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Milwaukee Journal Sentinel, March
6, 2005
OP ED: The birth
control maze
Let your age,
sexual activity, relationships and health conditions
guide you to the right choice -- and know that
choice may change over time
Author : SHARON MILLER CINDRICH, Special to
the Journal Sentinel, Milwaukee Journal Sentinel
When Claire Pankratz was first in the market
for contraception, her priorities were effectiveness
and convenience.
At the time, the pill was the answer.
"Over the course of eight years, I used
a variety of pills, trying to find the right
fit," the Wauwatosa woman said.
While the pill did fit her initial criteria,
she wrestled with hormonal side effects.
"Some pills caused me to gain about 10 pounds
and turned PMS into psychosis," she said.
When she began planning for pregnancy, Pankratz
wanted to rid her body of the extra hormones
from the pill and tried the diaphragm and the
sponge.
Three children later, Pankratz was in the market
for yet another contraceptive method. "After
baby number three, my husband got a vasectomy.
That was great, until I started having severe
cramps and extremely heavy bleeding,"
said Pankratz, who had a Mirena IUD (intrauterine
device) inserted to control peri-menopausal
symptoms.
Individual contraceptive needs are as varied
as the users themselves, and change in response
to age, sexual activity, relationships and
health conditions throughout a lifetime.
The Centers for Disease Control and Prevention's
National Survey of Family Growth found that
98% of women who have ever had intercourse
had used at least one contraceptive method,
and that about 62% of women 15 to 44 years
of age were using contraception in 2002.The
contraceptive market has changed, too.
Over the past decade, the patch, ring and shot
have been added to the list of birth control
choices, designed to accommodate individual
lifestyles, family goals and biology.
Discussing contraceptive options with a medical
professional is critical, and individuals interested
in changing their current method or exploring
alternatives should always consult their physician
first.
Whether you are satisfied with your current form
of contraception or still looking for the perfect
fit, here are some things you may not know
about birth control today.
By one measure, the pill is not the most common
form of birth control in the United States.
The 2002 National Survey of Family Growth cited
above reports that the pill is the leading
method of contraception; 18.9% of the respondents
used it. When the percentages of women relying
on either female sterilization (16.7%) or male
sterilization (5.7%) are combined, the total
percentage relying on sterilization is larger.
Seen as a permanent method of birth control,
sterilization includes vasectomy for men and
tubal ligation for women.
In the arena of reversible hormonal contraceptive
choices, however, the pill still reigns supreme
in the United States, especially among women
in their 20s.
"I think the pill is still the most popular,"
said Vanessa Barnabei, an associate professor
of obstetrics and gynecology with the Medical
College of Wisconsin.
"Even people who have never used the pill
are familiar with it. Everybody knows somebody
that's on it."
The pill uses hormones to prevent the ovaries
from releasing an egg, thereby preventing pregnancy.
Introduced in the 1960s, there are now dozens
of oral contraceptives available. New low-dose
pills offer users fewer side effects and health
risks.
The IUD is the most popular method of reversible
birth control in the world.
While only about 2% of women in the U.S. who
use contraception choose the intrauterine device,
it is the most popular form of reversible birth
control in the world. An estimated 128 million
women globally use IUDs, according to Family
Health International, a non-profit public health
organization that grew out of a contraceptive
research project that began at the University
of North Carolina-Chapel Hill in 1971.
Today, there are two kinds of IUDs on the market.
The copper IUD can stay in place for up to 12
years; it prevents pregnancy by releasing small
amounts of copper into the uterus, which is
toxic to sperm and not conducive to implantation.
The progesterone IUD does the same by releasing
small amounts of hormones into the uterus and
can stay in place for up to five years.
Use by American women took a sharp dive in the
1970s, when a series of deaths from miscarriage-related
infections were blamed on the design of a popular
IUD called the Dalkon Shield.
Lawsuits and public fear combined with the bankruptcy
of this IUD's manufacturer caused use of this
method to plummet drastically.
The IUD today has the lowest pregnancy rate of
all reversible contraceptives and the highest
satisfaction rate among users.
The introduction of the Mirena IUD, which releases
daily, low doses of a progestin called levonorgestrel,
has given this method a boost since its FDA
approval in 2000."My doctor recommended
the Mirena IUD. My insurance covered it; insertion
was a piece of cake. Since then, periods have
been wonderfully light and with no cramps,"
said Pankratz, who is hoping that she will
be among the many Mirena users who experience
almost no monthly bleeding after the first
year.
Contraceptive failure rates do not account for
human error.
Mara Kinosian of Wauwatosa still believes that
the oral contraceptive she is taking is safe
and effective, even though her third-grade
daughter is what she calls a "pill baby."
"I did take the pill every day, but they
say take it at the same time every day. Perhaps
that affected the effectiveness of the pill,"
Kinosian said.
Many variables can affect the effectiveness of
birth control methods, including weight, health,
drug interactions and individual compliance.
Failure percentages for contraceptive methods
are theoretical and based on perfect use.
Failure rates for actual users are significantly
higher, especially during the first-year use
of any method where human error can affect
appropriate use.
Natural family planning, for example, has a higher
failure rate than many of the other methods
because it depends heavily on human consistency
and attention, Barnabei said. "It is much
more challenging and takes much more of a commitment
that what people think. That's why it has gotten
a bad name, because people don't do it right."
New birth control choices are often old methods
in a new package.
While vaginal rings and patches seem to be new
forms of birth control, the novelty is in the
application.
"Most of the new contraceptives are just
like the old ones, except they have a new `package,'
" said Victoria Jennings, director of
the Institute for Reproductive Health at Georgetown
University. "They're the same hormones
as the pill, now in the form of a patch or
a ring. The only difference is that the user
needs to apply them to the skin (the patch)
or insert them into the vagina (the ring) instead
of take a pill every day."
The newest kids on the block include the NuvaRing
vaginal contraceptive ring and the Ortho Evra
transdermal contraceptive patch.
The NuvaRing is 2 inches in diameter and a one-size-fits-all
flexible transparent ring that is placed into
the vagina for 3 weeks. The ring is removed
during the fourth week, causing the woman to
have her period.
The Ortho Evra hormonal patch is applied to abdomen,
buttocks or outer upper arm, where it remains
for one week and is then replaced, for three
weeks in a row. No patch is worn on the fourth
week.
Contraceptive injections, like Depo Provera,
deliver the same hormones used in the pill.
Women using Depo Provera receive a shot every
three months.
Even natural family planning methods are getting
a makeover. Jennings and her colleagues have
developed the Standard Days Method along with
CycleBeads, a simple visual aid that identifies
all the fertile days in a woman's cycle and
helps users prevent or achieve pregnancy. CycleBeads
are an inexpensive, non-hormonal method of
birth control.
Using contraception to skip a period is not necessarily
unhealthy.
Several of the hormonal contraceptive methods
cause women to miss a period, including Depo
Provera, the Mirena IUD, and Seasonale, an
extended-regimen birth control pill designed
specifically to reduce monthly bleeding to
four times a year. The effect of the hormones
allows very little buildup of the uterine lining.
Not only is missing a period safe, but for many
women it is a major perk. They can avoid the
inconvenience of menses, and peri-menopausal
women can manage the erratic bleeding, increased
cramping and mood swings often associated with
their menstrual cycle.
"Baby boomers who grew up with birth control
don't want to go through the unpredictability
of menses during menopause," said Lois
Boyd, a nurse practitioner with Planned Parenthood
of Wisconsin. Methods that decrease or eliminate
bleeding are very popular among the peri-menopausal
group, she said.
Hormonal birth control methods for men are on
the horizon.
Since the pill hit the market in the 1960s, researchers
have been dabbling with hormonal contraception
for men. According to the Kaiser Family Foundation,
this year several of these male hormone contraceptives
are moving toward Phase III testing, the last
stage before the FDA approval process can begin.
The male hormonal method would work in the same
general way the female birth control pill works:
hormones, such as testosterone and progestins,
would be used to disable or significantly lower
the production of sperm.
The launch of this method is at least 5 years
away; it may arrive in the form of a shot or
implant instead of an oral contraceptive.
Emergency contraception cannot end a pregnancy.
Emergency contraception, sometimes referred to
as the "morning-after pill," can
only prevent a pregnancy from occurring. The
hormones released can delay or impede ovulation,
prevent fertilization and inhibit implantation.
Emergency contraception is most effective 72
hours after unprotected intercourse, but can
be used up to 5 days after intercourse.
Regular birth control pills can also be used
as emergency contraception if taken in higher
doses. A copper IUD is a non-hormonal emergency
contraception option and can be inserted into
the uterus within 7 days of intercourse to
prevent pregnancy. Again, discussing this option
with a medical professional is paramount.
Only one form of contraception prevents sexually
transmitted diseases.
The condom is still the only form of birth control
that also acts to prevent HIV and other sexually
transmitted diseases. The first published accounts
of the condom being used to prevent disease
were written in the 1500s during the syphilis
epidemic in Europe. Though the design has changed
little in the last century, recent awareness
of latex allergies have prompted manufacturers
to create condoms out of polyurethane. Not
only are they safe for folks with latex allergies,
but companies claim they are stronger, thinner
and don't have the smell of latex.
Disease prevention is a priority, however, in
contraceptive research, and microbicides may
be the one of the most important innovations
in reproductive health since the pill. Microbicides
refer to a range of potential products with
the ability to prevent the sexual transmission
of HIV, as well as other sexually transmitted
diseases when applied topically, and may be
available in the next 5 to 7 years.
Health insurance does not always cover contraception.
"At first (my birth control pills) were
covered 100%, but then insurance changed and
co-pays were required between $10 and $20 per
month depending on the prescription,"
said Lacretia Svenningsen of Muskego, who has
found insurance to be a consideration in her
choice of contraception.
Even when Svenningsen inquired about other birth
control options, her doctors warned her that
some methods may not be as well covered as
the pill. "It was not always clear what
would be covered by my insurance, so it seemed
to take a lot of legwork (by) the patient to
find out all the information."
Birth control can be costly. Oral contraceptives
can cost consumers up to $300 to $400 annually.
The NuvaRing and Ortho Evra Patch both cost between
$30 to $40 per month. Women can expect to spend
between $300 to $500 every five years for the
Mirena IUD.
Health care coverage for reversible contraception
has almost tripled in the last decade.
According to a 2002 study by the Alan Guttmacher
Institute, 86% of employer-provided health
care programs covered a full range of contraception
choices, in contrast to 28% in 1993.
Newer methods are less likely to be covered,
however. While 80% of health insurance companies
cover oral contraceptives, newer forms of contraception,
including the vaginal ring, transdermal patch
and IUD, were covered only 30% to 40% of the
time, according to a 2004 study sponsored by
the Association of Reproductive Health Professionals,
Black Women's Health Imperative and Planned
Parenthood Federation of America.
Despite increased research, improved insurance
coverage, and more contraceptive product options,
almost half of the pregnancies in the U.S.
are unplanned, according to the Alan Guttmacher
Institute .
"We still have 3 million unintended pregnancies
a year and probably a million or more abortions
a year," Barnabei said. "There's
something about the methodology or the message
that still isn't getting out."
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