure, blood clots, severe liver disease, strokes or bad migraines should not take the pill. Heavy smokers, women who are excessively overweight, and those with diabetes will usually be observed closely by their doctor and probably should not use the pill after they reach 35 years of age.

The pill has several positive benefits besides prevention of pregnancy. It regulates irregular periods, reduces menstrual pain and premenstrual tension, reduces the severity of acne in some women, and may increase libido (desire for sex). It sometimes increases the size of the breasts. It also reduces the incidence of some types of cancer.

If taken correctly, the pill is very effective as a contraceptive (close to 100%). The daily dosage must be maintained, however. If more than one pill is missed it is generally wise to use some other form of contraception for seven days after the missed pill. An attack of vomiting or diarrhoea can prevent the pill from being absorbed. Some antibiotics also interfere with absorption. If any of these things occur, continue to take the pill and use another method of contraception until seven days after.

A few women have unpleasant side effects from the pill. These include headaches, breakthrough bleeding, nausea, increased appetite and mood changes. If these problems occur, see your doctor, as a pill with a different balance of hormones might be prescribed.

In the early days of the pill it was recommended that women take a break from it every few years, but this is no longer considered necessary.

The mini pill. In its most commonly used forms, the pill is a combination of the hormones estrogen and progesterone. There is also a 'mini pill' which contains only a progestogen hormone and is suitable for some women, including breastfeeding mothers, who cannot take the combined pill. The mini pill is slightly less reliable than the combined pill and is more likely to give rise to breakthrough bleeding, but serious side effects are much less common. It is important to take it at the same time each day, and it has its greatest contraceptive effect about 4-20 hours after it is taken. Early evening is usually a good time to take it.

The morning-after pill. The morning-after pill is a short course of oral contraception which must be taken within 72 hours of sexual intercourse. The dose is repeated exactly 12 hours later, so if the first dose is taken at 10 a.m., then the second dose is due at 10 p.m. The morning-after pill prevents pregnancy in one of two ways — by preventing ovulation, or by preventing implantation of the fertilized egg in the womb. It can be used after unprotected sex at the woman's fertile period, in cases of condom or diaphragm misuse or mishap, and is also used in cases of rape.

Some women experience nausea after taking the morning-after pill, and some vomit. Anti-nausea pills are often provided together with it. Some women experience breast tenderness, headaches or light bleeding, but these symptoms usually go away without any treatment. Your period may be on time, delayed or could be early after taking the morning-after pill. In the time after you have used this pill until you have your next period, you must use some other form of contraception, as you are still at risk of pregnancy.

The morning-after pill should not be used as ongoing contraception. It should not be used more than once a month. You should discuss regular contraceptive methods with your doctor or a family planning clinic.

Depo-Provera

Depo-Provera is a means of contraception in which a synthetic form of the female sex hormone progesterone is injected into a woman's muscle and slowly released into the body, causing the ovaries to stop producing eggs. One injection lasts for 12 weeks or more. Following the first injection, it is necessary to use another method of contraception for seven days, but follow-up injections are effective immediately, provided they are administered regularly. If an injection is more than a week late, you could become pregnant and should use another method of contraception until seven days after the next injection.

During the first few months, Depo-Provera sometimes causes a change in the menstrual pattern, such as missed periods, irregular spotting, continual light bleeding, or heavy bleeding. Occasionally it gives rise to nausea, headaches, mild depression, abdominal cramps, breast tenderness and weight gain. These are not a cause for concern, but if they are prolonged or a source of discomfort you should see your doctor. Side effects cannot quickly be reversed because of the long-lasting nature of the injection.

In many women, the injections result in periods becoming lighter and less frequent, and eventually stopping. This is quite harmless and may even be welcome. It may take six months or longer after ceasing the injections for fertility to return to normal. However, there is no risk of permanent infertility.

If you are on Depo-Provera, you should tell a doctor whom you visit for any reason.

Doctors may prescribe it where they believe it is the best or only method of contraception. A woman who is on Depo-Provera should be monitored at regular intervals and should understand fully its advantages and disadvantages when making her decision.

Depo-Provera has the advantage that it is highly effective, long-acting, cannot be forgotten, is convenient, and avoids the possible side effects of the pill with its oestrogen base. However, its safety is not yet established beyond all doubt and its use as a contraceptive for some intellectually disabled women has aroused considerable controversy among people concerned with human rights.

Spermicide

There are various creams, foams, gels and tablets which act to kill sperm on contact. A tablet can be inserted high into the vagina at the opening to the womb by hand, but creams, gels and foams are usually inserted with an applicator. Generally a spermicide must be inserted no more than 20 minutes before intercourse and a new application must be used before each ejaculation. Even used strictly as directed, the failure rate of such contraceptives is very high, and they are more suitable for use in conjunction with other methods rather than on their own. Generally the use of spermicides is advised with a diaphragm. They also increase the reliability of a condom.

Condom

The condom is the simplest barrier method of artificial contraception and the only reversible contraceptive so far developed which is used by men. A condom is a thin rubber sheath which is placed on the penis before penetration. When the man ejaculates, the sperm are held in the rubber tip.

Condoms have the advantage that they are cheap and readily available. They are not completely foolproof because the rubber can tear or they can come off, but if they are used in accordance with instructions they are very effective. Used with a spermicide, the failure rate has been estimated as only 3%. Condoms have the further advantage that they not only protect the woman against becoming pregnant, they protect both partners against sexually transmitted disease, and since the advent of the AIDS virus, anyone engaging in sex with a partner who is not long-term and well known to them should use a condom. Some men complain that the rubber lessens the sensation ('like showering with a raincoat' is a common analogy), but modern ultra-thin rubbers reduce this disadvantage considerably, and the risks of engaging in unprotected sex in this day and age make such objections foolish in the extreme.

Diaphragm

The diaphragm for women works on a similar principle as the condom (see above), i.e. it provides a physical barrier to the sperm meeting the egg. A diaphragm is a rubber dome with a flexible spring rim. It is inserted into the vagina before intercourse, so that it covers the cervix, or entry to the womb. It should be used with a spermicidal cream or jelly to kill any sperm that manage to wriggle around the edges. A woman must be measured by a doctor for a diaphragm of the correct size and she will also need to be instructed how to insert it properly.

Most women find a diaphragm easy enough to use, and it has a high reliability. Some women find the fact that it has to be inserted before intercourse aesthetically displeasing, but generally it presents no problems. It can be put in place some time before if necessary. It must be left in place for six hours after intercourse to ensure that all the sperm are dead before removal. Its failure rate of between 10 and 15% makes it somewhat less reliable than the condom.

A diaphragm poses no health risks unless (very rarely) either partner is allergic to the rubber.

Cervical Cap

Like the diaphragm, the cervical cap is a barrier method of contraception, but it is much smaller because it fits tightly over the cervix, rather than filling the vagina. There are several types of cervical caps, but the one most commonly used attaches to the cervix by suction. The cap must be fitted carefully. It should be used in the same way as the diaphragm, with spermicides and following the same precautions. It has about the same reliability as the diaphragm.

Contraceptive Sponge

This recently introduced device is a sponge impregnated with spermicide which is inserted into the vagina so that it expands to cover the cervix. Like a diaphragm it is inserted before intercourse but is disposable and thrown away after use. It does not need to be fitted by a doctor and can be bought over the counter.

Intra-Uterine Device

The intra-uterine device (IUD) consists of a small piece of plastic, shaped like a 7, or the letter T, or a loop like an S, sometimes with fine copper wire wound round the plastic. It is inserted into the womb, and because it is a foreign body irritating the lining of the womb it stops the egg implanting (and hence the IUD can also be used as a postcoital contraceptive device if inserted within five days of unprotected intercourse). The insertion is done by a doctor and should not produce any more than minimal discomfort. A fine thread hangs down into the vagina and is used to remove the IUD when desired and also to check that it is still in place. The IUD is tiny (about 3 mm in diameter) so that it can be slid gently through the cervix into the womb; once inside it springs open into its true shape. When the time comes for it to be removed, it folds back in on itself so that it can be guided out. An IUD can be left in place for two or three years (longer if it does not have the copper) but it should be checked at least once a year by a doctor. It has the strong advantage that once it is in place it has a high degree of reliability (about 97%) and can virtually be forgotten about.

Not all women are suited to the use of lUDs. Sometimes they fall out, or they may cause heavy and painful periods. The use of an IUD results in an increased risk of pelvic infection and also an increased possibility of tubal pregnancy. IUDs seem to have fewer side effects in women who have had children, but they can be used by women who have had no children.

Natural Methods

One of the so-called natural methods of contraception in which no artificial aids are used is coitus interruptus, in which the man withdraws his penis from the woman's vagina before orgasm so that his sperm is not ejaculated into her. This has the disadvantage of being unreliable since sperm sometimes leak out before ejaculation, and in any event the man's timing has to be accurate — not infrequently difficult to achieve. It can also take the edge off full sexual enjoyment for both partners, especially the man.

The other natural method of preventing conception is the rhythm method. A woman can only become pregnant for a short period each month, a few days either side of ovulation. If she has intercourse at other times, she will not become pregnant. Theoretically, if a woman can establish when she ovulates and she and her partner refrain from having intercourse during that time and engage in sexual activity only in her 'safe period', she should not fall pregnant. Ovulation takes place in the middle of a woman's menstrual cycle, 14 days before her period, and because viable sperm may last up to seven days in her body, the time she can conceive is from seven days prior to ovulation to three days after. If a woman has a standard textbook cycle of five days bleeding out of 28, she would be 'safe' from 11 days before her period to two days after. Shorter cycles are not uncommon, and it is possible to become pregnant during periods. Many people practice this form of contraception successfully for several years, but it is notoriously unreliable. Certainly it depends on the woman having a regular cycle, but even women who are regular will sometimes vary, in which case the system breaks down. The failure rate depends a lot on the users but is generally high.

There are various more scientific means of ascertaining the safe period, involving the taking of the woman's temperature daily or analyzing the appearance of the mucus produced by the cervix. These can be successful for people wishing to avoid artificial means of contraception who are prepared to be properly instructed by a doctor or family planning clinic in what to do and to follow the required procedures diligently. The Billings method (named after the Australian doctor who first recommended the technique), which combines both procedures, is said to be the most reliable.

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