Contraceptive Confusion
There's a slew of new birth control methods to choose from. The best for you? It's the one you'll use correctly
It's been nearly half a century since the birth control pill changed the way Americans manage their sex lives. But despite the availability of myriad methods of contraception today, a staggering 50 percent of pregnancies in the United States every year are unintentional--and 60 percent of those 3 million annual accidents occur when the woman is using birth control.
Clearly, something's not working. "It's a consumer failure," says David Archer, professor of obstetrics and gynecology at Eastern Virginia Medical School in Norfolk, Va., and director of the school's center for research on birth control. It's not enough to go on the pill, Archer says: Women need to take it every day without fail--which proved impossible for nearly 30 percent of patients in one well-regarded study from the Centers for Disease Control and Prevention. Miss often enough, he says, and "sooner or later, you're going to get burned."
To the rescue comes a proliferation of new choices, intended to be more convenient and fail-safe. Can't remember to take a pill every day? Try a monthly vaginal ring or an every-three-month shot. Do side effects from the pill undermine your effort to be responsible? New formulations may be easier on your body (and, as a bonus, they'll do away with your menstrual periods). Would you rather not think about birth control at all? Consider a new implant approved by the Food and Drug Administration in July that promises protection for up to three years.
You've undoubtedly heard some fanfare about all the new birth control methods. Consumer advertising by pharmaceutical companies for prescription options increased from a mere $459,000 in 2001 to $31.2 million four years later, according to TNS Media Intelligence in New York. But doctors, too, want you to get this message: More choice leads to more effective contraception. If you're happy with your method, there's no need to ponder a switch. If you're not, or if your record on compliance isn't good, here's a quick guide to the whole range of choices. Sometimes insurance plans cover them; sometimes they don't.
The pill. It's by far the most popular method of birth control--and can be 99.7 percent effective for women who take it faithfully, without a slip. The pill is cheap, too ($15 to $35 a month) and usually is covered by insurance.
Women already have more than two dozen versions of the pill to choose from, and new combinations seem to arrive every day. Drug companies keep working to lower the dose of estrogen, which is associated with blood clots, heart attack, stroke, and high blood pressure in some women, and are now racing to introduce pills that limit or put an end to periods. Most pills contain both estrogen and progestin, which work together to inhibit ovulation. Progestin also thins the uterine lining and thickens cervical mucus, making it difficult for the sperm to reach the egg. A few progestin-only "minipills" do away with estrogen--but need to be taken at the exact same time each day, which many women find an unmeetable challenge.
For most people, the pill is considered extremely safe. The wide variety of hormone combinations available can help women minimize the headaches, nausea, and mood changes that often put them off the pill. But beware of paying more money for a new version that may not work any better for you, says Rebekah Gee, an obstetrician-gynecologist and a fellow at the University of Pennsylvania. (She recommends generic versions, in fact.) Smokers over age 35 and women who have had strokes should not take any pill that contains estrogen, nor should women who suffer migraines, especially if the migraines are accompanied by visual disturbances.
The latest trend--"continuous contraception"--doesn't address the compliance problem but dangles a vacation from menstrual periods. Rather than taking contraceptive pills for three weeks and then switching to dummy pills for a week, as women on traditional pills do, people on Duramed Pharmaceuticals' Seasonale, for example, take active pills every day for three months, then take dummy pills for a week, for a total of just four periods a year. In May, the FDA approved Duramed's Seasonique, which does the same thing with a slightly different formulation. "I love the idea of it," says Margaret Littman, a journalist in Chicago who switched to Seasonale last year after 18 years on the traditional pill. "But I was skeptical. There's something about it that seems it shouldn't be good for you."
Doctors say that really isn't an issue. "If Mother Nature had intended for women to have a certain number of periods, it would probably be far fewer than what most western women experience," says Mark Nichols, professor of obstetrics and gynecology at Oregon Health and Science University in Portland, Ore. Women stop menstruating when they're pregnant or breast-feeding, so someone using no contraception might not have periods for 20 years or more, if she has six or seven children and breast-feeds them all. Someone preventing pregnancy completely, on the other hand, might have periods for 40-plus years. And when women take the pill continuously, their uterine lining doesn't thicken as much and need to be shed every month.
But continuous contraception doesn't work flawlessly for everyone. Littman has had "all sorts of spotting," and, after 16 months on Seasonale, she isn't sure she'll stick with it. In fact, most women taking Seasonale experience spotting or unpredictable "breakthrough" bleeding during the first year. Even later, the total number of bleeding days about equals what women experience on a traditional pill.
Researchers are undeterred. Wyeth Pharmaceuticals' Lybrel, now nearing approval, will be taken 365 days a year straight. In clinical trials, many women found they had no bleeding at all after a year.
The vaginal ring. As effective as the pill if used properly, the NuvaRing, approved by the FDA in 2001, is a soft, flexible polymer plastic ring that releases daily doses of estrogen and progestin. Women remove it after three weeks, then insert a new one seven days later. The device, which costs $30 to $35, has been a particular hit among teens. "It's out of sight, so Mom won't find the birth control pills in the purse," says Nichols.
Because the NuvaRing uses both estrogen and progestin, it carries the same risks as the pill; however, a lower level of hormones is absorbed into the blood. One drawback: The ring can slip out. But as long as you replace it within three hours, it still works.
The patch. You wear the Ortha Evra skin-colored patch on your stomach, back, arm, or buttocks for three weeks, changing it weekly, while it doses you with estrogen and progestin. It comes off for a week and then is replaced with a new patch. Assuming you never forget to replace it, the patch is 99 percent effective. It costs $30 to $40 a month. In 2005, the FDA required the manufacturer to warn on the label that women are exposed to 60 percent more estrogen than with most forms of the pill--though it's not clear that the extra estrogen poses extra risk.
The shot. Depo Provera injections, which contain progestin only, are given by your doctor every three months. The shots cost $30 to $75 per injection and are slightly more effective than the pill. But the injected hormones can lead to a temporary thinning of the bones, so most women are advised to use the method for no longer than two years. It can also cause heavy bleeding and irregular spotting. And it's not a good choice if you want to become pregnant right after you go off birth control: Because the hormones build up in your system, you may find it takes a year to get pregnant after stopping the injections.
The IUD. Yes, the intrauterine device is back (box). "We're seeing a lot more women asking for IUDs," says Philip Darney, chief of obstetrics, gynecology, and reproductive sciences at San Francisco General Hospital. "I think we're overcoming the undeservedly bad reputation in the U.S." Typically, the devices run $175 to $500, including insertion by a doctor; about 40 percent of employer plans cover them.
Barrier methods. Not a great choice for someone who lacks discipline. Like the diaphragm, the over-the-counter Today sponge and two new prescription methods--Lea's Shield and FemCap--work with spermicide and are inserted to cover the cervix and prevent sperm from passing. "I don't recommend barrier methods unless a patient is married and would be fine having a baby," says Gee. "They're only 80 to 90 percent effective." And unlike condoms, women's barrier methods offer no protection against the spread of sexually transmitted disease.
Implants. Remember Norplant? The implant--six matchstick-size plastic rods that were inserted under the skin of the upper arm and released progestin--disappeared from the market in 2002 after the effectiveness of one batch was called into question. In mid-July, the FDA approved the next generation: a single slender rod called Implanon that stays in place for up to three years. Problems can include irregular bleeding, although many women stop having their period altogether. A welcome side effect: In clinical trials, 59 percent of women who had acne when they began using Implanon said it improved or went away.
While researchers continue to look for safer, easier-to-use, more effective methods, one long-talked-about option remains conspicuously absent: a pill for men. "The concepts have been proven, but finding a sponsor to develop [them] has been difficult and slow," says Archer. His best guess about when a men's pill might hit the shelves? "Ten years."
This story appears in the August 7, 2006 print edition of U.S. News & World Report.