Which birth control method should I use?

Which birth control method should I use?
Introduction
Medical Information
Your Information
Wise Health Decision
References
Credits

Content provided by Healthwise

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

Birth control methods allow a woman or a couple to choose whether or when to have a child. Consider the following when making your decision:

Permanence. If you are certain that you don't want children (or more children), you might consider a permanent method of birth control, such as female tubal ligation or implants or male vasectomy.
Effectiveness. Consider how important it is to you to avoid pregnancy, and then look at how well each method works. Hormonal implants and injections (Depo-Provera) and the hormonal and copper IUDs are the most effective. Birth control pills (both estrogen-progestin and progestin-only), patches, and rings are highly (but slightly less) effective. Barrier methods such as condoms, diaphragms, and spermicides are only moderately effective. See a reliability table for details on each method.
Convenience. Some methods require more effort than others. Do a reality check by asking yourself how likely you are to use the method consistently. Answer whether you are willing to interrupt lovemaking, to abstain from sex during certain times of the month, or to remember to take a pill every day.
Sexually transmitted disease protection. The most highly effective hormonal and IUD methods do not protect you from sexually transmitted diseases (STDs). Condoms are the only dependable protection you have from STDs. But condoms alone are not a highly effective birth control method. To avoid both STD infection and pregnancy, be sure to combine a condom with a more effective birth control method.
Health risks. If you have health risks, some birth control methods may not be right for you. For example, combined (estrogen and progestin) birth control methods are not recommended for women older than 35 who smoke. Other conditions that may limit your choices of birth control include having migraines, heart disease, high blood pressure, blood clots, or diabetes.
Return to fertility. If you plan to have children within the next year or two, you may want to avoid the Depo-Provera (progestin-only) shot, which can stop your monthly periods and delay your return to fertility.¹ Taking estrogen-progestin for a long time can also make your periods stop. You might not start periods again for several months after you stop taking hormones. But it isn't permanent. You will start ovulating and having your periods, and your fertility should get back to normal.
Other benefits. Some birth control methods have beneficial side effects. Combination hormonal methods (estrogen and progestin) can improve acne. Both combination and progestin-only methods reduce menstrual cramping and flow. In fact, with the Lybrel combination pill, the Depo-Provera shot, or the Mirena IUD, your period may stop altogether.

Medical Information

What are the different methods of birth control?

Sterilization is a surgical procedure done for men or women who decide that they do not want to have any or more children. Sterilization is one of the most effective forms of birth control. Sterilization is intended to be permanent, and while you can try to reverse it with another surgery, reversal is not always successful. Methods include:

Tubal ligation or implants. The fallopian tubes , which carry the eggs from the ovaries to the uterus, are tied, cut, or blocked. A new type of procedure, using a device (called Essure) to block the fallopian tubes, is done without an incision and on an outpatient basis.
Vasectomy. In this minor procedure, the vas deferens, the tube that carries sperm from the testicles to the seminal fluid (semen), from each testicle is cut and blocked so that sperm are no longer present in the semen.

Hormonal methods are very effective means of birth control. Hormonal methods use two basic formulas:

Combination hormonal methods contain both estrogen and progestin (synthetic progesterone). Combination methods include pills, skin patches, and rings .
Progestin-only hormonal methods include pills (also called the "mini-pill") and injections (Depo-Provera). Progestin-only methods are an option for women who cannot take estrogen.

Compare the:

Advantages and disadvantages of combination hormonal methods with progestin-only pills, patches, and rings.
Advantages and disadvantages of the progestin-only (Depo-Provera) shot.

An intrauterine device (IUD) is a small device that is placed in your uterus to prevent pregnancy. IUDs usually contain copper (Copper T 380-A) or a hormone (the Mirena IUD, which releases a progestin called levonorgestrel). IUDs can provide birth control for 5 to 10 years.

Barrier methods include the diaphragm, cervical cap, Lea's Shield, male condom, female condom, spermicidal foam, sponges, and film. Barrier methods prevent sperm from entering the uterus and reaching the egg. Typically, barrier methods are not highly effective, but they generally have fewer side effects than hormonal methods or IUDs. Spermicides and condoms should be used together or along with another method to increase their effectiveness. Barrier methods can interrupt lovemaking because they must be used every time you have sex. (A diaphragm, cap, or shield can be put in a few hours beforehand, if you can plan ahead.)

Fertility awareness, or natural family planning, requires that a couple chart the time during a woman's menstrual cycle that she is most likely to become pregnant and avoid intercourse or use a barrier method during that time. Fertility awareness is not a highly effective method of preventing pregnancy.

If you are at risk of getting or spreading a sexually transmitted disease (such as genital herpes, chlamydia, and AIDS), use a condom. To most effectively prevent pregnancy, combine a condom with a highly effective birth control method.

How effective are birth control methods?

Hormonal implants, injections (Depo-Provera), and the hormonal and copper IUDs are very highly successful methods of birth control. These methods are 97% to 99.9% effective. That means fewer than 1 to 3 women out of 100 women who are using these methods will become pregnant during the first year of use.

Birth control pills (both combination and progestin-only) have a high success rate of 92%. But if taken properly (every day or at the same time every day), birth control pills can be highly successful. The hormonal skin patch and vaginal ring are thought to be about as effective as birth control pills, but how well they actually work has not been well studied.

Barrier methods, such as the diaphragm or condom, are moderately successful at preventing pregnancy. The diaphragm and cervical cap are 84% effective for women who have not had children or who have had a cesarean section. Women who have delivered children vaginally have lower rates of success with diaphragms and cervical caps. They are more effective when used consistently and fitted correctly, although not all women are able to achieve this.

Doctors often recommend that you use spermicides and condoms together or along with another method to increase their effectiveness. The male condom is 85% effective. The female condom is 79% effective. Spermicide is 71% effective. In real numbers, this means that of women who use male condoms alone for birth control each time they have sex, 15 out of 100 will become pregnant in the first year of use. Consider carefully whether this risk is acceptable to you.

Using fertility awareness takes organization, good record keeping, close observation of your body changes, and cooperation from your partner. Even when practiced carefully and consistently, fertility awareness is not a reliable method of birth control. Of women who use fertility awareness for birth control, 20 to 25 out of 100 will become pregnant in the first year of use.

See a table detailing the failure rate of each method.

Consider how comfortable you feel about using a particular method of birth control. If you are not comfortable or will not consistently use a birth control method for any reason, that method may not be effective. A reality check for birth control methods can help you determine which method is right for you.

Patch warnings

The patch delivers more estrogen than the low-dose birth control pills do. Some research has found that women using the patch are more likely to get dangerous blood clots in the legs and lungs. The risk may be higher if you smoke or have certain health problems. The U.S. Food and Drug Administration (FDA) suggests that you talk to your doctor about your risks before using the patch.
Direct sunlight or high heat can increase, then lower, the amount of hormone released from a patch. This can give you a big dose at the time and leave less hormone for the patch to release later in the week. This increases your risk of pregnancy. Avoid direct sunlight on the hormone patch. Also avoid using a tanning bed, heating pad, electric blanket, hot tub, or sauna while you are using a hormone patch.

What are health risks that may affect my choices?

Some health conditions may limit your choice of birth control methods. Discuss appropriate methods of birth control with your health professional if you:

Have a chronic illness, such as diabetes or heart disease.
Have a history of cardiovascular problems, such as high blood pressure (hypertension), stroke, high cholesterol, or blood clots.
Have a history of nervous system problems, such as seizures or headaches.
Have a history of migraines.
Smoke cigarettes.
Have a history of cancer.
Use prescription medications. Certain antibiotics, antiretrovirals, and anticonvulsants, as well as St. John's wort, make certain hormonal birth control less effective.²
Have low bone density (osteoporosis) in your personal or family history.
Are overweight. The pill and the patch may not work as well if you are overweight (body mass index greater than 30).^3,⁴

Bone thinning. Using Depo-Provera for 2 or more years can cause bone loss, which may not be fully reversible after stopping the medication and can lead to osteoporosis in later life. This concern may be greatest during the teen years, when young women should be building bone mass. Depo-Provera use is not recommended to be used for longer than 2 years unless you are protecting your bones with daily calcium and regular weight-bearing exercise, such as walking or running.^5,⁶ Talk to your doctor about your risks if you have been using Depo-Provera for longer than 2 years.

Sexually transmitted disease. If a sexually transmitted disease is present at the time an IUD is inserted, a woman is at increased risk for pelvic inflammatory disease (PID) in the 20 days after insertion. Pelvic inflammatory disease can lead to infertility.⁷ This is why a test for STDs is important before inserting an IUD.

For more information, see the topic Exposure to Sexually Transmitted Diseases.

Will some temporary birth control methods prevent me from having children when I want them?

Consider how soon, if ever, you would like to become pregnant. Except for sterilization methods, which permanently prevent pregnancy, all currently available birth control methods allow you to become pregnant again, although some may cause a delay.

Depo-Provera. For some women, it may take 3 to 18 months to get pregnant after the last Depo-Provera (a progestin-only hormonal method) shot.

The estrogen-progestin pill. If you take monthly cycles of birth control hormones for a long time, your periods might stop. You might not start periods again for several months after you stop taking hormones. But it isn't permanent. You will start ovulating and having your periods, and your fertility should get back to normal. Since it is common to ovulate before your first period comes back, it is possible to get pregnant sooner than you expect. So if you aren't in a rush to get pregnant, use some form of birth control after you stop birth control hormones.

What can I do if I have unprotected sex?

Emergency contraception is a backup method for unprotected intercourse. This would be when you have not used a birth control method or have reason to believe that your method has not protected you as it should. For example, you could use emergency contraception if the condom breaks during sex.

Your Information

One method may work better than others for a woman or for a couple. You may use more than one method at a time, especially if you need sexually transmitted disease protection and highly effective birth control. And birth control needs change over time. Consider the information below as you make your decision.

**Deciding about birth control**
Method	Reasons to use the method	Reasons not to use the method
Fertility awareness	You and partner can be diligent about charting fertile times and either using barrier methods or not having sex during those times. Your birth control options are limited by your moral beliefs or your religion's laws.	Not highly reliable (75% effective, or 25 pregnancies out of 100 women/year) Requires close observation of body changes and abstinence or use of barrier methods during fertile times You are looking for protection from sexually transmitted diseases. This method provides no protection.
Condoms (male or female)	Reduces risk of sexually transmitted diseases (STDs) You want a method that is inexpensive and widely available.	Not highly reliable (79%–85%, or 15–21 pregnancies out of 100 women/year) Interrupts lovemaking and decreases sensation Some men don't like or are not willing to use
Female barriers (diaphragm, cap, Lea's Shield, sponge)	You have health risks, such as having migraines or being a smoker older than 35, and can't use other methods. Your relationship will comfortably and consistently allow their use. You want a method that is available without a prescription (sponge).	Can interrupt lovemaking and be messy Not highly reliable (60%–85%, or 15–40 pregnancies out of 100 women/year) You are looking for protection from sexually transmitted diseases. This method provides no dependable protection.
Combination estrogen and progestin hormone methods (pill, ring, patch)	You want a method that doesn't interrupt intercourse. Use once a day (pills), once a week (patch), or once a month (vaginal ring). You need a highly effective method (92%–97% or 3–8 pregnancies out of 100 women/year). You want a method that lessens acne and reduces menstrual cramping and flow and premenstrual symptoms. You want to have few or no menstrual periods. Ring and patch: You don't have to remember to take a pill every day.	You have health risks, such as being a smoker older than 35, or have migraines, high blood pressure, stroke, blood clots, liver disease, heart disease, or diabetes. Pills: You have difficulty remembering to take one every day. Patch: You cannot avoid exposing the patch to direct sunlight or high heat, which can make it less effective. Patch: You want a low-estrogen option. The birth control patch delivers more estrogen than the low-dose birth control pills do. You are looking for protection from sexually transmitted diseases. (Condoms are necessary for protection.) You experience side effects, including nausea and vomiting, headaches, breast tenderness, or mood changes. You are overweight. The pills and the patch may not work as well if your body mass index is greater than 30.^4,³
Progestin-only pills, injection (Depo-Provera)	You have health risks and can't use combination hormonal methods. You need a highly effective method (92%–97%, or 3–8 pregnancies out of 100 women/year). You want a method that doesn't interrupt intercourse. Use once a day (pills) or once every 3 months (injection). You are breast-feeding.	Pills: You must remember to take them at the same time each day. Injections: You don't like shots. You are looking for protection from sexually transmitted diseases. (Condoms are necessary for protection.) Depo-Provera use may increase your risk of chlamydia or gonorrhea infection if you are exposed.⁸ You experience side effects, including breast tenderness, spotting, mood changes, and weight gain. Injections: You need a long-term method. Using Depo-Provera for 2 or more years can cause significant bone loss, which may not be fully reversible after stopping the medication.⁵
IUD	You need a highly effective means of birth control (more than 99%, or fewer than 1 pregnancy per 100 women/year). You have a low risk of having a sexually transmitted disease infection (which could be carried into the uterus with IUD insertion). You want a method that requires little effort. You do not have to remember to take pills, and the IUD can prevent pregnancy for 5 to 10 years. Hormonal IUDs decrease menstrual flow and cramping.	You are looking for protection from sexually transmitted diseases. (Condoms are necessary for protection.) You find the IUD to be uncomfortable (more common in women who have not had children). Copper IUD increases menstrual flow and cramping.
Tubal ligation or implants or vasectomy	You are absolutely sure you do not want children or do not want more children. You want a method that is permanent.	You may regret your decision later (if you are young, have few or no children, or are choosing sterilization for the wrong reasons). Permanent (although vasectomy takes several months after surgery before it is effective) You are looking for protection from sexually transmitted diseases. (Condoms are necessary for protection.)
	Are there other reasons you might want to use a certain method?	Are there other reasons you might not want to use a certain method?

These personal stories may help you make your decision.

Wise Health Decision

Use this worksheet to help you decide if the method you're considering is right for you. After completing it, you should have a better idea of your priorities. Discuss the worksheet with your health professional.

Circle the answer that best applies to you.

I have had problems or became pregnant while using this method.	Yes	No	N/A*
I am not comfortable with and would rather not use this method.	Yes	No	Unsure
I am comfortable using condoms with every act of sexual intercourse.	Yes	No	Unsure
I am comfortable using a diaphragm, cap, Lea's Shield, or sponge with every act of sexual intercourse.	Yes	No	Unsure
I have no difficulty remembering to take a birth control pill every day.	Yes	No	Unsure
I like the health benefits of hormonal methods but would find using a patch once a week more convenient.	Yes	No	Unsure
I am concerned about getting a sexually transmitted disease.	Yes	No	N/A
I don't want my menstrual periods to be longer or more painful.	Yes	No	Unsure
I have health risks that limit my birth control choices.	Yes	No	N/A
I can afford this method.	Yes	No	Unsure
I am opposed to this method because of my religious beliefs.	Yes	No	N/A
My partner is willing to use this method.	Yes	No	Unsure
I am too embarrassed to use this method.	Yes	No	Unsure
I might not use this method if it interrupts lovemaking.	Yes	No	Unsure
I like the health benefits of combination hormonal methods but want the convenience of using a vaginal ring once a month or patch once a week.	Yes	No	N/A
I have health risks and cannot use estrogen.	Yes	No	Unsure
I like the health benefits of hormonal methods but would find getting an injection every 3 months more convenient.	Yes	No	Unsure
I am comfortable keeping track of my menstrual cycle each month and avoiding sexual intercourse at my most fertile time.	Yes	No	Unsure
I want a long-term but not permanent method of birth control.	Yes	No	Unsure
I want a permanent method of birth control.	Yes	No	Unsure

*N/A = Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use a particular birth control method.

Check the box below that represents your overall impression about your decision.

Leaning toward (you fill in) method

Return to the topic Birth Control.

Effectiveness data for birth control methods from:

U.S. Food and Drug Administration (2003). Birth Control Guide. Available online: http://www.fda.gov/fdac/features/1997/babytabl.html.

Trussell J (2004). The essentials of contraception: Efficacy, safety, and personal considerations. In RA Hatcher et al., eds., Contraceptive Technology, 18th ed., pp. 221–252. New York: Ardent Media.

References

Citations
Speroff L, Fritz MA (2005). Oral contraception. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 861–942. Philadelphia: Lippincott Williams and Wilkins.
Hatcher RA, Nelson A (2004). Combined hormonal contraceptive methods. In RA Hatcher et al., eds., Contraceptive Technology, 18th ed., pp. 391–460. New York: Ardent Media.
Hatcher RA, et al. (2005). Pocket Guide to Managing Contraception 2005–2007. Tiger, GA: Bridging the Gap Foundation.
Holt VL, et al. (2005). Body mass index, weight, and oral contraceptive failure risk. Obstetrics and Gynecology, 105(1): 46–52.
U.S. Food and Drug Administration (2004). Black box warning added concerning long-term use of Depo-Provera contraceptive injection. FDA Talk Paper No. T04-50. Available online: http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01325.html.
Hatcher RA (2004). Depo-Provera injections, implants, and progestin-only pills (minipills). In RA Hatcher et al., eds., Contraceptive Technology, 18th ed., pp. 461–494. New York: Ardent Media.
Cheng D (2000). The intrauterine device: Still misunderstood after all these years. Southern Medical Journal, 93(9): 859–864.
Morrison CS, et al. (2004). Hormonal contraceptive use, cervical ectopy, and the acquisition of cervical infections. Sexually Transmitted Diseases, 31(9): 561–567.

Credits

Author	Merrill Hayden
Editor	Kathleen M. Ariss, MS
Associate Editor	Terrina Vail
Primary Medical Reviewer	Joy Melnikow, MD, MPH - Family Medicine
Specialist Medical Reviewer	Kirtly Jones, MD - Obstetrics and Gynecology
Last Updated	May 23, 2006

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Last updated:	May 23, 2006
Author:	Merrill Hayden
Reviewed By:	Joy Melnikow, MD, MPH - Family Medicine, Kirtly Jones, MD - Obstetrics and Gynecology
Editors:	Kathleen M. Ariss, MS, Terrina Vail

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