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A Doctor’s Overview of Family Planning Options

Image credit: http://www.123rf.com/
Image credit: http://www.123rf.com/

Birth control options have changed a lot over the years, and I get a lot of questions about what is available out there for women of all ages… so I thought it might be helpful to describe each option and who each of these might work best for or not be recommended for. 

“The pill”– there is a huge variety of birth control pills available. There are “monophasic”, “biphasic” “triphasic” and even “quadraphasic” that all alternate the amount of estrogen and progesterone you receive at different times in the month. These hormones are the two most important things that control a woman’s fertility and menstrual cycles, and when taken in pill form they stop the ovary from releasing an egg, which prevents pregnancy. There are also the “extended cycle” or “continuous cycle” pills that give you fewer menstrual cycles that work in the same way. A common issue is remembering to take these every day, around the same time, and there are things that can interfere with them, such as some herbal and prescription medications and antibiotics, which can lead to accidental pregnancy. And there are some people who should not take birth control pills- such as anyone who has a strong family or personal history of blood clots, or migraines with aura, or women over the age of 35 who smoke cigarettes, as the pill can increase your risk of blood clot or stroke. The most common side effects are usually spotting and weight gain.

“The patch” – Very similar to the combination birth control pill, it contains steady doses of estrogen and progesterone that stop ovulation to prevent pregnancy. Same risks, as it should not be used in anyone with a strong family or personal history of blood clots, migraines with aura, or women over the age of 35 who smoke. It’s helpful for women who have difficulty remembering to take a pill every day, as you apply 1 patch weekly for each of 3 weeks, then have a menstrual cycle the final week with no patch worn. 

“The ring” – Again, similar to the combination pills and patches in the way it works, with estrogen and progesterone preventing ovulation to prevent pregnancy. It also has the same contraindications as the pills and the patch, and cannot be used in women who have a strong family or personal history of blood clots, migraines with aura or smokers over 35. It takes a level of comfort on the woman’s part to be able to insert the ring into the back of the vagina near the cervix, and it remains in place for 3 weeks, being removed the 4th week to allow for a period. 

“The mini pill” – This is different from the combination birth control pills as it is just a low dose of progesterone, without estrogen. It works by thinning the lining of the uterus and creating a thick mucous over the cervix, which makes it difficult for sperm to pass. They are commonly recommended for women who are breast feeding, as the combination pills can decrease milk supply, and sometimes recommended for women who want a pill option but aren’t candidates for the combination pills due to migraines, smoking status, or a history of blood clots. These are not as effective as other methods of birth control and MUST be taken at the same time every day to work, which is a big problem for a lot of people. 

“The shot” – Depo provera is a long acting form of progesterone that is injected every 3 months, which stops ovulation and also thins the lining of the uterus, as well as creating a thick mucous over the cervix similarly to the mini pill. It’s benefit is that as long as you get your injections on time it’s highly effective, and people who have a history of blood clots, migraines, or smokers can use this form of birth control safely, however it has several drawbacks. It can cause erratic bleeding for 6-12 months as the body adjusts to the hormone levels, and can cause weight gain more than other forms of birth control. Also, if used for more than 3 years it can cause a decrease in bone density. It does work well for a lot of women, but is not one I typically recommend except for special circumstances. 

“IUDs”– intrauterine devices got a bad rap back in the 70s when the Dalcon Shield came out and was associated with a high rate of “pelvic inflammatory disease”- infections in the uterus and fallopian tubes that can lead to infertility from scarring. There’s been a lot of research and change in IUDs since then, and now there are 3 available that are considered very safe and effective for preventing pregnancy. They are all inserted the same way and are generally very easy to place and well tolerated. For the woman it’s not too much different than how a pelvic exam feels in the set up, however there can be significant cramping associated with the procedure, every woman is different. 

There are 3 different IUDs available; the Paragard is a copper iud that does not have hormones, and is thought to work by the toxic effect of the copper on sperm motility, as well as creating an environment in the uterus that a fertilized egg could not implant. It has the benefit of lasting 10 years and needs very little thought on the woman’s part. We recommend you or your partner confirm the strings are present monthly, which usually takes inserting a finger to the back of the vagina and feeling for the cervix, as the strings typically stick out about 1 inch from here (no… They do not protrude from the vagina and the majority of men cannot “feel them” during intercourse). The most common side effects from the paragard are heavy bleeding and cramping, which typically resolve in the first 6 months. 

There are also the Skyla and the Mirena, which are both progesterone containing devices. The skyla is the newest, and is the smallest iud available, with a lower dose of progesterone than the mirena. It is also the only one that is “indicated by the FDA for use in women who have never been pregnant” for its small size, thought to fit better in a woman’s uterus who has never carried a child. These both work in ways similar to the Paragard to prevent pregnancy, with the additional benefit of the direct effects of the progesterone on the lining of the uterus which helps make periods lighter, or non existent for some women. The Mirena is good for 5 years and the skyla for 3 years, and they should be checked in the same way as the paragard monthly. They can also cause spotting and cramping as the paragard does, but usually less so. There is not felt to be any higher risk of pelvic inflammatory disease with any of these devices and they can be used in almost any women, with the exception of women who have uterine abnormalities such as bicornuate uterus. 

“The implant” – There have been many variations of this over the years and lots of issues with removable progesterone devices, however the current option available, the Nexplanon, has been available for almost 10 years and has had many of these issues resolved. It works by releasing low doses of progesterone over the course of 3 years and works by preventing ovulation and thickening cervical mucous as some of the other methods we discussed do. Insertion is really easy- a large bore needle is used to place it in the arm, and it is fairly easy to remove as well at any point in the 3 years. There can be some mild pain at the insertion site, which typically quickly resolved, and the device can cause irregular bleeding and cramping, which usually resolves in 6-9 months. 

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About Amanda Magrini

Amanda Magrini
Amanda Magrini, MD, is a board-certified family medicine physician at Northern Nevada Medical Group’s Los Altos location in Sparks. She completed her undergraduate degree at the University of Nevada, Reno and her medical training at the University of Nevada School of Medicine. Dr. Magrini has practiced family medicine for seven years, including residency, and enjoys her specialty, because she likes taking care of the whole family, from newborns to grandparents. She likes preventative medicine, helping people take care of themselves and the relationships she is able to form with her patients. Dr. Magrini grew up in Sparks, NV and likes that it is a safe place to live with great educational opportunities and beautiful scenery. She thinks Northern Nevada is a great place to raise a family and looks forward to raising her own children here. In her spare time, she enjoys outdoor activities such as hiking, biking, camping, boating, running and traveling the world. Dr. Magrini is also very close with her family; she is married to her high school sweetheart and values spending time with him and the rest of her family. Disclosure: "The author is a licensed physician practicing with Northern Nevada Medical Group, but all opinions expressed are solely the opinions of the author and do not necessarily reflect the views of Northern Nevada Medical Group or any other affiliates of Universal Health Services, Inc."

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