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Lifespan’s A - Z Health Information Library |
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Birth control options for womenHighlightsBirth Control Options Birth control options for women include:
Ortho Evra Warning
Nonoxynol-9 Warning
IntroductionContraceptives are devices or methods for preventing pregnancy, either by preventing the fertilization of the female egg by the male sperm or by preventing implantation of the fertilized egg. Contraceptive OptionsChoosing the appropriate contraceptive is a personal decision that varies from individual to individual. Contraceptive options include:
The condom is the only birth control method that provides protection against sexually transmitted diseases (STDs). 
The pill works in several ways to prevent
pregnancy. The pill suppresses ovulation so that an egg is not
released from the ovaries, and changes the cervical mucus, causing
it to become thicker and making it more difficult for sperm to swim
into the womb. The pill also does not allow the lining of the womb
to develop enough to receive and nurture a fertilized egg. This
method of birth control offers no protection against
sexually-transmitted diseases.
Determining EffectivenessContraceptive effectiveness is characterized by "typical use" and "perfect use":
The most effective standard female contraceptives are surgical sterilization, intrauterine devices (IUDs), and the implant. They all have an estimated failure rate of 1% or less during the first year of normal (typical) use. Vasectomy (male surgical sterilization) is the only male contraceptive that is equally effective. By comparison, the estimated failure rate of the male latex condom is 17% with typical use and 2% with perfect use. To put these rates into perspective, a sexually active woman of reproductive age who does not use contraception faces an 85% likelihood of becoming pregnant in the course of a year. Oral Contraception and Combination Hormonal MethodsOral contraceptives (birth control pills) are available only by prescription and come in either a combination of estrogen and progestin or progestin alone. Many brands of each form are available. Although both are equally effective with typical use, the combined pill is more effective with perfect use, and most women choose this form. Some women, however, experience severe headaches or high blood pressure from the estrogen in the combined pill and must take the progestin-only pill. Not all combined pills or progestin-only pills are alike, and brands differ in the amount of estrogen or progestin they contain. Many oral contraceptive combined brands now use lower estrogen doses than previous brands and are proving to be safe and effective with fewer side effects than earlier oral contraceptives. For all oral contraceptive users, a check-up at least once a year is essential. It is also important for women to have their blood pressure checked 3 months after beginning the pill. Former pill users who want to bear children usually regain fertility in 3 - 6 months, but they may regain it even sooner. Hormones Used in ContraceptivesEstrogen (Estradiol) Estrogen is the major female hormone and is responsible for female characteristics. The estrogen compound used in most oral contraceptives is estradiol, which is always used with a progestin. Effects on Reproduction. When used throughout a menstrual cycle with progesterone, estrogen suppresses the actions of other reproductive hormones (luteinizing hormone, or LH, and follicle stimulating hormone, or FSH) and prevents ovulation. Progesterone (Progestin) When used in contraception, progesterone is referred to by one of several names:
Progestins may be used alone or with estrogen in oral contraceptives. In addition, certain specific progestins are used in other kinds of contraceptives, such as etonogestrel in the Implanon implant and depo-medroxyprogesterone acetate in the injectable contraceptive Depo-Provera. Progesterone can prevent pregnancy by itself in several ways:
Progestins used in contraceptives are referred to as:
Combination Estrogen-Progestin Contraceptive PillsOral contraceptives that contain both estrogen and progestin are the more common type of oral contraceptive. At least 10 million American women and 100 million women worldwide use combination oral contraceptives. When they were first marketed in the early 1960s, oral contraceptives contained as much as 5 times the amount of estrogen and up to 10 times the amount of progestins currently used. After reports of severe complications (stroke, heart attack, and pulmonary embolisms) in young women, the hormone amounts were significantly reduced. The estrogen compound used in most oral contraceptives is ethinyl estradiol (also called estradiol, or EE). Fifty micrograms of estradiol is considered high dose, 30 - 35 micrograms are considered average dose, and 20 micrograms or fewer is low-dose. (The high doses found in current oral contraceptives are still much lower than earlier forms of the pill.) Doctors recommend using the lowest possible progestin and estrogen doses. Estrogen doses should not exceed 50 micrograms, as higher doses increase the risk for complications. Many different types of progestins are used in combination with estradiol. Some common types of progestin, and popular combination oral contraceptive brands, include:
Many types of medications and supplements (acetaminophen, anti-seizure drugs, antibiotics, St. John's wort) can interact with progestin and reduce its effectiveness. Make sure your doctor is aware of any drugs, vitamins, and herbal supplements that you take. Types of Regimens. Combination pills are sold in 21-day or 28-day packs:
Oral contraceptives may be taken in cycles that include pills of the same or different strengths. These are categorized as monophasic (one-phase), biphasic (two-phase), or triphasic (three-phase). Monophasic pills contain the same amount of hormones in each dose. Biphasic and triphasic pills contain different dosages of hormones within the pill packs. Because monophasic pills have a consistent amount of hormones, they tend to cause fewer hormone-fluctuating side effects than biphasic or triphasic pills. Research shows little difference in effectiveness between these three types of oral contraceptives. Monophasic pills are often recommended as the best first-choice for birth control pills. Taking the Pills. A woman usually takes the first pill either on the Sunday after her period starts or during the first 24 hours of her period. (The first pill can be started at any time during the menstrual cycle without affecting the bleeding patterns. Ovulation can occur that month, however.) The remaining pills are taken once a day, ideally at the same time of day, until the pack is used up. If a woman has a 21-day pack, she waits 7 days before starting a new pack. If she is on the 28-day pack, she takes the 7 inactive pills. Women should use another method of birth control during the first month taking the pill. If you skip one or more pills, take the following precautions:
Continuous-Dosing Oral ContraceptivesStandard oral contraceptives come in a 28-pill pack that contains 21 active pills and 7 inactive pills. Newer "continuous-dosing" (also called "continuous-use") oral contraceptives aim to reduce -- or even eliminate -- monthly periods and thereby prevent the pain and discomfort that often accompanies menstruation. Women who have medical conditions, (such as endometriosis), which cause heavy or painful menstrual periods may benefit from continuous-dosing oral contraceptives. These oral contraceptives contain a combination of estradiol and the progesterone levonorgestrel, but use extending dosing of active pills. Seasonale, the first continuous-dosing contraceptive, was approved in 2003. It contains 81 days of active pills followed by 7 days of inactive pills. Women who take Seasonale have on average a period every 3 months. Seasonique, a follow-up to Seasonale, was approved in 2006. As with Seasonale, it produces about 4 periods a year. With Seasonique, a woman takes 84 days of levonorgestrol-estradiol pills followed by 7 days of pills that contain only low-dose estradiol. In 2007, the Food and Drug Administration (FDA) approved Lybrel, which supplies a daily low dose of levonorgestrol and estradiol with no inactive pills. Because Lybrel contains only active pills, which are taken 365 days a year, it completely eliminates monthly menstrual periods. In clinical trials, 59% of women who took Lybrel completely stopped menstrual periods by the end of the first year. Some women, however, experienced occasional unscheduled bleeding or spotting during the first 3 - 6 months. Progestin-Only Oral Contraceptives ("Mini-Pills")Progestin-only pill brands include:
Progestin-only pills, which only contain progestins, are always sold in 28-day packs and all the pills are active. (An exception is Plan B, which is emergency contraception.) Progestin-only pills, which are also called “mini-pills,” must be taken at precisely the same time each day to maintain top effectiveness. If a woman deviates from her pill schedule by even 3 hours, she should call her doctor about using back-up contraception for the next 2 days. Progestin-only pill users experience even lighter periods than those taking combination pills. Some may not have periods at all. Because these pills do not contain estrogen, they may be a safer choice for women over age 35, smokers, and those who have other risk factors that contraindicate estrogen use. Advantages of Oral ContraceptivesOral contraceptives are the choice of most American women who use birth control, making them the most popular reversible contraceptives in the U.S. Oral contraceptives are among the most effective contraceptives. Failure rates are relatively low (9% with typical use) and are usually due to noncompliance. Oral contraceptives also have the following advantages:
Endometriosis is the condition in which
the tissue that normally lines the uterus (endometrium) grows on
other areas of the body causing pain and irregular bleeding.
Disadvantages of Oral ContraceptivesCommon Side Effects. Many women experience some side effects during the first 2 - 3 months of birth control use. These side effects usually subside. Estrogen and progesterone have different side effects, and women on the combined pill may experience different effects from those on the progestin-only pill. Common side effects of oral contraceptives include:
Newer formulations of combination pills that use low-dose estrogen, and newer progestins, may reduce and even lower the risk of many of these side effects, including weight gain. Serious Side Effects. Symptoms of serious problems include severe abdominal pain, chest pain, unusual headaches, visual disturbances, or severe pain or swelling in the legs. If you experience any of these symptoms, you should immediately contact your doctor. Potential Risks. Combination birth control pills can increase the risk of developing or worsening certain serious medical conditions. The risks depend in part on a woman’s medical history. You should discuss your health history with your doctor to determine if combination oral contraceptives are safe for you. This is especially important for women who are age 35 or older, smoke, or have a history of high blood pressure, high cholesterol or unhealthy blood lipid profile, diabetes, or migraine headaches. Serious risks of birth control pills may include:
 Click the icon to see an image of cervical cancer. Other Methods for Administering Combination Hormones (Patch and Ring)New methods of administering the combination of progestin and estrogen are now available. Failure rates with perfect use (0.1 - 0.6%) are similar to those of combined oral contraceptives. Skin Patch. Ortho Evra was approved in 2002 as the first birth control skin patch. It contains a progestin (norelgestromin) and estrogen. The patch is placed on the lower abdomen, buttocks, or upper body (but not on the breasts). Each patch is worn continuously for a week and reapplied on the same day of each week. After three weekly patches, the fourth week is patch-free, which allows menstruation. (The patch remains effective for 9 days, so being slightly late in changing it should not increase the risk for pregnancy.) The Ortho patch exposes women to higher levels of estrogen than most birth control pills, and therefore increases the risk for blood clots in the veins (venous thromboembolism). Venous thromboembolism can cause blockage in lung arteries and other serious side effects. Older women (over age 40) and women with risk factors for blood clots (such as cigarette smoking) may find other birth control products to be a safer choice. Discuss with your doctor whether the patch is appropriate for you. Vaginal Ring. NuvaRing is a 2-inch flexible ring that contains both estrogen and progestin (etonogestrel). It is inserted into the vagina. Women can insert the ring by themselves once a month and take it out at the end of the third week to allow menstruation. It works well and may cause less irregular bleeding than oral contraceptives. Some women find it uncomfortable, and a few have reported vaginal irritation and discharge, but such problems rarely cause a woman to discontinue use. As with the patch, NuvaRing may put women who take it at higher risk for blood clots than oral contraceptives. Implant ContraceptionImplant contraception involves inserting a rod under the skin. The rod releases into the bloodstream tiny amounts of the hormone progestin. The first implant was the Norplant system, which used six rods that contained levonorgestrel. Due in part to serious complications, Norplant was withdrawn from the U.S. market in 2002. The main complication was difficulty inserting and, in particular, removing the rods. (Many women experienced scarring.) In addition, some women who used Norplant experienced heavy irregular bleeding. A two-rod implant called Jadelle is sold in other countries, but not the United States. In 2006, the Food and Drug Administration approved Implanon, a new implant contraceptive. In contrast to Norplant:
Implanon insertion takes about a minute and is performed with a local anesthetic in a doctor’s office. The rod remains in place for 3 years, although it can be removed at any time. (The removal procedure takes a few minutes longer than insertion.) After the rod is removed, a new one can be inserted. Studies indicate that Implanon is safe. Irregular bleeding and headaches are the main side effects. However, some doctors are concerned that Implanon may have some of the same risks as Norplant. Injected ContraceptionInjected contraceptives are given once every 3 months. Most injectables are progestin-only. In the United States, depo-medroxyprogesterone acetate (Depo-Provera) is the only approved injected contraceptive. Depo-Provera (also called Depo, or DMPA) uses a progestin called medroxyprogesterone. Like other progestin contraceptives, Depo-Provera prevents pregnancy by halting ovulation, thickening the cervical mucus, and stopping the implantation of fertilized eggs in the uterine lining. Depo-Provera is very effective in preventing pregnancies. About 3 in 100 women who use it become pregnant. However, Depo also carries the risk for many mild and serious side effects. The most serious side effect is loss of bone density (see "Disadvantages"). Because of this complication, Depo-Provera should not be used for more than 2 years. Administering Injections:
CandidacyBecause Depo-Provera does not contain estrogen, it is safe for many women who are not candidates for combination oral contraceptives, such as women smokers over age 35. Depo-Provera should not be given to women who have a history of:
Because of the long lag time between ending treatments and restoration of fertility, Depo-Provera is not recommended for women who are thinking of becoming pregnant within 2 years. Advantages of Depo-Provera
Disadvantages and Complications of Depo-Provera
Intrauterine Devices (IUDs)The intrauterine device (IUD) is a small plastic T-shaped device that is inserted into the uterus. An IUD's contraceptive action begins as soon as the device is placed in the uterus and stops as soon as it is removed. IUDs have an effectiveness rate of close to 100%. They are also a reversible form of contraception. Once the device is removed, a woman regains her fertility. The intrauterine device (IUD) is one of the safest, least expensive, and most effective contraceptive devices available. In spite of its clear advantages and current safety record, only 2% of American women who practice contraception currently use the IUD. (Over 10% of European women have chosen the IUD.) This low use in America is mainly due to persisting and now unwarranted fears of serious infection and other complications. However, the evidence available today should reassure providers and patients about the following concerns:
The intrauterine device (IUD) shown uses
copper as the active contraceptive. Others use progesterone in a
plastic device. IUDs are very effective at preventing pregnancy
(less than 1% chance per year). IUDs come with increased risk of
ectopic pregnancy and perforation of the uterus and do not protect
against sexually transmitted disease. IUDs are prescribed and
placed by health care providers.
Intrauterine Device FormsTwo types of intrauterine devices (IUDs) are available in the United States:
Inserting an Intrauterine DeviceWith some exceptions, an intrauterine device (IUD) can be inserted at any time, except during pregnancy or when an infection is present. It may be inserted immediately postpartum or after elective or spontaneous miscarriage. It is typically inserted in the following manner by a trained health professional:
The strings have two purposes:
The insertion procedure can be painful and sometimes causes cramps, but for many women it is painless or only slightly uncomfortable. Patients are often advised to take an over-the-counter painkiller ahead of time. They can also ask for a local anesthetic to be applied to the cervix if they are sensitive to pain in that area. Occasionally a woman will feel dizzy or light-headed during insertion. Some women may have cramps and backaches for 1 - 2 days after insertion, and others may suffer cramps and backaches for weeks or months. Over-the-counter painkillers can usually moderate this discomfort. Candidates for the Intrauterine DeviceIntrauterine devices are an excellent choice of contraception for women who are seeking a long-term and effective birth control method, particularly those wishing to avoid risks and side effects of contraceptive hormones. The LNG-IUS may be better suited for women with heavy or regular menstrual flow. Around the time of insertion and shortly afterwards, women should be considered at low risk for sexually transmitted disease (mutually monogamous relationship, using condoms, or not sexually active). Women with risk factors that preclude hormonal contraceptives should probably avoid progestin-releasing IUDs, although the progestin doses are much lower with LNG-IUS and probably do not pose the same risks. Women with the following history or conditions may be poor candidates for IUDs:
IUDs have the following advantages:
Additional advantages, depending on the specific IUD, include:
Complications of Specific Intrauterine DevicesMenstrual Bleeding. Both intrauterine device (IUD) forms have effects on menstruation, although they differ significantly by type:
Ovarian Cysts. The LNG-IUS may increase the risk for benign ovarian cysts, but such cysts usually do not cause symptoms and resolve on their own. Expulsion. An estimated 2 - 8% of IUDs are expelled from the uterus within the first year. Expulsion is most likely to occur during the first 3 months after insertion. Expulsion rates may be higher than average if the IUD is inserted immediately after delivery of a child. In 1 in 5 cases, the woman fails to notice that the device is gone, and thus faces the risk of unintended pregnancy. The risk for expulsion is highest during menstruation, so women should be sure to check the strings to make sure the IUD is in place. Effects on Pregnancy. None of the current IUDs increase the risk for infertility. In the very unlikely event that a woman conceives with an IUD in place, however, there is a higher risk of an ectopic pregnancy or miscarriage.  Click the icon to see an image of an ectopic pregnancy. If the IUD is removed right after conception, the risk for miscarriage is close to average (about 20%). There is no evidence that the IUD in a pregnant woman increases the risk for birth defects in the infant. Perforation. A potentially serious complication of the IUD is the accidental perforation of the uterus during insertion or later perforation if the IUD shifts position. Such an occurrence is very rare, and the risk is higher or lower depending on the skill of the doctor. Spermicidal and Barrier ContraceptionBarrier contraceptives are devices that provide a physical barrier between the sperm and the egg. Examples of barrier contraceptives include the male condom, female condom, diaphragm, cervical cap, and sponge. The condom is the only contraceptive method that helps prevent sexually transmitted diseases (STDs). SpermicidesVaginal spermicides are sperm-killing substances available as foams, creams, or gels, and are often used in female contraception with barrier and other devices. Spermicides are usually available without a prescription or medical examination. The active ingredient in U.S.-made spermicides is usually nonoxynol-9, which attacks the surface of the sperm cell. Nonoxynol-9, however, does not provide any protection against sexually-transmitted diseases or HIV (the virus that causes AIDS). Research indicates that frequent use can cause vaginal and rectal irritation and abrasions that may actually increase the risk for HIV transmission in women. In addition, use of a spermicide with a barrier device may increase the risk for a urinary tract infection in women, regardless of whether the device is a condom or diaphragm. (Non-spermicidal lubricated condoms are safe to use.) In general, spermicides may be an appropriate choice for women who have intercourse only once in a while, or need backup protection against pregnancy (for instance, if they forget to take their birth control pills). Spermicides should not be used alone as the primary method of birth control. In general, spermicides may be an appropriate choice for women who have intercourse only once in a while, or need backup protection against pregnancy (for instance, if they forget to take their birth control pills). Spermicides should not be used alone as the primary method of birth control. The Male CondomThe condom is still the only reversible form of male contraception currently available. Pregnancy Protection. The condom should be put on before intercourse when the penis is erect, long before ejaculation, since the male can discharge sufficient semen to cause pregnancy before ejaculation occurs. With typical use, the average rate of pregnancy for couples that rely only on condoms for protection is high -- about 17%. For those who use a condom correctly each time, the annual risk for pregnancy is 2%. Prevention of Sexually Transmitted Diseases. Condoms are important in the prevention of sexually transmitted disease including gonorrhea, Chlamydia, syphilis, herpes, trichomoniasis, and HIV. Some condoms come pre-lubricated. Lubricants can also be purchased and applied separately. Only water-based lubricants (K-Y Jelly, Astroglide, AquaLube, glycerin) should be used with latex condoms. Do not use petroleum jelly or other oil-based lubricant products as these can damage the condom. In general, it's best to use a pre-lubricated condom or to apply a water-based lubricant. Unlubricated condoms may injure vaginal tissue and make it vulnerable to infections. Condom Materials. Condoms made of latex rubber are the most common types. They are less likely to slip or break than those made of polyurethane, and they are contoured for a better fit that can provide fairly effective protection. Some people are allergic to latex, however, and in some cases the reaction can be very dangerous. The latex smell may also be unpleasant for some people. Condoms made from animal membrane (such as lambskin) can prevent pregnancy, but they are permeable and do not protect against sexually transmitted infections. Female CondomThe female condom (Reality, Femidom) is a lubricated, loose-fitting pouch that lines the vagina. It is designed to create a physical barrier against sperm and sexually transmitted diseases by surrounding the penis during intercourse. The failure rate for the female condom is about the same as for the diaphragm and cervical cap. It is available without a prescription but may be hard to find. The female condom may be a good option for women at risk for sexually transmitted diseases and who are not certain that their male partner will use a condom. Use and Insertion of the Female Condom. The female condom is about 3 inches wide and 6 - 7 inches long (larger than a male condom), with a flexible ring at both ends. Current products are made of polyurethane.
The insertion process may seem difficult at first but becomes much easier with practice:
The female condom should be removed in the following circumstances:
The female condom may be the best option for women at risk for sexually transmitted diseases and who are not certain that their male partner will use a condom. There are virtually no obstacles against its use except a negative psychological perception. It is not completely fail-proof against pregnancy or sexually transmitted diseases. Advantages of the Female Condom. In one study, 75% of the women preferred the female to the male condom. Many men also find it more appealing than the latex male condom. The female condom has a number of advantages over the male condom:
Disadvantages and Complications of the Female Condom. Compliance rates are low for many reasons. About 25% of women have difficulty on the first attempt at self-insertion. Some women are distressed by self-insertion. The inner ring may be uncomfortable for some women (in which case it can be removed). Some couples complain that the female condom is unpleasant to look at and can be noisy during intercourse. Without sufficient lubrication, it can also be pushed out of place by the penis. Using more lubricant can help keep the female condom in place and reduce the noise. Female condoms are also expensive, and some women wash them out and reuse them to save money. (In such cases, they should be disinfected first and then washed carefully.) Repeated washings can increase the risk for damage and holes. DiaphragmThe diaphragm, which is generally used with a spermicidal cream, foam, or gel, is a small dome-shaped latex cup with a flexible ring that fits over the cervix. The cup acts as a physical barrier against the entry of sperm into the uterus. A diaphragm is usually used along with a spermicide, although whether spermicide is necessary is an issue of some debate. 
The diaphragm is a flexible rubber cup
that is filled with spermicide and self-inserted over the cervix
prior to intercourse. The device is left in place several hours
after intercourse. The diaphragm is a prescribed device fitted by a
health care professional and is more expensive than other barrier
methods, such as condoms.
Diaphragms come in different sizes and require a fitting by a trained health care provider. The health care provider also advises and prescribes the correct size of diaphragm for the user. Some women will need to be refitted with a different-sized diaphragm after pregnancy, abdominal or pelvic surgery, or weight loss or gain of 10 pounds or more. As a general rule, diaphragms should be replaced every 1 - 2 years. Although the diaphragm has a relatively high failure rate, even with perfect use, it is considered a good choice for women whose health or lifestyle prevents them from using more effective hormonal contraceptives. Certain conditions of the vagina and uterus, a history of toxic shock syndrome, or a history of recurrent urinary tract infections, may disqualify a woman from using the device. The diaphragm should not be used if either partner is allergic to latex or spermicides. Using and Inserting the Diaphragm. The diaphragm can be placed in the vagina up to 1 hour before intercourse and can be used even when a woman is menstruating. The following are general guidelines for insertion:
Advantages of the Diaphragm. The diaphragm can be carried in a purse, can be inserted up to an hour before intercourse begins, and usually (although not always) cannot be felt by either partner. It does not interfere with a woman’s hormones. Disadvantages and Complications of the Diaphragm. Some disadvantages or complications are as follows:
Cervical CapThe cervical cap (FemCap) is a thimble-shaped latex cup that fits over the cervix. It is always used with a spermicidal cream or gel. It is similar to a diaphragm, but smaller, and is available in only four sizes. The cap is sold by prescription and requires a pelvic examination, Pap test, and fitting by a health care provider. Insertion and Use of the Cervical Cap. After a small amount of spermicide is placed in the cap, the device is inserted by hand. As in diaphragm use, instruction and practice is required. The cap must be kept in the vagina for 8 hours after the final act of intercourse. Caps wear out and should be replaced every 1 - 2 years. A refitting may also be needed when a woman experiences certain changes in her health or physical status.  Click the icon to see an image of a cervical cap. Candidacy for the Cervical Cap. Because of the restricted range of available sizes, about 1 in 5 women will not be able to be fitted for the cap. The cap is not widely used, and some women, particularly those who live in sparsely populated areas, may not have access to health care professionals who are trained in fitting this device. Other conditions that can preclude cap use include:
Advantages of the Cervical Cap. Among women who have never given birth, the cap's failure rate is similar to that of the diaphragm. The cap in general is also similar to the diaphragm in terms of cost, ease of use, and also the potential for latex or spermicidal allergies. But unlike the diaphragm, the cap can safely remain in the vagina for up to 48 hours (twice the time limit for a diaphragm), so it can be inserted well in advance of intercourse. The cap is rarely associated with urinary tract infections. Disadvantages of the Cervical Cap. The following are disadvantages of the cervical cap:
Lea’s Shield. Approved in 2002, Lea’s shield is similar to a cervical cap but contains an air valve that helps it stick to the vaginal walls and allow for the passage of cervical mucus. Unlike cervical caps, it is available in only one size and does not need to be fitted. Lea’s shield is made of silicone, and its cup-shaped bowl completely surrounds the cervix without resting on it. The shield is as effective as the diaphragm and cap when used with spermicide. Its advantages are:
The SpongeThe sponge (Today, Protectaid) is a disposable form of barrier contraception. It is made of soft polyurethane, is round in shape, and fits over the cervix like a diaphragm, but is smaller and easily portable. In 1994, the popular over-the-counter contraceptive was taken off the U.S. market because of problems at the company's manufacturing facility. In April 2005, the Food and Drug Administration granted re-approval for the Today sponge to return to the U.S. market. A new company acquired the rights to manufacture the sponge, but sold those rights to another company, which went bankrupt at the end of 2007. In June 2008, yet another company acquired the rights to the sponge. At this point it is unclear when or if the Today sponge will return to the market. Use and Insertion. To use the sponge, the woman first wets it with water, then inserts it into the vagina with a finger, using a cord loop attachment. It can be inserted up to 6 hours before intercourse and should be left in place for at least 6 hours following intercourse. The sponge provides protection for up to 12 hours. It should not be left in for more than 30 hours from time of insertion. The sponge should not be used during menstruation, after childbirth, miscarriage, or termination of pregnancy, or by women with a history of toxic shock syndrome. Advantages and Disadvantages. The sponge is easy to use, is not felt during intercourse, and can be inserted up to 6 hours before intercourse. However, the original Today sponge used extremely high amounts of the spermicide nonoxynol-9, which does not protect against sexually transmitted diseases and may increase the risk for vaginal irritation and transmission of HIV. [See Spermicides section.] Fertility Awareness MethodsFertility awareness methods, also called natural family planning, do not use drugs, physical devices, or surgery to prevent pregnancy. Instead, these cycle-based methods rely on tracking the changes in the body that signal fertility. A woman is only fertile during part of her menstrual cycle. By monitoring certain changes in her body, a woman can more or less predict the fertile phase and abstain from sexual intercourse during that time. She can also use barrier methods if they are not prohibited by religious beliefs. Fertility awareness methods include:
Temperature Method. To determine the most likely time of ovulation and therefore the time of fertility, a woman is instructed to take her body temperature, called her basal body temperature. This is the body's temperature as it rises and falls in accord with hormonal fluctuations.
By studying the temperature patterns over a few months, couples can begin to anticipate ovulation and plan their sexual activity accordingly. To avoid losing spontaneity, couples should try to avoid becoming fixated on the chart in scheduling their sexual activity. Cervical Mucus Method. The cervical mucus method (also called the ovulation method) requires a woman to take a sample (by hand) of her cervical mucus every day for a least a month and to record its quantity, appearance, feel, and to note other physical signs connected with the reproductive system. Cervical mucus changes in predictable ways over the course of each menstrual cycle:
Once a woman's individual pattern is understood, analyzing cervical mucus can provide a highly accurate guide to fertility. Calendar Method. The calendar (rhythm method) is considered the least reliable of fertility awareness methods. Women who have very irregular periods may have even less success with this method. In the calendar method, the woman first keeps a record of her menstrual periods for about 6 - 12 months. She then subtracts 18 days from the shortest and 11 days from the longest of the previous menstrual cycles. For example, if a woman's shortest cycle was 26 days and her longest cycle was 30 days, she must abstain from intercourse from day 8 through day 19 of each cycle. Symptothermal Method. This method combines the temperature, cervical mucus, and calendar methods and is considered the most effective fertility awareness method. In addition, the woman tracks symptoms that may identify her fertile period. These symptoms include changes in the shape of the cervix, breast tenderness, and cramping pain. Candidacy for Fertility Awareness MethodsBecause of the high risk for pregnancy, fertility awareness methods are recommended only for those whose strong religious beliefs prohibit standard contraceptive methods. Couples who are not guided by religious authority, but who simply want a more natural sexual life, may use a barrier contraceptive during the fertile phase and no contraception during the rest of the cycle. However, they should understand the risk of pregnancy will be higher with this method. To be effective against pregnancy, cycle-based methods require not only training, commitment, discipline, and perseverance, but also the cooperation of the male partner. Cycle-based methods are not recommended for women unless they are in a stable, monogamous relationship, and can count on their partner's willing participation. Advantages of Fertility Awareness MethodsMany couples, especially older ones, who have used these methods for a while and are strongly motivated, are able to successfully incorporate fertility awareness into their lives. For those with strong religious beliefs, fertility awareness allows them to have a fulfilling sexual life yet still adhere to the rules of their religions. Disadvantages and Complications of Fertility Awareness MethodsCouples who adopt a cycle-based approach to pregnancy avoidance must often abstain from sex or substitute other kinds of sexual intimacy for vaginal intercourse. Some couples find this self-denial and the need for vigilant tracking of the cycle difficult and stressful for the relationship. Failure rates are high. The risk for sexually transmitted diseases is also of particular concern, because such methods offer no protection against infection and religious beliefs may preclude barrier protection. Emergency ContraceptionEmergency contraception is available to prevent pregnancy:
Basics of Emergency ContraceptionEmergency contraception, also called the “morning after pill,” uses the levonorgestrel progestin hormone found in some birth control pills to prevent either fertilization or the implantation of a fertilized egg in the uterine lining. The morning after pill is not the same thing as the "abortion pill." In 2006, the Food and Drug Administration approved the Plan B brand as the first over-the-counter emergency contraception. It is available without a prescription at pharmacies and health clinics for adults 18 and older, with proof of age. Anyone younger than age 18 needs a prescription from her doctor. Plan B is taken in one or two doses within 72 hours of unprotected sex. Side effects of Plan B may include:
Immediate side effects typically subside within 1 - 2 days of taking the second dose. Family planning experts warn that emergency pill use should not be treated as a substitute for regular contraception. Copper-Releasing Intrauterine Device. An alternative emergency contraception relies on insertion of a copper-releasing intrauterine device (IUD) within 5 days (120 hours) of unprotected intercourse. It can be removed after the woman's next period, or left in place to provide ongoing contraception. The copper IUD reduces the risk of pregnancy by 99.9%. Female SterilizationFemale surgical sterilization (also called tubal sterilization, tubal ligation, and tubal occlusion) is a low-risk, highly effective one-time procedure that offers lifelong protection against pregnancy. About 700,000 women undergo this procedure each year in the United States. Basics of Female SterilizationFemale surgical sterilization procedures block the fallopian tubes and thereby prevent sperm from reaching and fertilizing the eggs. The ovaries continue to function normally, but the eggs they release break up and are harmlessly absorbed by the body. Tubal sterilization is performed in a hospital or outpatient clinic under local or general anesthesia. 
The uterus is a hollow muscular organ
located in the female pelvis behind the bladder and in front of the
rectum. The ovaries produce the eggs that travel through the
fallopian tubes. Once the egg has left the ovary it can be
fertilized and implant itself in the lining of the uterus. The main
function of the uterus is to nourish the developing fetus prior to
birth.
Sterilization does not cause menopause. Menstruation continues as before, with usually very little difference in length, regularity, flow, or cramping. Sterilization does not offer protection against sexually transmitted diseases.  Click the icon to see an image of tubal ligation. Specific Tubal Sterilization TechniquesLaparoscopy. Laparoscopy is the most common surgical approach for tubal sterilization:
 Click the icon to see an illustrated series detailing tubal ligation. Minilaparotomy. Minilaparotomy does not use a viewing instrument and requires an abdominal incision, but it is small -- about 2 inches long. The tubes are tied and cut. Generally speaking, minilaparotomy is preferred for women who choose to be sterilized right after childbirth, while laparoscopy is preferred at other times. Minilaparotomy usually takes approximately 30 minutes to perform. Women who undergo minilaparotomy typically need a few days to recover and can resume intercourse after consulting their doctor. Essure. Approved in 2002, the Essure method uses a small spiral-like device to block the fallopian tube. Unlike tubal ligation, the Essure procedure does not require incisions or general anesthesia. It can be performed in a doctor’s office and takes about 45 minutes. A specially trained doctor uses a viewing instrument called a hysteroscope to insert the device through the vagina and into the uterus, and then up into the fallopian tube. Once the device is in place, it expands inside the fallopian tubes. During the next 3 months, scar tissue forms around the device and blocks the tubes. This results in permanent sterilization. Candidacy for Female SterilizationBefore undergoing sterilization, a woman must be sure that she no longer wants to bear children and will not want to bear children in the future, even if the circumstances of her life change drastically. She must also be aware of the many effective contraceptive choices available. Possible reasons for choosing female sterilization procedures over reversible forms of contraception include:
If married, both partners should completely agree that they no longer want to have children and should also have ruled out vasectomy for the man. Vasectomy is a simple procedure that has a lower failure rate than female surgical sterilization, carries fewer risks, and is less expensive. [For more information, see In-Depth Report #37: Vasectomy.] Even if all these factors are present, a woman must consider her options carefully before proceeding. Women at highest risk for regretting sterilization include:
If a woman changes her mind and wants to become pregnant, a reversal procedure is available, but it is very difficult to perform and requires an experienced surgeon. Subsequent pregnancy rates after reversal depend on the surgeon’s skill, the age of the woman, and, to a lesser degree, her weight and the length of time between the tubal ligation and the reversal procedure. Not all insurance carriers cover the cost of reversal. Advantages of Female SterilizationWomen who choose sterilization no longer need to worry about pregnancy or cope with the distractions and possible side effects of contraceptives. Sterilization does not impair sexual desire or pleasure, and many people say that it actually enhances sex by removing the fear of unwanted pregnancy. Disadvantages and Complications of Female Sterilization
Resources
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Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. The information provided herein should not be used during any
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